The rising use of opioid prescriptions to treat pain has led to significant chronic opioid use and abuse. This situation has led to significantly increased morbidity and mortality rates, prompting policymakers at local, national, and global levels to enact measures to address this epidemic.1 In the last 20 years, prescribers using opioids to treat nonmalignant pain have gradually increased. Using opioids routinely for postoperative pain management is common; however, opioid-related adverse events after surgery are costly to the hospital and potentially increase lengths of stay.2
Furthermore, exposure to narcotics in opioid-naïve patients has potential addiction-related consequences. As indicated by one study recently published in the Journal of the American Medical Association (JAMA), opioid-naïve patients who undergo a surgical procedure and are exposed to opioids postoperatively are more susceptible to becoming chronic opioid users.3 Bariatric patients are especially at risk for opioid addiction, given their higher incidence of chronic pain, depression, and potential for cross-addiction after surgery. Another recent JAMA study showed that chronic opioid use after bariatric surgery was 13 percent higher the first year after bariatric surgery and 18 percent higher three years after surgery. The study suggested that chronic pain management in bariatric patients is better addressed with a multimodal regimen.4
Measures to initiate reduction of non-narcotic analgesic practices have been emerging to address this issue. Especially in postoperative patients, pathways have been developed to initiate pain control in the preoperative phase. Enhanced Recovery After Surgery (ERAS) pathways after colorectal surgery have been well documented to improve patient outcomes while reducing length of stay and hospital cost.5 These pathways focus on optimizing pain control, reducing narcotic use, and facilitating early ambulation and gastrointestinal recovery with early ambulation and oral intake.
Although the success and standardization of ERAS in colorectal surgery suggests this outcome would be easily duplicated in other surgical disciplines, implementation of enhanced recovery protocols in bariatric surgery has been less consistent and is relatively new to the field. Protocols vary widely among bariatric institutions in terms of perioperative and postoperative care. Defining ERAS can involve changing intraoperative measures, such as routine placement of drains during an operation, or organizing specifically dedicated nursing floors for bariatric patients. Most of the literature about ERAS in bariatric surgery (ERABS) focuses on length of stay with minimal complications.6-9 This column addresses the implementation of ERABS at a community hospital and reduction of opioid requirements after bariatric surgery.
Identification of local problem
Opioid overdose rates in California’s Central Valley are higher than state averages, prompting local community actions to address this epidemic. As our bariatric patients are followed long term after their operation, the concern to minimize opioid exposure and potential chronic opioid use within this higher risk population was the driving factor in the development of an ERABS program, with the goal of making Fresno Heart and Surgical Hospital an opioid-free center after bariatric surgery. Before implementation of the ERABS protocol, almost all patients undergoing bariatric surgery required narcotics during their hospital stay and generally were prescribed opioids for home care after discharge.
How was the QI activity put in place?
Fresno Heart and Surgical Hospital has been accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) since 2009. Approximately 11,500 primary and revisional bariatric operations have been performed at the hospital since 2006. Fresno Heart and Surgical Hospital is a relatively small specialty hospital with 57 inpatient and 12 intensive care unit beds, with two primary service lines of bariatric and cardiac surgery. The hospital is ranked within the top 5 percent in the U.S. for patient experience.
The length of stay after bariatric surgery is already below the national average; therefore, our goal in implementing ERABS was to decrease overall narcotic requirements. We also wanted to see if the protocol could reduce the number of hours for the postoperative inpatient stay for higher bed turnover, decrease the percentage of postoperative bariatric patients who stayed more than one midnight, and reduce already low readmission rates.
ERABS was the first ERAS protocol implemented within the hospital system with the intent to expand these practices to other service lines and become a larger initiative.
Hospital and staff involvement
A critical component of this quality improvement (QI) initiative was staff buy-in and participation, which extended from ancillary staff to the chief nursing officer and vice-president of the hospital. Without this global support, implementation of the program would be unsuccessful, as it was dependent on more than physician changes in protocols and order sets.
