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Impact of a 2-stage intervention to reduce oxycodone consumption after cesarean delivery
Abstract Number: F3C-241
Abstract Type: Original Research
Multimodal post-operative analgesia has been advocated for years to reduce opioid consumption, but opioid-sparing post-operative protocols have not been widely implemented. In addition, adherence to analgesia protocols is often hindered by insufficient nursing education about what the goals are, and scarce patient information on how to take pain medications. To address these limitations, we decided a 2-stage intervention with sustained provider education followed by a change in our institutions’ post-cesarean order sets introducing the concept of stepwise multimodal opioid-sparing analgesia. We present here the effect of this 2-stage intervention on adherence to analgesia protocols and oxycodone consumption.
During the 1st stage (July-Oct 2017), all OB providers (nurses, NPs, OB residents/Faculty) were educated about the concept of stepwise multimodal opioid-sparing analgesia. The 2nd stage (Nov 2017) was a change in the computerized order sets for post-CD pain management such as 1) ibuprofen 600mg with acetaminophen 975mg to be given together every 6h regardless of pain scores, and 2) oxycodone to be given only for moderate/severe pain (footnote in Table). Data were collected for all CDs between Jan-April 2017 (BEFORE) and Jan-Sept 2018 (AFTER). Primary outcome was adherence to new order set. Secondary outcomes were proportion of women not using any oxycodone, total cumulative oxycodone dose and time to 1st oxycodone dose.
After exclusion of CDs under GA, there were 491 CDs BEFORE and 1125 CDs AFTER. There were several demographic and obstetrical differences between the 2 epochs, notably a reduction in primary and planned CD (Table). Adherence to the new prescription of scheduled q6h NSAIDs & acetaminophen was 82.8%. The proportion of women not using oxycodone increased from 9.6% to 29.8%, cumulative median oxycodone dose decreased from 60mg to 25mg, and time to 1st oxycodone dose increased by 4h (Table).
The impact of our 2-step intervention promoting a stepwise multimodal opioid-sparing approach exceeded expectations and resulted in a profound culture change. Adherence to the new orders was over 80% and allowed a 3-fold increase in the number of women not taking any oxycodone post-cesarean and an almost 3-fold decrease in cumulative oxycodone dose. Further efforts to achieve 100% adherence to this protocol will include additional nursing education and focused patient information to enable shared-decision making.