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FIGURE 1

Sample Performance Improvement Project:
Reducing # of post-surgery ED visits in Day Case Surgeries
Background:
Orthopedic surgeries are increasingly done as day cases around the world. In the U.K., for example, inpatient surgery is chosen only by excluding
the possibility of day surgery. With notable exceptions, day surgery is considered generally safer than inpatient surgery.

In marked contrast, patients in the UAE, particularly THIQA patients, have been accustomed to surgeries that include a long inpatient stay to
recuperate. Such a custom increases the risk of hospital-acquired infections and can delay the start of rehabilitation.
Problem:
A small yet meaningful number of surgery patients (5 out of 439) visited the ED (Emergency Department) within 48 hours of their surgery for
the same cause: Pain. International post-operative pain management standards dictate that postoperative pain with oral analgesia ± regional
anesthesia techniques, central neuraxial blockade and a range of regional anesthetic techniques are effective for day surgery. Nevertheless, a
small segment of patients felt the need to return to the ED within 48 hours of surgery to address the pain they were feeling.

Root Cause Analysis:
A review of cases was undertaken to determine why some patients felt the need to visit the ED for pain management. Interestingly, results showed
consistently that it was not the magnitude of pain that was being experienced that caused the ED visits. Some post-operative pain is inevitable and
is in fact part of the healing process. Patients were given instructions pre-operatively regarding pain management and accepted the inevitability
of some post-operative pain. Nevertheless, patients who visited the ED were afraid that the pain they themselves were experiencing actually
represented post-operative complications. In addition, those patients were not happy with the side effectives of some of the pain medications and
did not take them, so experienced more pain than necessary.
Process Changes:
As a result of our findings, tools were incorporated pre-operatively to better prepare patients for post-operative pain. A diagnostic tool now reveals
patients who are more likely to react poorly to pain, and additional preparation is given. We also learned that some patients were avoiding some
medications because they were suffering from undesirable side effects, so the post-surgery medication protocol was modified to include access to
a dermal patch which has minimal side effects. We also made available a clinician on call 24 / 7 dedicated to post-surgical patients and established
a more rigorous post-op call process. In the past, all patients had been called 48 hours after surgery to insure proper adherence to care guidelines
and to address any issues. We added a call within 24 hours post-surgery for patients identified as potential candidates for an ED visit without
intervention on our behalf.
Outcome
Adding education and the pre-operative tool vastly reduced the ED visits. There has only been 1 case since the new process was implemented
over 1 year ago.
The Shoulder and Upper Limb Unit