H. N. Overton1, V. Valero1, J. F. Griffin1, J. P. Taylor1, K. Giuliano1, A. B. Blair1, B. Moeckli1, R. B. Fransman1, A. Graham1, A. AwadElkarim1, R. Beckman1, S. He1, J. Liu1, S. DiBrito1, M. C. Bicket2, M. A. Makary1, E. R. Haut1, B. C. Sacks1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Anesthesiology,Baltimore, MD, USA
Introduction: Recent data show that 1 in 16 patients become chronic opioid users after undergoing a surgical procedure, and 45% of patients are over-prescribed opioids at the time of hospital discharge compared to their inpatient opioid use. The primary objective of this quality improvement project was to improve rates of appropriate opioid prescribing at discharge at an urban, academic hospital.
Methods: We performed a retrospective cohort study with pre-post analysis after an educational intervention for surgical residents and discharge nurses. Patients who underwent a surgical procedure and required postoperative inpatient admission were included. An initial month long enrollment was followed by a resident-led educational intervention to individualize prescriptions based on the amount of opioids used in the 24-hours prior to discharge. Additional information on patient age, length of stay, admission status, acetaminophen and/or NSAID scheduled on day prior to discharge, and acetaminophen prescribed at discharge was collected. Patients with Methadone use during the hospitalization and/or at the time of discharge were excluded. The primary outcome was the difference between the total morphine milligram equivalents (MME) used in the 24 hours prior to discharge and the total daily MME prescribed at discharge. The mean differences were compared in the pre- and post-intervention groups. Secondary outcomes were the frequency of scheduled non-opioid pain medication during the inpatient admission and at the time of discharge.
Results: The prescribing patterns for 80 patients in the pre- and 69 patients in the post-intervention group (n=149) were reviewed. There were no significant differences between the pre- and post-intervention groups for any of the selected patient characteristics. The univariate model was determined to be most predictive by stepwise selection. The primary outcome of difference in MME was significantly different between the groups with the post-intervention group having 12.1 times less difference in MME than the pre-intervention group (95% CI: -20.9, -3.2; p=0.01) (Figure). Rates (mean (SD)) of prescribing non-opioid pain medication (Acetaminophen +/- NSAID) did not significantly differ between groups both during the inpatient admission (pre: 0.75 (0.49), post: 0.74 (0.44); p=0.88)) and at the time of discharge (pre: 0.63 (0.49), post: 0.70 (0.46); p=0.37).
Conclusion: An educational intervention for surgical residents and discharge nurses on how to customize the amount of opioids prescribed at the time of discharge resulted in significantly less over-prescription of opioids after surgical procedures. Future work should include optimization of non-narcotic pain medication usage in all settings of post-operative care.
