title: Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction.
abstract: BACKGROUND
  Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR.
  
  
  METHODS
  CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011-September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block.
  
  
  RESULTS
  One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block.
  
  
  CONCLUSIONS
  CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.
authors.affiliation: Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.
authors.forename: Bruce
authors.initials: B
authors.lastname: Ramshaw
authors.affiliation: Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.
authors.forename: Brandie Remi
authors.initials: BR
authors.lastname: Forman
authors.affiliation: Academic Assessment and Planning, Daytona State College, Daytona Beach, Florida.
authors.forename: Karla
authors.initials: K
authors.lastname: Moore
authors.affiliation: Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.
authors.forename: Eric
authors.initials: E
authors.lastname: Heidel
authors.affiliation: Department of Surgery, Halifax Health, Daytona Beach, Florida.
authors.forename: Michael
authors.initials: M
authors.lastname: Fabian
authors.affiliation: Department of Surgery, University Surgeons Associates, Knoxville, Tennessee.
authors.forename: Greg
authors.initials: G
authors.lastname: Mancini
authors.affiliation: Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Director of Perioperative Medicine and Ambulatory Anesthesia, Parkland Health and Hospital System, Dallas, Texas.
authors.forename: Girish P
authors.initials: GP
authors.lastname: Joshi
mesh_terms: D034861:Abdominal Wall / Q000601:surgery*; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000627:therapeutic use; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D058996:Quality Improvement; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D013526:Surgical Mesh / Q000706:statistics & numerical data
chemical_list: D000701:Analgesics, Opioid