(CSEMP079) EVALUATION OF PERI-OPERATIVE PATIENT CARE AFTER IMPLEMENTATION OF A STANDARDIZED PITUITARY SURGERY ORDER SET: A QUALITY ASSURANCE STUDY

Abstract:

Background: Peri-operative pituitary surgery care varied greatly within our organization, leading to lack of standardized practices or optimization for endocrine outcomes, particularly regarding peri-operative steroid use. In 2018, a combined Endocrinology-Neurosurgery clinic was established for assessment and management of patients with pituitary tumors. Concurrently, a pituitary surgery admission order set was implemented to standardize and improve the detection and management of immediate post-operative endocrine complications.

Objectives: (1) To evaluate the use of the pituitary surgery order set on improving the appropriate use of steroids peri- and post-pituitary surgery. (2) To evaluate screening and detection of endocrine complications post-pituitary surgery.

Methods: Retrospective chart review was conducted of all patients aged ≥18 years who underwent pituitary surgery at our centre between 2014-2022. Data collection included parameters such as baseline pituitary function; peri-operative steroid use; peri-operative lab testing; and post-operative complications [transient or permanent diabetes insipidus, SIADH, adrenal insufficiency (AI), and thyroid dysfunction]; as well as hormone replacement discharge prescriptions.

Results: 79 patients underwent pituitary surgery during 2014-2022, 46 of whom underwent surgery prior to the implementation of the standardized order set. Patient demographics including age, gender, baseline pituitary function or surgical method did not significantly differ (all p>0.05) between groups. Following implementation, there was increased appropriate peri-operative steroid use, defined as peri-operative steroids only used in patients who had established AI (p= 0.022) and improved frequency of appropriate discharge steroid prescriptions, defined as prescription only to patients who had established pre- or post-operative AI (p= 0.019). Secondarily, rates of post-operative complications did not significantly differ between groups (all p>0.05). Length of hospital stay, and readmission did not significantly differ between groups (p>0.05). After order set implementation, there was also increased frequency of complete pre-operative pituitary hormone testing (all p< 0.05), increased frequency of standardized post-operative fluid balance monitoring (p < 0.001), and blood work (all p< 0.05), and improved frequency of complete post-operative pituitary hormone assessment (all p< 0.05).

Conclusions: Prior to implementation of the pituitary surgery order set, there were high rates of incomplete peri-operative endocrine investigations and inappropriate short- and long-term post-operative steroid use in patients with intact hypothalamic-pituitary-adrenal axis. Following implementation, we observed improved resource stewardship in terms of endocrine hormone testing and increased standardization of peri- and post-operative steroid use. Results of this work may support implementation of standardized order sets for peri-operative pituitary surgery care at other centers.