ERABS committee members included hospital administrators, bariatric surgeons, anesthesiologists, and nursing and ancillary staff from the bariatric office, preoperative units, postoperative recovery units, medical-surgical units, operating rooms, bariatric dietetics, psychology, and pharmacy. There were approximately 24 committee members, with three surgeon and anesthesiologist champions, and two administrative co-chairs.
ERABS subcommittees were formed, which met monthly, and representatives from each subcommittee met with physician champions. Review of current literature on ERABS and ERAS were discussed to develop best practices with staff consensus. Hospital administrators also were involved, analyzing data to identify potential savings with decreased length of stay, tracking patient satisfaction scores, and evaluating narcotic use. Systemwide involvement of each department in the project was key to getting buy-in and training staff in each department in pain management. Generally, nursing supervisors spearheaded the training after developing a consensus on how to manage patient expectations and staff efforts to test adjunctive therapies for pain control. Particular emphasis was placed on reassurance, ambulation, and usage of non-narcotic medications to decrease patient anxiety and distinction of postoperative laparoscopic gas pain versus incisional pain was directed to staff in recovery and night shift staff on the medical-surgical unit floors.
After multiple meetings, we implemented a four-week trial, gradually implementing changes in protocol to work with nursing medication schedule administration and pharmacy formularies. ERABS protocol was gradually developed as depicted in Figure 1.
Figure 1. ERABS protocol
Implementation throughout the phases of care
During the preoperative office visit, patients are seen by the operating surgeon and a nurse who provide specific instructions, along with informational handouts emphasizing pain management and initiation of gabapentin and acetaminophen use the night before and the morning of surgery.10 A clear liquid diet is allowed up to two hours before surgery.
In the preoperative holding area, patients received a combination of medications decided by consensus from the anesthesiologist and the operating surgeon to decrease postoperative nausea and pain. Melatonin was administered to improve sleep and pain control.11
Before the initiation of ERABS, injection of bupivacaine and Exparel (liposomal bupivacaine) was used routinely intraoperatively for either laparoscopic port site injection or transversus abdominis plane block. Anesthesia limited narcotic administration to less than 150 mcg of intravenous (IV) fentanyl. Otherwise, anesthesia administration protocol was based on the anesthesia provider’s judgment.
Goal-directed fluid therapy was emphasized. Indwelling urinary catheters and intraoperative intra-abdominal drain placements were not routinely used.
Anesthesiologists ordered post-anesthesia care unit (PACU) medications, with emphasis of early mobilization and adjunctive support measures for laparoscopic gas pain versus incisional pain during recovery.
Postoperatively, patients were admitted to the medical-surgical unit floor with bariatric-dedicated, surgery-trained nursing staff. Standardized protocols included early mobilization, scheduled non-narcotic oral and IV analgesics ordered, as well as medications for anxiety. Discharge criteria included adequate oral intake of liquids, pain and nausea control, dietician visits, and provision of hospital/bariatric educational videos on pain management and postoperative care. Follow-up was within one week of surgery at the bariatric surgeon’s office, and a journal was provided to document daily pain assessment. At the time of discharge, the patient received a printed card listing personal information, type of operation, surgeon’s name, and an emergency phone number for 24-hour access.
The test period began in February 2017, and the ERABS protocol was fully implemented in July 2017. No additional costs were incurred.
We conducted a retrospective review of patients who underwent laparoscopic primary bariatric surgeries of either Roux-en-Y gastric bypass or sleeve gastrectomy June 2016 to October 2017. Three groups were examined: a control or pre-Exparel group defined as without any protocol changes; an Exparel group without ERABS but with the addition of intraoperative injection of Exparel; and the ERABS/Exparel group composed of patients in which the ERABS protocol was fully applied. Postoperative course, narcotic use, and 30-day outcome rates were analyzed using a combination of t-test and Mann-Whitney U.
A total of 1,314 patients were studied. Table 1 illustrates the addition of Exparel without ERABS. Narcotic requirements were measured as morphine equivalent units (MEU). Overall MEU decreased, and improved patient experience and pain level scores were reported. With the addition of ERABS, a significantly greater response was found even when compared to the control/pre-Exparel group and even the Exparel alone group, with a 60 percent reduction in narcotic use in the hospital and fewer patients (10 percent versus 0 percent of patients in control group, p < 0.05) requiring any narcotics postoperatively.
