Oct 25, 2018
As we celebrate Healthcare Quality Week, October 21–26—a time dedicated to celebrating the contributions professionals have made to improve health care quality—we’re highlighting a quality improvement project that was featured in the Quality Care Symposium press program in September.
For this project, which was published in a study titled “Reducing opioid utilization after urologic oncology surgery,” members of an oncology care team achieved a 46% reduction in opioid use among patients who underwent a range of urologic surgeries by using a systemic approach that identified multiple key drivers of opioid use, resulting in multiple interventions. At the risk of oversimplification, one could break the approach down into two basic pillars: (1) maximizing the use of adjuvant, over-the-counter therapies for pain management; and (2) changing the way they communicated with patients.
Researchers from Stanford Health Care were searching for resources to help them manage pain and opioid use among their post-operative patients but realized that there were no existing guidelines or pathways available. The authors set out to create their own guidelines, receiving support as part of Stanford Health Care’s Clinical Effectiveness Leadership Training (CELT) project, which supports clinicians leading quality improvement projects. As the authors reviewed patients’ opioid use, pain, and anxiety scores after urologic surgeries over several months, the new systemic approach emerged, and clinical staff were trained to use the new approach to help manage post-operative pain.
Lead author Kerri Stevenson, MN, NP-C, RNFA, CWOCN, believes that the new approach was successful in large part because of both increased provider awareness of alternatives and patient buy-in. “The result of this project was a very patient-centric approach to pain management after surgery,” Stevenson said. “When we had conversations with patients about pain control, they appreciated that we didn’t withhold opioids, but made them aware of alternative methods for pain management, which subsequently reduced opioid use by half.”
Pathway development included reviewing surgical cases and fully maximizing the use of non-opioid pain medications, such as over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs, gabapentin, icepacks, and local anesthetics, to provide effective pain control. Opioids were prescribed but at a lower dose and escalated only as necessary.
The second piece of the approach—communication—involved changing how nurses approached postoperative pain management conversations with patients. Before the project, nurses would routinely ask patients whether they wanted any pain medication (referring to the opioid) at routine intervals throughout the day, causing patients to think they had better take the opioid to prevent developing severe pain. With some minor changes to communication, the authors trained nurses to instead begin by discussing with patients the current adjuvant pain medications they were taking, including how they worked, the doses, and the frequency administered—i.e., emphasize that non-opioid pain medications are medications too! As Stevenson described it, “The opioid was always there. It wasn’t withheld from the patient; it’s just that it was no longer the automatic default.”
The care team staff were also trained to discuss potential side effects of opioids, of which patients may not be aware. According to Stevenson, this improved communication led to informed decision-making and a greater sense of empowerment among patients.
The authors believe that this quality improvement approach may be applicable to other types of surgery and view it as a potential “best practice” for reducing patient opioid use. Next steps for this research include conducting additional collaborative studies that illuminate the identification and maximizing of alternative therapies available and ideal scheduling routines available; broadening this approach to a larger number of patients; and applying it to other specialties to see how it performs under different circumstances.