Fifty million Americans have surgery each year. Approximately 2 million of these surgical patients will develop persistent opioid use (meaning they continue to use opioids 90–180 days after surgery). For far too many people, surgery is a critical gateway to the tragedy of opioid addiction.
As a practicing anesthesiologist, I’ve been administering opioids for 20 years to patients under my care. That’s how I was trained. Surgery is painful, so opioid medications have long been a standard part of anesthesia practice. Despite advances in pain management alternatives, most surgical patients are still administered opioids during surgery and immediately after surgery and are prescribed opioid medication to take in the days and weeks following surgery.
This is a story of how our team helped break the cycle of unnecessary opioid prescribing at a surgery center and decreased patient exposure from 85 percent to zero. Our goal was to develop anesthesia and surgical protocols that enable patients to go through surgery with minimal or no exposure to opioids while effectively treating their post-operative pain.
Figure 1: Seattle Children’s Hospital Bellevue Surgery Center – Monthly Opioid Use
I work in a surgery center with a team performing over 4,000 surgeries each year in a variety of specialties. This includes orthopedics, urology, dental, ophthalmology, and more. Historically, 85 percent of patients typically received an intraoperative dose of an opioid medication, with 12–15 percent typically requiring additional opioids in the recovery room.
In July 2018, our team made a deliberate effort to develop opioid-free surgical pathways starting with tonsillectomies, the most common surgery. We reviewed evidence from the literature and applied basic improvement concepts like PDSA cycles and statistical process control (SPC) charts to understand if our changes resulted in improvement.
By May 2019, our team had successfully run multiple PDSA cycles across all of our outpatient surgical pathways (including hernia repair, strabismus surgery, ACL reconstruction, shoulder surgery, hypospadias correction, and pulse dye laser therapy) and we’d lowered the opioid administration rate from 85 percent to less than 1 percent.
Figure 1 shows the number of vials of morphine, fentanyl, and alfentanil used per month over the transition period. Before this work, usage had increased every year. Now, we have dramatically lowered our reliance on opioids for surgery.
Here is an example of how our teams used SPC charts to understand how our protocols effected outcomes and improved our systems.
Figure 2: Percent of Cases with Rescue Morphine (P Chart), starting from opioid baseline and spanning three PDSA cycle
These charts show three successive iterations of an opioid-free tonsillectomy protocol over the course of fourteen months. Post-operative morphine requirements dropped from 22 percent to 13 percent of patients.
Figure 3: Percent of Cases with Rescue PONV Meds (P Chart), starting from opioid baseline and spanning three PDSA cycles
Post-operative nausea and vomiting dropped from 2.7 percent to 0.3 percent.
Figure 4: Pain Scores (X-bar Chart), starting from opioid baseline and spanning three PDSA cycles
We achieved these improvements without an increase in pain scores or the 30-day return to surgery rate (<1 percent).
We were proud to publish the details of this quality improvement project in Pediatric Anesthesia earlier this year to inspire other surgery programs to follow our lead.
The four key components necessary for success are clinician engagement, improvement methodology, data, and analytics. An inverted pyramid leadership model worked well here with an organizational goal of reducing opioids delivered by innovation from the frontline clinicians. Historically, it has been hard to get buy-in from such a wide group to implement changes in practice. However, we now use real-world data to understand how protocol changes effect outcomes. This is the catalyst that aligned and engaged our clinical team, resulting in accelerated improvement across the surgery center.
We believe our surgery center is the first in the US to have scaled opioid-free anesthesia across such a broad range of surgeries. A next phase will be to learn from our data to understand real-world use of opioids after discharge so we can rationalize opioid prescribing protocols to match actual need. In the meantime, our teams continue to iterate their protocols within the surgery center to deliver better care and lower complications.
For our clinical teams, this project has represented a paradigm shift for our improvement work. The combination of easy and rapid visibility into outcomes data, together with IHI’s improvement framework, has empowered our clinicians to challenge our assumptions not only about use of opioids but about many of our long-held practices. I’m very excited to see this cultural shift across our teams’ everyday work, with standardization of clinical protocols, continuous measurement of outcomes and balancing metrics, and automated creation and daily monitoring of SPC charts across our performance.
Daniel Low, MD, is Associate Professor of Anesthesiology, University of Washington, Seattle Children’s Hospital.
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You may also be interested in:
IHI's Quality Improvement Essentials Toolkit
No More Excuses: It's Time to Treat Opioid Addiction