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The impact of changing post-cesarean delivery pain order sets on opioid intake in a community-based hospital
Abstract Number: F3C-231
Abstract Type: Original Research
Multimodal analgesia after cesarean delivery (CD) is associated with enhanced recovery after surgery (ERAS) and reduced opioid use. Implementation of ERAS requires standardized protocols for pain management with scheduled non-opioid analgesics and opioids for breakthrough pain only. To achieve this goal, a change in post-CD pain order sets with scheduled non-opioid analgesics and opioids for rescue only was introduced end of 2017. We report here patterns of opioid use before and after the change in order set in a community-based hospital.
Data from consecutive CDs from Jan-April 2017 (BEFORE cohort) was collected without postpartum care providers (nurses, OB residents/Faculty) or patients being aware that a change was about to occur. New order set was launched in Nov 2017 (see below Table) written by the Anesthesia team for pain management from CD until discharge. To allow for nurses to adjust to the change, the AFTER cohort included all CDs from Jan-Sept 2018. Comparisons between the 2 cohorts included the number of non-users of oxycodone, cumulative in-hospital oxycodone dose, and time from CD to 1st oxycodone dose.
After exclusion of CDs under GA ± failed neuraxial anaesthesia, we analyzed 206 CDs BEFORE and 510 CDs AFTER. Demographic data was similar in both cohorts, except for a decrease in the AFTER cohort in the proportion of non-White patients and planned CD (Table). Adherence to the new prescription of scheduled q6h NSAIDs & acetaminophen was 78%. The proportion of non-users of oxycodone increased from 31% to 40% (aOR for non-use of oxycodone=1.853 (95%CI 1.227-2.798). Cumulative oxycodone dose decreased by 25% but with no change in timing of 1st dose (Table).
Our data show that a relatively simple change in order sets may succeed in reducing opioid use (number of users & cumulative in-hospital oxycodone dose); however we were expecting a larger effect of the new order sets. The modest impact of this intervention may be explained by (1) the fact that opioid use was already relatively low before the change in order sets in this community-based hospital, (2) adherence to the prescription of non-opioids was lower than anticipated (78%), (3) there was no structured/formal education for the postpartum nurses surrounding this initiative, and (4) patients did not receive any information about how to manage analgesics after CD. These findings will guide further initiatives in this specific hospital setting.