Improving Safe Opioid Prescribing in the Peri-Operative Period
Abstract
Background
Data were collected in the older adults with neck of femur and distal femur fractures on Orthogeriatric wards, Leeds General Infirmary.
Introduction
Older adults undergoing surgery are particularly vulnerable to opioid-related harm due to age-related changes in pharmacokinetics, multiple morbidity, frailty, and poly pharmacy. Variation and inconsistency of peri-operative opioid relating to dose selection, complications and duration were identified resulting potentially avoidable complications including delirium, constipation, prolonged recovery times.
Data from the first cycle showed 35% risk assessment review and weaning down of opioids, 92% appropriate regular dihydrocodeine, 24% appropriate PRN Oxycodone and 70% of patients-discharges on opioids without duration.
The aim is to improve Safety and Appropriateness of opioid prescribing in patients during peri-operative period according to Surgery and Opioids Best Practice Guidelines by Faculty of Pain Medicine of the Royal College of Anaesthetists over 3-months-period.
Methods
The Quality Improvement was structured with two Plan-Do-Study-Act (PDSA) cycles.
67 patients were reviewed including clinical notes and medication charts for compliance with:
- Appropriate opioid choice and dose
- Review post-operative pain score and weaning down opioids
- Evidence of opioid-related complications
- Duration of opioids on discharge
Interventions included the introduction of adult opioid prescribing checklist poster, targeted teaching for the resident doctors, discussion with pharmacy.
Results
This result in 14% reduction in regular dihydrocodeine use, 3% reduction in modified-release opioids use and 4% increase of the patient-discharges without regular opioids improving opioid stewardship. Discharged opioids supplies were standardised to 7-days-maximum-course improving adherence to national duration guidance. However, 9% increase in PRN Oxycodone reflecting more individualised analgesic selection.
Conclusion(s)
Targeted education, structured discharge processes and pharmacy collaboration significantly improve safer opioid prescribing in older adults. Sustained teaching, electronic prescribing and regular re-audit are essential to embed safe opioid stewardship.
Comments
Access to educational resources
It was very interesting to learn of your improvements following interventions such as targeted teaching and poster display. How did you align the ‘MDT Approach’ with pharmacists? Were there any perceived barriers to accessing all resident doctors for teaching given the rotational nature of the role?
Thank you.
Thank you for your interest…
Thank you for your interest. We discussed with the consultants and ward pharmacists in the wards, and also via email. The pharmacists also involved in the data collection process of the project in the second cycle.
We did of course have challenges in arranging the teaching sessions to the each rotational resident doctors. Therefore, we created a poster for the safe opioid prescription and distributed to every doctors, pharmacists and put on the visible areas of the wards, which significantly improved the project.
Thank you.
Thank you. We collaborated…
Thank you. We collaborated with Pharmacists throughout the process and their insights were very helpful. In terms of teaching for the residents: every 4 months there is a day of T&O induction incl. Orthogeriatrics (OG) as well as weekly teaching incl safer prescribing to help reiterate this. We also use an easily accessible padlet containing relevant info for all team members