From 2015 to 2018 key steps were sequentially introduced in stages. Throughout implementation, in the outpatient preoperative setting patients were introduced to and taught an educational module with extensive details of their upcoming care. This included education on their inpatient medication regimen for pain and nausea such that they would be able to appropriately ask for treatment for their symptoms in a timely and effective manner after their surgeries.
In our first implemented stage, on the day of surgery prior to the operation, each patient is given a scopolamine patch. Intraoperatively, anesthesia administered 1g IV acetaminophen. Our first postoperative intervention was to eliminate patient-controlled analgesia (PCA), which required engagement of anesthesia and the pain service as well as our floor nurses. Nursing was engaged via in-service teaching facilitated by charge nurses as well as the surgeons. The next step was implementation of a global reduction in postoperative narcotic utilization, again by re-education of the nurses on the bariatric patient unit and outpatient expectation-setting with our patients. Along with the intraoperative acetaminophen, patients are given scheduled PO acetaminophen, PRN oxycodone, and rescue PRN morphine based on strict pain score guidelines.
Patients were discharged with 10 tabs of 5mg oxycodone.
Our second stage introduced intraoperative transversus abdominal plane (TAP) and rectus sheath blocks using 60 mL 0.25 percent Marcaine with 1 percent epinephrine expanded to 90 mL administered by the surgeon intraoperatively via laparoscopic visualization.8-9 Our patients were discharged with only 5 tabs of 5mg PO oxycodone.
During our third stage we introduced an aggressive standardized anti-nausea protocol, which required engagement of both preoperative and postoperative nursing staff on the proper sequence and timing of ondansatron, haldol, and diphenhydramine. This required implementing a nausea score that would guide the administration of antiemetic. The house staff was briefed on this protocol as to not disrupt the protocol with adjunct anti-emetics. Finally, we held intensive bariatric unit nursing education and expectation-setting on post-operative ambulation and diet, implementing an inpatient checklist with hourly walking and oral intake goals. Additionally, each sequential step required physician-led education of the house officers, as well as changing electronic order sets via help from bariatric office coordinators and the university’s information technology (IT) department.
