Reducing post-tonsillectomy haemorrhage rates through a quality improvement project using a Swedish National quality register: a case study

Erik Odhagen, Ola Sunnergren, Anne-Charlotte Hessén Söderman, Johan Thor, Joacim Stalfors, Erik Odhagen, Ola Sunnergren, Anne-Charlotte Hessén Söderman, Johan Thor, Joacim Stalfors

Abstract

Purpose: Tonsillectomy (TE) is one of the most frequently performed ENT surgical procedures. Post-tonsillectomy haemorrhage (PTH) is a potentially life-threatening complication of TE. The National Tonsil Surgery Register in Sweden (NTSRS) has revealed wide variations in PTH rates among Swedish ENT centres. In 2013, the steering committee of the NTSRS, therefore, initiated a quality improvement project (QIP) to decrease the PTH incidence. The aim of the present study was to describe and evaluate the multicentre QIP initiated to decrease PTH rates.

Methods: Six ENT centres, all with PTH rates above the Swedish average, participated in the 7-month quality improvement project. Each centre developed improvement plans describing the intended changes in clinical practice. The project's primary outcome variable was the PTH rate. Process indicators, such as surgical technique, were also documented. Data from the QIP centres were compared with a control group of 15 surgical centres in Sweden with similarly high PTH rates. Data from both groups for the 12 months prior to the start of the QIP were compared with data for the 12 months after the QIP.

Results: The QIP centres reduced the PTH rate from 12.7 to 7.1% from pre-QIP to follow-up; in the control group, the PTH rate remained unchanged. The QIP centres also exhibited positive changes in related key process indicators, i.e., increasing the use of cold techniques for dissection and haemostasis.

Conclusions: The rates of PTH can be reduced with a QIP. A national quality register can be used not only to identify areas for improvement but also to evaluate the impact of subsequent improvement efforts and thereby guide professional development and enhance patient outcomes.

Keywords: Healthcare quality improvement; Post-tonsillectomy haemorrhage; Quality improvement project; Tonsillectomy.

Conflict of interest statement

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by The Regional Ethical Review Board in Gothenburg, Sweden (Reg. No. 257-14).

Informed consent

For this type of study, formal consent is not required.

Figures

Fig. 1
Fig. 1
Techniques for dissection and haemostasis at baseline, intervention period and follow-up, displayed with 95% confidence interval
Fig. 2
Fig. 2
PTH rates at baseline, intervention period and follow-up, displayed with 95% confidence interval

