Effect of Surgical Team Communication on Adherence to Opioid Discharge Guidelines in Post-Operative Inpatients

OBJECTIVE

Current opioid prescribing guidelines state that post-operative inpatients who do not receive opioids in the 24 hours preceding discharge do not require an opioid prescription on discharge. This study was designed to assess providers' understanding of opioid discharge guidelines and explore drivers of adherence.

DESIGN

An electronic survey was released which assessed knowledge of opioid discharge guidelines and probed surgical team communication. Kruskal-Wallis tests were used to determine differences between provider types. Spearman's correlation evaluated relationships between estimated and observed adherence to guidelines.

SETTING

Yale New-Haven Hospital, (tertiary, university-based) PARTICIPANTS: Surgical residents, advanced practice providers (APPs) and attendings who discharged inpatients with opioids between November 2017-August 2019 RESULTS: The response rate was 36% (90/253), including 36% (49/136) of residents, 23% (13/56) of APPs, and 46% (28/61) of attendings. Seventy eight percent of participants believed patients who met the guideline should "never" or "sometimes" receive opioids on discharge. There was a significant difference between attending preferences and what residents (H²₂ = 202.7, p = 0.0001) and APPs (H²₂ = 24.6, p = 0.003) believed were the attending's preferences. Eleven percent of attendings preferred their patients to "most of the time" or "always" receive opioids on discharge, while 45% of residents and 54% of APPs reported the same. Overall, 57% of attendings reported they "most of the time" or "always" communicated their discharge preferences while 12% of residents (H²₂ = -20.4, p = 0.0003) and 8% of APPs (H²₂ = -23.5, p = 0.003) reported the same. There was no correlation between all groups' estimated adherence to the guidelines and observed adherence (r_s = 0.135, p = 0.206).

CONCLUSIONS

This study demonstrates that surgical residents, APPs, and attendings are aware of the guideline but breakdowns in communication between the attending and the surgical team may contribute to deviation from this guideline. Improving communication may lead to improved adherence to post-operative opioid discharge prescribing guidelines.

Dual adjunct therapy with dexamethasone and dexmedetomidine in transversus abdominis plane blocks reduces postoperative opioid use in colorectal surgery

BACKGROUND

The objective of this study is to determine if the addition of dexmedetomidine to dexamethasone in transversus abdominis plane (TAP) blocks lowers postoperative opioid use following colorectal surgery.

METHODS

Retrospective review of patients undergoing minimally invasive colorectal surgery and perioperative TAP block with either 1) local anesthetic and dexamethasone or 2) local anesthetic, dexamethasone, and dexmedetomidine. Post-operative opioid use was converted to morphine milligram equivalents (MME).

RESULTS

55 patients were identified: 38 (69%) receiving dexamethasone only and 17 (31%) receiving dexamethasone and dexmedetomidine. The dexamethasone and dexmedetomidine group had significantly lower median MME use at 12-h (2 vs. 13 mg), 24-h (4 vs. 28 mg), 36-h (8 vs. 38 mg), and 48-h (17 vs. 53 mg) (all p < 0.05). There was no difference at 72-h.

CONCLUSION

Perioperative TAP blocks with dexamethasone and dexmedetomidine following colorectal surgery results in significantly less postoperative opioid use up to 48 h after surgery.