Table 1. Addition of Exparel without ERABS
Table 2 describes changes in pain scores of 1–10, length of stay, and total narcotic requirements. Table 3 shows decreased readmission rates and reoperation rates with 30-day outcomes.
Table 2. Changes in pain scores, length of stay, and total narcotic requirements
Table 3. Decreased readmission rates and reoperation rates within 30-day outcomes
Barriers encountered in the QI activity included getting patients to agree to go narcotic-free and addressing unrealistic pain expectations, as some patients wanted an unrealistic pain score of 0 after surgery.
The initial cost of using Exparel was a concern for the hospital administration. However, early results regarding outcomes, length of stay, and reduction after the use of narcotic medication with discontinuation of patient-controlled analgesics resulted in benefits outweighing the cost of drug administration. In addition, we are now conducting a randomized control trial to explore the use of Exparel versus bupivacaine intraoperative injection to see if there is a difference in postoperative pain control under ERABS.
Other revisions included working with nursing and pharmacy staff to ensure medications were given in a timely fashion, and that medications were stocked in automated medication dispensing systems for ease of nursing access.
At this time, cost savings are minimal for the hospital as the slightly decreased length of stay and fewer readmissions/reoperations have yet to offset the use of Exparel. An additional benefit was the savings from discontinuing routine use of patient-controlled analgesia pumps.
Tips for others
Buy-in from not just the physicians and nursing staff, but also from hospital administration, is paramount. Changes in physician order sets and following a set protocol may not exact similar changes unless systemwide support and champions from hospital departments are secured. An open dialogue during monthly meetings with nursing, pharmacy staff, and physician champions allows a smooth transition to ERABS. The support from the administration was key to empowering the nursing staff and pharmacists to go forward with ERABS with appropriate allocation of the pharmacy budget for Exparel use. Hospital analysts are necessary to objectively show reduction in narcotic usage, increased patient satisfaction scores, decreased length of stay, and readmission rates, therefore increasing productivity from increased bed availability to allow more operations to be performed. With the implementation and success of ERABS, Fresno Heart and Surgical Hospital is now able to further explore implementation of similar ERAS protocols in other service lines.
- Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686-691.
- Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug events in surgical hospitalizations: Impact on costs and length of stay. Ann Pharmacother. 2007;41(3):400-406.
- Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.
- Raebel MA, Newcomer SR, Reifler LM, et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013;310(13):1369-1376.
- Jung AD, Dhar VK, Hoehn RS, et al. Enhanced recovery after colorectal surgery: Can we afford not to use it? J Am Coll Surg. 2018;226(4):586-593.
- Awad S, Carter S, Purkayastha S, et al. Enhanced recovery after bariatric surgery (ERABS): Clinical outcomes from a tertiary referral bariatric centre. Obes Surg. 2014;24(5):753-758.
- Blanchet MC, Gignoux B, Matussiere Y, et al. Experience with an enhanced recovery after surgery (ERAS) program for bariatric surgery: Comparison of MGB and LSG in 374 patients. Obes Surg. 2017;27(7):1896-1900.
- Singh PM, Panwar R, Borle A, et al. Efficiency and safety effects of applying ERAS protocols to bariatric surgery: A systematic review with meta-analysis and trial sequential analysis of evidence. Obes Surg. 2017;27(2):489-501.
- Sinha A, Jayaraman L, Punhani D, Chowbey P. Enhanced recovery after bariatric surgery in the severely obese, morbidly obese, super-morbidly obese and super-super morbidly obese using evidence-based clinical pathways: A comparative study. Obes Surg. 2017;27(3):560-568.
- Siddiqui NT, Yousefzadeh A, Yousuf M, Kumar D, Choudhry FK, Friedman Z. The effect of gabapentin on delayed discharge from the postanesthesia care unit: A retrospective analysis. Pain Pract. 2018;18(1):18-22.
- Ivry M, Goitein D, Welly W, Berkenstadt H. Melatonin premedication improves quality of recovery following bariatric surgery—a double blind placebo controlled prospective study. Surg Obes Relat Dis. 2017;13(3):502-506.