References

    1. Goldman JL, Baugh RF, Davies L, Skinner ML, Stachler RJ, Brereton J, Eisenberg LD, Roberson DW, Brenner MJ. Mortality and major morbidity after tonsillectomy: etiologic factors and strategies for prevention. Laryngoscope. 2013;123(10):2544–2553.
    1. Stalfors J, Ericsson E, Hemlin C, Hessén Söderman A-C, Odhagen E, Sunnergren O (2014) Annual Report 2013 of The National Tonsil Surgery Register in Sweden. Karolinska University Hospital, Stockholm, Sweden. 10.13140/2.1.1680.1605
    1. Hallenstal N, Sunnergren O, Ericsson E, Hemlin C, Hessen Soderman AC, Nerfeldt P, Odhagen E, Ryding M, Stalfors J. Tonsil surgery in Sweden 2013–2015. Indications, surgical methods and patient-reported outcomes from the National Tonsil Surgery Register. Acta Otolaryngol. 2017;137(10):1096–1103. doi: 10.1080/00016489.2017.1327122.
    1. Borgstrom A, Nerfeldt P, Friberg D, Sunnergren O, Stalfors J. Trends and changes in paediatric tonsil surgery in Sweden 1987–2013: a population-based cohort study. BMJ Open. 2017;7(1):e013346. doi: 10.1136/bmjopen-2016-013346.
    1. Sarny S, Ossimitz G, Habermann W, Stammberger H. Hemorrhage following tonsil surgery: a multicenter prospective study. Laryngoscope. 2011;121(12):2553–2560. doi: 10.1002/lary.22347.
    1. Ostvoll E, Sunnergren O, Stalfors J. Increasing readmission rates for hemorrhage after tonsil surgery: a longitudinal (26 Years) national study. Otolaryngology. 2017
    1. Windfuhr JP. Tonsil surgery in Germany: rates, numbers and trends. Laryngorhinootologie. 2016;95(Suppl. 1):S88S109.
    1. Mueller J, Boeger D, Buentzel J, Esser D, Hoffmann K, Jecker P, Mueller A, Radtke G, Geissler K, Bitter T, Guntinas-Lichius O. Population-based analysis of tonsil surgery and postoperative hemorrhage. Eur Arch Otorhinolaryngol. 2015;272(12):3769–3777. doi: 10.1007/s00405-014-3431-6.
    1. Ostvoll E, Sunnergren O, Ericsson E, Hemlin C, Hultcrantz E, Odhagen E, Stalfors J. Mortality after tonsil surgery, a population study, covering eight years and 82,527 operations in Sweden. Eur Arch Otorhinolaryngol. 2014
    1. Sarny S, Habermann W, Ossimitz G, Schmid C, Stammberger H. Tonsilar haemorrhage and re-admission: a questionnaire based study. Eur Arch Otorhinolaryngol. 2011;268(12):1803–1807. doi: 10.1007/s00405-011-1541-y.
    1. Soderman AC, Odhagen E, Ericsson E, Hemlin C, Hultcrantz E, Sunnergren O, Stalfors J. Post-tonsillectomy haemorrhage rates are related to technique for dissection and for haemostasis. An analysis of 15734 patients in the National Tonsil Surgery Register in Sweden. Clin Otolaryngol. 2015;40(3):248–254. doi: 10.1111/coa.12361.
    1. Alm F, Jaensson M, Lundeberg S, Brattwall M, Hemlin C, Hessén Söderman A-C, Nerfeldt P, Odhagen E, Sunnergren O, Stalfors J, Ericsson E (2016) Adherence to Swedish guidelines for pain treatment in tonsil surgery in pediatric patients. Paper presented at the 13th Congress of the European Society of Pediatric Otorhinolaryngology, Lisbon
    1. Elinder K, Soderman AC, Stalfors J, Knutsson J. Factors influencing morbidity after paediatric tonsillectomy: a study of 18,712 patients in the National Tonsil Surgery Register in Sweden. Eur Arch Otorhinolaryngol. 2016;273(8):2249–2256. doi: 10.1007/s00405-016-4001-x.
    1. Annual report 2014 of The National Tonsil Surgery Register in Sweden (2015). Svensk ÖNH-tidsskrift officiell tidskrift för Svensk Förening för Otorhinolaryngologi 22(S1)
    1. Carlhed R, Bojestig M, Peterson A, Aberg C, Garmo H, Lindahl B. Improved clinical outcome after acute myocardial infarction in hospitals participating in a Swedish quality improvement initiative. Circ Cardiovasc Qual Outcomes. 2009;2(5):458–464. doi: 10.1161/CIRCOUTCOMES.108.842146.
    1. Peterson A, Hanberger L, Akesson K, Bojestig M, Andersson Gare B, Samuelsson U. Improved results in paediatric diabetes care using a quality registry in an improvement collaborative: a case study in Sweden. PloS One. 2014;9(5):e97875. doi: 10.1371/journal.pone.0097875.
    1. Thor J, Peterson A, Lindahl B. The role of quality registries in health care improvement. In: Jacobsson Ekman G, Lindahl B, Nordin A, editors. National quality registries in Swedish health care. Solna: Karolinska Institutet University Press; 2016. pp. 53–67.
    1. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290–298. doi: 10.1136/bmjqs-2013-001862.
    1. Lowe D, van der Meulen J. Tonsillectomy technique as a risk factor for postoperative haemorrhage. Lancet. 2004;364(9435):697–702. doi: 10.1016/S0140-6736(04)16896-7.
    1. Tomkinson A, Harrison W, Owens D, Harris S, McClure V, Temple M. Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope. 2011;121(2):279–288. doi: 10.1002/lary.21242.
    1. Baker GR. The contribution of case study research to knowledge of how to improve quality of care. BMJ Qual Saf. 2011;20(Suppl 1):i30-35. doi: 10.1136/bmjqs.2010.046490.
    1. Socialstyrelsen (2017) The National Patient Register. . Accessed Nov 08 2017
    1. Kaplan HC, Provost LP, Froehle CM, Margolis PA. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf. 2012;21(1):13–20. doi: 10.1136/bmjqs-2011-000010.
    1. Bate P, Robert G, Fulop N, Øvretviet J, Dixon-Woods M, Health F (2014) Perspectives on context: a collection of essays considering the role of context in successful quality improvement (Original research)
    1. Aydin S, Taskin U, Altas B, Erdil M, Senturk T, Celebi S, Oktay MF. Post-tonsillectomy morbidities: randomised, prospective controlled clinical trial of cold dissection versus thermal welding tonsillectomy. J Laryngol Otol. 2014;128(2):163–165. doi: 10.1017/S0022215113003253.
    1. Cardozo AA, Hallikeri C, Lawrence H, Sankar V, Hargreaves S. Teenage and adult tonsillectomy: dose-response relationship between diathermy energy used and morbidity. Clin Otolaryngol. 2007;32(5):366–371. doi: 10.1111/j.1749-4486.2007.01529.x.
    1. Walijee H, Al-Hussaini A, Harris A, Owens D. What Are the Trends in Tonsillectomy Techniques in Wales? A Prospective Observational Study of 19,195 Tonsillectomies over a 10-Year Period. Int J Otolaryngol. 2015
    1. Nolan T (2007) Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper
    1. Majholm B, Engbaek J, Bartholdy J, Oerding H, Ahlburg P, Ulrik AM, Bill L, Langfrits CS, Moller AM. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta Anaesthesiol Scand. 2012;56(3):323–331. doi: 10.1111/j.1399-6576.2011.02631.x.

Source: PubMed

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