OR Manager - June 2018 - 15

Opioid prescriptions drop after orthopedic team changes protocol
Patient safety
C
an hospital leaders and surgeons
partner to reduce opioid
use while maintaining high
patient satisfaction scores? Leaders
at OSS Orthopaedic Hospital in York,
Pennsylvania, answer that question with
a yes.
Meghan McNelly, PharmD, MHA,
FACHE, who was director of pharmacy
at OSS when the opioid-reduction project
started, says that from 2015 to
2016, the hospital saw a 15% decrease
in total prescriptions and a 33% decrease
in the overall number of prescribed
oral opioids. The change did
not have a negative effect on patient
satisfaction scores.
Achieving results like these depends
on collaboration among pharmacists,
nurses, and physicians.
Driving change
Suzette Song,
MD
Suzette Song, MD, an
orthopedic surgeon and
vice president of medical
affairs for OSS,
spearheaded participation
by the largest physician
group. " If you have
seven physicians, you
get at least eight opinions, "
says Dr Song.
That meant it was important to start
with the facts. Baseline data for the
top 10 inpatient and outpatient procedures
were gathered from the electronic
health records for the hospital and the
physician offices.
" The results surprised us, " Dr Song
says. " We felt we were on the conservative
end and were mindful about what
we were prescribing, but when you take
20 or more physicians who do many
cases, it makes for a lot of prescriptions
and a lot of pills. "
The underestimation isn't uncommon.
For example, a study in Academic
Emergency Medicine reported that
nearly two-thirds (65%) of emergency
department physicians underestimated
the number of opioids they prescribed.
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Raising awareness resulted in fewer
prescriptions.
A closer look at
the OSS data
showed significant variability among
physicians about type of medication,
amount prescribed, and when patients
were seen for their first postoperative
visit. " Everyone had a logical reason for
why they did what they did, but we still
had to address the variability, " Dr Song
says. " It wasn't that anyone was doing
anything wrong, it's just that they were
doing things differently, " McNelly adds.
McNelly and Dr Song emphasize the
importance of physician champions,
and Dr Song asked the surgeon with
the highest volume of total knee arthroplasty
(TKA) and total hip arthroplasty
(THA) procedures for the practice to trial
the project.
Dr Song says volume is key when
choosing a champion. For instance,
when the team-which included Dr
Song, McNelly, and Joseph Alhadeff,
MD, president and chief executive officer
for OSS-later worked on opioid prescribing
for carpal tunnel surgery, they
chose a surgeon with a high volume for
that procedure.
The goal was to manage pain and
reduce opioid prescribing without leaving
patients short of medication. " There
are about six steps that have to happen
for patients to get a refill, and you don't
want to make your patients go through
that, " Dr Song says.
TKA was the first surgery the team
tackled. When patients returned for
their initial postoperative visit, 2 weeks
after surgery, the surgeon and his physician
assistant asked them how many
pills they had left. " It gives you a sense
if you overshot the number you prescribed
or got it right, " Dr Song says.
" We needed a better internal database
in our brains. "
That database gives physicians a
more precise idea of the number of
opioid pills needed for most patients.
Eventually, the average number of pills
prescribed dropped from 100 to 60,
although Dr Song emphasizes that the
number is adjusted based on patient
need.
The pilot was soon expanded, and
the team used the same approach for
each common procedure and injury.
Dr Song appreciates the courage of
her colleagues' willingness to change
their practice. " We were asking them
to change when no one was really complaining
about receiving too many [opioids], "
she says. " We were asking them
to take a risk with their patient relationships. "
Opioids are inexpensive, so
patients are unlikely to complain about
being given too many.
Administrative support was also key.
" Dr Alhadeff was behind it, and you
need that support from the top, " Dr
Song says.
Staff on board
" This was an 'all hands on deck' initiative, "
McNelly says, adding that education
was key so everyone who had
contact with patients could talk about
the program and answer questions.
Standardization helped keep people
on message. " The more we can come
to agreement with a standard starting
point, the more effectively people can
educate patients because they can be
specific instead of too generalized, " Dr
Song says.
For example, a patient undergoing
TKA hears the same message in total
joint class, the day of surgery, and postoperatively
from nurses, physical therapists,
pharmacists, and other staff.
That message includes what pain medication
will be ordered and when the
patient should expect to be weaned
off of it. This consistency isn't possible
when different surgeons have different
expectations.
Education also included nonpharmacologic
interventions such as positioning
and distraction.
" The most important thing is open
Continued on page 16
OR Manager | June 2018
15
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OR Manager - June 2018

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