Post-Operative Opioid Use with a Modified ERAS Protocol: A before-and-after Comparison

Abstract

<h3>Study Objective</h3> To determine if limited, post-operative changes to patient care in the model of enhanced recovery after surgery are sufficient to decrease post-operative opioid prescriptions. <h3>Design</h3> A pre- and post-implementation study of a modified Enhanced Recovery protocol. <h3>Setting</h3> Post-operative setting in a tertiary academic medical center. <h3>Patients or Participants</h3> Included women undergoing scheduled gynecologic surgery at one hospital system where minimally-invasive procedures are predominant, aged 18-95 years. Procedures included hysterectomy or urogynecologic procedures performed by physicians involved in the study. The cohorts were broken up into a year prior to implementation of the intervention (n=175), and a year after (n=149). Excluded were patients discharged on the same calendar day. <h3>Interventions</h3> A post-operative order set including scheduled non-opioid analgesics and anti-emetics, expedited diet advancement, and standardized order sets for post-operative prescriptions. <h3>Measurements and Main Results</h3> The primary outcome was the amount of opioid prescribed through post-discharge day 14. Opioids were converted today's supply and morphine milligram equivalents (MME). Baseline demographics were similar between the two groups, with exceptions being race (White race 96% in the first cohort vs. 89% in the second, p=0.0369) and tobacco use (19% use in the first cohort vs. 10% in the second, p=0.0288). Percent of patients with baseline chronic opioid use was similar between the two groups (15 vs. 10, p=0.5318). Mean pain scores before and after the intervention were not significantly different. There was a significant decrease in both day's supply (3.23 vs. 2.43, p=0.0311) and MME prescribed following the intervention (47.98 vs. 41.42, p=0.0022). There was a non-significant decrease in cumulative MME through post-discharge day 14 (210.8 vs. 143.2, p=0.3631), as well as total day's supply through post-discharge day 14 (3.45 vs. 3.15, p=0.4604). <h3>Conclusion</h3> Simple changes to the post-operative experience in line with an enhanced recovery protocol are sufficient to decrease post-operative opioid use in a population including patients with baseline chronic opioid use.