What Was Done?
Global Problem Addressed
The rising use of opioid prescriptions to treat pain has led to significant chronic opioid use and abuse, which has led to significantly increased rates of morbidity and mortality, prompting concern at local, national, and global levels to enact measures to address this epidemic.1
In the last 20 years, prescribers using opioids to treat non-malignant pain has gradually increased. Using opioids routinely for postoperative pain management is common; however, opioid-related adverse events after surgery are costly to the hospital and potentially increase length of stay.2
However, exposure to narcotics in opioid-na'i've patients has potential consequences. In one study recently published in JAMA, opioid-na'i've patients undergoing a surgical procedure exposed to opioids postoperatively can have a significantly increased risk of developing chronic opioid use.3
Bariatric patients are especially at risk for developing opioid addiction, especially since bariatric patients have a higher incidence of chronic pain, depression, and potential for cross addiction after surgery leading to substance abuse. In a recent JAMA study, chronic opioid use after bariatric surgery was found to be 13 percent higher the first year after bariatric surgery and 18 percent higher three years after surgery. The study suggested that chronic pain management in bariatric patients needs a better multimodal regimen, as weight loss in chronic pain patients may not be directly correlated to amount of weight loss.4
Measures to initiate reduction of non-narcotic analgesic practices have been emerging to address this issue. Especially in postoperative patients, pathways have been developed to initiate pain control in preoperative phase.
Enhanced Recovery after Surgery (ERAS) or Enhanced Recovery Pathways (ERPs) after colorectal surgery has been well documented in literature to improve patient outcomes, reduce length of stay, and reduce hospital costs.5 These pathways focus on optimizing pain control, reducing narcotic use, facilitating early ambulation, and gastrointestinal recovery with early ambulation and oral intake.
Although the success and standardization of ERAS in colorectal surgery suggests this would be easily duplicated in other surgical disciplines, implementation of ERAS in bariatric surgery has not been as consistent and is relatively new to the field. Protocols vary widely among bariatric institutions in terms of perioperative and post-operative care. Defining ERAS can mean changing intraoperative measures such as routine placement of drains during surgery, or organizing specifically dedicated nursing floors for bariatric patients. The majority of the literature about ERAS in bariatric surgery (ERABS) focuses on length of stay with minimal complications.6-9 This manuscript addresses the implementation of ERABS at a community hospital and reduction of opioid requirements after bariatric surgery.
Identification of Local Problem
Opioid overdose rates in the Central Valley are found to be higher than California state averages, which prompted local community actions to address this epidemic. As our bariatric patients are followed long term after their operation, the concern within this higher-risk population to minimize opioid exposure and potential chronic opioid use was driving concern to develop an ERABS program to eventually become an opioid-free center after bariatric surgery. Prior to implementation of our ERABS protocol, almost all patients undergoing bariatric surgery required narcotics during their hospital stay and generally prescribed opioids for home after discharge.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
Fresno Heart and Surgical Hospital has been an accredited bariatric center since 2009 with Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accreditation. Approximately 11,500 primary bariatric and revisional surgeries have been performed since 2006 to a majority of the Central Valley of California. Fresno Heart and Surgical Hospital is a relatively small specialty hospital with 57 inpatient and 12 intensive care unit beds and two primary service lines of bariatric and cardiac surgery. The hospital is ranked within the top 5 percent in the nation for patient experience.
At our facility, the length of stay after bariatric surgery is already below national average; therefore, we chose to implement best recommended practices of ERABS at our facility to decrease overall narcotic requirements. Additional motivations were to see if protocol could reduce number of hours in length of stay for higher bed turnover and decrease the percentage of postoperative bariatric patients who stayed greater than one midnight, and decrease already low readmission rates.
ERABS was the first ERAS protocol implemented within the hospital system with the hopes to expand these practices to other service lines and become a larger initiative.
Description of the Quality Improvement Activity
Hospital and Staff Involvement
A critical component to the success of this QI initiative was staff buy-in and participation, which extended all the way from ancillary staff to the chief nursing officer and vice-president of the hospital. Without this global support, implementation of the program could not be successful. Success cannot rely solely on physician changes in protocols and order sets.
ERABS subcommittees were created to including nursing and ancillary staff from the bariatric office, preoperative, postoperative recovery, and medical surgical units, along with operating room staff, bariatric dieticians and psychologists, and pharmacy staff. These subcommittees would meet monthly, and representatives from each subcommittee would meet with physician champions from anesthesia and surgery departments. Review of current literature on ERABS and ERAS was discussed to develop best practices with consensus from staff. Hospital administration was also involved with data analysis to identify potential savings with decreased length of stay, tracking patient satisfaction scores, and analyzing the amount of narcotic use. Global involvement of each department in the project was key to buying into the protocol and staff training of pain management in each department. Generally, the training was spearheaded by nursing supervisors after developing a consensus on how to direct patient expectations and staff efforts to try adjunctive therapies for pain control. Particularly, emphasis of reassurance, ambulation, and other usage of non-narcotic medications to decrease anxiety and distinction of postoperative laparoscopic gas pain versus incisional pain was directed to staff in recovery and night shift staff on the medical surgical unit floors.
After multiple meetings, we implemented a four-week trial period with staff, gradually implementing changes in protocol to work with nursing medication schedule administration and pharmacy formularies. ERABS protocols were gradually developed, as depicted in Figure 1.
Preoperative Phase
During the preoperative phase, patients are seen by the operating surgeon during the preoperative office visit, and a nurse provides specific instructions along with informational handouts emphasizing pain management and initiation of use of gabapentin and acetaminophen the night before and morning of the surgery.10 A clear liquid diet was allowed up to two hours prior to surgery.
In preoperative holding, patients received the combination of medication decided on consensus from anesthesia and surgeons to decrease postoperative nausea and pain. Melatonin was administered to improve sleep and pain control, as seen in bariatric surgery case reports.11
lntraoperative Phase
Prior to initiation of ERABS, injection of bupivacaine and Exparel©, liposomal bupivacaine, was being used routinely for either laparoscopic port site injection or transversus abdominus plane block. Anesthesia limited narcotic administration to less than 150 mcg of IV fentanyl. Otherwise, anesthesia administration protocol was per anesthesia provider.
Goal directed fluid therapy was emphasized. There was no routine administration of indwelling urinary catheters and intraoperative intraabdominal drain placements.
Recovery Phase
Postoperative medications were ordered by anesthesiologists, with emphasis of early mobilization and adjunctive support measures for laparoscopic gas pain versus incisional pain.
Postoperative Phase
Patients were admitted to the medical-surgical unit floor with bariatric dedicated, surgery-trained nursing staff. Standardized protocols included early mobilization, scheduled non-narcotic oral and IV analgesics ordered, and as needed medications for anxiety. Discharge criteria included adequate oral intake of liquids, pain and nausea control, dietician visit, and requirement of hospital/ bariatric educational videos on pain management and postoperative care. Follow up is within one week of surgery at the bariatric surgeon's office, and a pain journal was provided to document daily pain assessment. At time of discharge, a printed card is given to each patient with his or information listed, type of operation, surgeon's name, and an emergency phone number for 24-hour access.
