A Quality Improvement Initiative to Reduce Opioid Consumption after Cesarean Birth

Abstract

Background: One in 300 opioid naïve women become addicted to opiates after cesarean birth. After cesarean, women are often prescribed more opiates at discharge than necessary, resulting in increased opportunity for diversion. Purpose: To improve use of comfort strategies and nonopioid medications to decrease the amount of opioids required postoperatively and prescribed at discharge, in women who gave birth via cesarean. Methods: An interdisciplinary workgroup was convened to assess data on opioid use, prescribing practices at discharge, and nurses' use of alternative comfort strategies from January to March 2018. A comfort bundle was designed to include standardized use of preoperative acetaminophen, postoperative comfort education, simethicone, postoperative gum chewing, and abdominal binders. Nurses and healthcare providers were educated on the initiative. Data were reevaluated and compared with preintervention data assessing for improvement and adherence to the bundle components. Results: There was a 61% reduction in morphine milliequivalents given to women after cesarean birth between the first quarter in 2018 and the fourth quarter in 2018. Comparing March with December, 2018 data, adherence to each bundle component improved. The percentage of women receiving less than 20 tabs of oxycodone at discharge increased from 26.3% to 96.7%. Implications for Nursing Practice: Nurses should evaluate comfort options provided after cesarean birth and educate women about use of nonopioid pain relief strategies. A standardized process to address pain and comfort after cesarean birth may decrease exposure to opioids while maintaining comfort.

Effectiveness of organisational interventions on the appropriate use of opioids for non-cancer pain upon hospital discharge: A systematic review

“…Of the 43 articles included in this review, there were three randomised controlled trials (RCTs), [14][15][16] four cohort studies, [17][18][19][20] one case-control study 21 and 35 pre-post intervention/interrupted time series studies. Nineteen studies involved patients discharged from the ED, 15,16,[22][23][24][26][27][28][29]31,34,[39][40][41][42]46,48,50,56 four focused on women recovering from caesarean delivery, 18,25,32,45 eight looked at all surgical patients, 14,20,33,35,42,[52][53][54] and four involved all discharge patients. 38,42,55,56 The remaining studies focused on more specialised surgical procedures including endocrine, orthopaedic and cardiac surgery.…”

A Quality Improvement Initiative to Reduce Postcesarean Opioid Consumption

“…Women who give birth via cesarean rank avoidance of pain during and after surgery as their highest priority (Sutton & Carvalho, 2017). Inadequate postcesarean pain management may impair parental independence and parent-newborn bonding, decrease breast-or chestfeeding and participation in newborn care, and increase risk for postpartum depression (Burgess et al, 2019;Gamez & Habib, 2018).…”

“…ACOG (2018) recommends use of two or more different methods or medications to manage post-op pain, with nonopioid analgesia as first-line therapy, recognizing after cesarean birth, women may experience pain from incisional trauma, inflammation, uterine muscle contractions, and gas (Burgess et al, 2019). This can be successful for postcesarean pain relief, while minimizing use of opioids (ACOG, 2018;Smith et al, 2019).…”

“…A quality improvement project used a standardized "comfort bundle" to improve postoperative comfort while reducing exposure to opioids. It emphasized nonpharmacological interventions for postcesarean pain relief such as splinting abdominal incisions with an abdominal binder, early ambulation and regular voiding, and gum chewing to improve bowel motility (Burgess et al, 2019).…”

“…As some women may experience significant gas pain after cesarean birth, and consequently take opioids (Burgess et al, 2019), the team emphasized first-line use of the antiflatulent simethicone and hot water or mint tea to reduce gas discomfort at the same time as regularly scheduled ibuprofen and acetaminophen. Women were encouraged to chew gum to promote early return of bowel motility and ability to pass gas (Burgess et al).…”