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Quality or Safety Problem

Over-prescription of opioids in the post-operative setting contributing to the growing opioid epidemic in the United States. 6-8% of opioid-naïve patients develop long-term dependence and unused opioids risk dispersion into the community.

Background

Opioids are not required by the majority of patients after endourologic surgery- specifically ureteroscopy with ureteral stent placement. While stent pain is a significant morbidity, NSAID’s and other adjunct medications manage these symptoms as well as opioids and avoid the above risks.

Project Objectives

1. The aim of this study was to construct a clinical pathway for the effective and efficient management of adult To decrease opioid prescribing after ureteroscopy
2. To evaluate patient outcomes (calls to the office for concerning symptoms, need for additional pain medication prescriptions, visits to the Emergency Department) and determine whether these outcomes were impacted by receiving an opioid prescription.

Intervention

Pathway developed consisting of patient education (surgery-specific and symptom expectations), intraoperative NSAID use, and discharge with diclofenac and adjunct medications and no opioids. Education provided to the urology faculty and the resident staff. Resident education was key as post-operative disposition and prescriptions are usually under resident control. Information provided to additional stakeholders including anesthesia staff and post-operative recovery room nursing.

Measures of Success

1. Telephone calls to the Urology clinic for concerning postoperative symptoms
2. Additional prescriptions received (opioid or non-opioid) for pain management after discharge
3. Emergency Department visits for pain/symptoms in the postoperative setting

Mainly descriptive statistics were used to look at general trends as this was not a randomized controlled study.

Outcomes

Initial outcomes were the safe and successful discharge of 75% of patients without opioids. Updated data after 3 years of continued practice is up to a 90% success rate. There were no increases in health resource utilization (increased phone calls to clinic, visits to the ER, or prescription refills).

Potential Impact and Scalability

Decreased opioid prescriptions in the post-operative setting with no compromise to patient safety or satisfaction. Algorithm development to standardize practice patterns and implementation through stakeholder education can be used for many quality improvement problems.

Sustaining the Changes

It has become standard practice to discharge patients undergoing ureteroscopy and ureteral stent placement without opioids now for over 3 years.

Key Summary

1. The majority of patients (>90%) do well in terms of postoperative pain management when opioids are not prescribed after ureteroscopy.
2. There were minimal roadblocks to changing our prescribing practices and these changes have endured over several years to become standard practice.
3. Provider and patient education are keys to the successful implementation of limiting postoperative opioid

Project Lead Contact Information

Kevan Sternberg, MD
University of Vermont Urology
Kevan.sternberg@uvmhealth.org