Success of Hospital Intervention and State Legislation on Decreasing and Standardizing Postoperative Opioid Prescribing Practices.

BACKGROUND: We sought to evaluate change in postoperative prescription practices in an independent community-based hospital after hospital interventions and a state legislation change. STUDY DESIGN: This is a retrospective review of opioid-naïve adult subjects who underwent 5 common general surgical procedures between 2015 and 2017, including cholecystectomy, appendectomy, minimally invasive inguinal hernia repair, open inguinal hernia repair, and breast lumpectomy. Educational interventions were introduced, new statewide legislation was passed, and 129 subsequent cases were reviewed. RESULTS: Mean ± SD oral morphine equivalent (OME) prescribed for all procedures on retrospective review was 218.8 ± 113.7 (n = 722), cholecystectomy 235.3 ± 133.8 (n = 248), appendectomy 220.2 ± 103.2 (n = 175), open inguinal hernia repair 214.4 ± 97.2 (n = 119), minimally invasive inguinal hernia repair 187.7 ± 87.8 (n = 117), and lumpectomy 212.5 ± 114.5 (n = 63). There was significant variation in OME prescribed by procedure and by surgeon (p = 0.006 and p = 0.008, respectively). Review of post-intervention cases showed a significant reduction in the OME prescribed each year (mean OME 197.6 in 2015 to 2017 vs 72.3 in 2018; p < 0.005), and a 60% to 70% reduction in mean OME per procedure. Post-intervention data also revealed resolution of previously seen variation in prescription practices, and a significant increase in the percentage of patients prescribed multimodal pain therapy (23.5% in 2015 to 2017 to 31.5% in 2018; p < 0.05). CONCLUSIONS: We achieved a 60% to 70% decrease in postoperative opioid prescription at our community hospital for 5 common surgical procedures, and resolution of variation in opioid prescription practices after a hospital-wide intervention and statewide legislation.

Improving adherence to recommended venous thromboembolic prophylaxis in abdominal and pelvic oncologic surgery.

BACKGROUND: We reviewed rates of adherence to the American College of Chest Physicians guidelines for venous thromboembolism prophylaxis in abdominal and pelvic oncologic surgery at our community hospital compared with rates statewide. METHODS: We completed a retrospective review of adult patients undergoing abdominal or pelvic oncologic surgery from January 1, 2015 to December 31, 2016, compared with statewide data from the Michigan Surgical Quality Collaborative during the same period. Educational intervention included creation of hospital guidelines and presentations reviewing American College of Chest Physicians guidelines and hospital adherence rates. A short-term observation of extended-duration venous thromboembolism prophylaxis rates was completed after the intervention. RESULTS: The rates of in-hospital venous thromboembolism prophylaxis (general surgery: 93.7%, n = 106; gynecology: 40.0%, n = 32) were comparable to statewide in-hospital prophylaxis rates (89.6% general surgery, 41.8% gynecology). Five patients (4.5%) were prescribed extended-duration prophylaxis, which was lower than statewide rates (20.3%). In comparison, there was a statistically significant improvement in the rate of extended prophylaxis in the 6 months following intervention to 23.6% (n = 5, P < .0005). CONCLUSION: The rates of extended-duration venous thromboembolism prophylaxis prescription were lower than the state average at our community hospital; however, the short-term evaluation revealed significant improvement after intervention.

Factors Influencing Length of Stay in Cholecystectomy Patients in a Community Hospital.

CONTEXT: Gallstone disease is a major health problem addressed by general surgeons, with approximate incidence of 10-15% in the Western world. With increasing focus in the healthcare literature on cost containment, controlling excess lengths of hospital stay (LOS) in this population is paramount. The aim of this study was to determine the factors that influence LOS in cholecystectomy patients to examine whether results would indicate a possible improvement in perioperative patient care and decrease costs at our community hospital in a suburban setting. METHODS: This is a retrospective review during a two-year period from 1/1/2013-12/31/2014 of patients admitted from the emergency department and undergoing cholecystectomy during the same admission. The study team analyst conducted univariate analysis for significant predictors of length of stay. RESULTS: The authors identified a total analytic sample of 312 subjects who met inclusion criteria. Sample patients admitted to the surgical service had a statistically significant shorter LOS than those patients who were not (3.4 days +/- 1.7 vs 5.6 days +/- 3.0; p value <0.0005). There was also a moderate positive correlation between decreased time to surgery and LOS (Pearson R-value 0.420, p value < 0.0005). Patients admitted to non-surgical services were more likely to have comorbidities like COPD, DM, arrhythmia, CAD, anticoagulation, CHF and previous abdominal surgeries. However, when placing each comorbidity into an analysis of covariance, patients admitted to surgical services still had a significantly shorter LOS (p value < 0.0005). CONCLUSIONS: Admission to a non-surgical service and increased length of time to surgical intervention were associated with prolonged LOS and potentially increased cost in cholecystectomy patients in this study sample. Though patients admitted to non-surgical services are "sicker," they still had prolonged LOS when controlling for comorbidities. Based on these findings, the establishment of an acute care surgery service may help to address this disparity in care.