NSF CHOT IUCRC PROGRESS REPORT – PROJECT # 14
Practice Variance: Outcome-Driven Process Redesign & Systems Optimization:
II. Practice Variance at Epidural Processes
Research team
Eva K Lee, Haozheng Tian, David Little, Jr.,
Jinha Lee, Raghav Srinath, Will Lewis, Cody
Wang, Georgia Tech
Description
Practice variance is an important issue to
analyze as a means to optimize care delivery
(quality and efficiency) and to encourage
collaborative learning for broad quality
improvement. The project focuses on epidural
procedure for labor delivery. Epidural
anesthesia is used to improve pain relief in a
variety of lower abdominal and lower
extremity surgeries, including cesarean and
labor deliveries. While epidural analgesia is
used in hospitals across the country to assist in
deliveries, there is significant inter and intrafacility practice variance.
Our objective is to quantify needle-based
epidural strategies: focusing on effectiveness
vs efficiency vs outcome vs patient
satisfaction. In particular, we seek to
understand and optimize medication resource
usage (dose, duration vs patient response and
outcome); develop metrics to measure
outcome (quality vs patient satisfaction, initial
process vs final outcome); identify best
practice, and potentially develop clinical
practice guidelines. We aim to capture the
variance and establish evidence-based
outcome documentation.
How is this different than related
research? General practice for injecting
anesthesia applies medication primarily
through the catheter. Little is known or
published regarding needle-based approach.
Dosage, efficacy and safety have not been
documented. This study aims to provide
evidence that needle-based epidural
practice is safe; and that patients can
achieve proper sensory level
within the same duration as in the catheterbased approach. We will analyze the
proficiency of physician practice, and provide
insights on their preference in terms of
medication and dosage.
Milestones achieved to date
We have thus far:
 Performed on-site observation and
documentation of practice and variance
among 41 providers. A total of 412 patient
cases were collected.
 Established preliminary process maps and
annotated practice variance among
providers.
 Analyzed patient sensory response versus
medication, dosage, providers, and varying
care practice.
 Analyzed providers’ preference and
outcome response.
 Identified practice variance among
providers.
 Identified potential error-causing factors.
 Performed patient-dose sensory response
analysis
 Completed process maps for epidural
procedures
 Designed decision-simulation model to
analyze practice reliability to determine best
practice.
 Reported needle-based findings to
practitioners and prioritized
recommendations.
Next Steps
 Prepare first journal article for public
dissemination.
 Capture and document practice and
variance in C-section and vaginal birth.
 Contrast outcome against hospital resources
and patient satisfactory
 Collaboratively design clinical practice
guideline for optimal needle-based epidural
practice.
Potential member benefits
 Establish dose response factors and practice characteristics
 Improve quality of care, and reduce potential complications
 Provide documentation and evidence of needle-based epidural practice
 Facilitate development and standardization of best practice clinical guidelines
 Facilitate evidence-based practice