Department of General Surgery, Swedish Medical Center First Hill, Seattle, WA, USA.
Department of General Surgery, Swedish Medical Center First Hill, 747 Broadway, Heath Tenth Floor, Seattle, WA, 98122-4307, USA.
Surg Endosc. 2022 Aug;36(8):6250-6254. doi: 10.1007/s00464-022-09107-y. Epub 2022 Feb 15.
Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control. With the opioid epidemic and a demonstrated link between excessive narcotic prescriptions paving the way to dependence and addiction, it is more important than ever to decrease the circulation of these medications. We hypothesized that a perioperative, multimodal analgesia strategy coupled with monthly feedback reports comparing hospitals narcotic prescribing habits would decrease, and in some cases eliminate, the use of outpatient narcotics in adults after laparoscopic appendectomy.
A quality improvement project was initiated to provide monthly feedback to surgeons on narcotic prescribing habits after adult laparoscopic appendectomies. A multi-hospital database was created to include adult patients that were diagnosed with acute appendicitis, treated with laparoscopic appendectomy, and discharged within 48 h of surgery. The database provided information regarding the number of narcotic doses prescribed on discharge. Participating hospitals selected a site champion who distributed monthly prescribing reports. A protocol was created and distributed to participating sites that provided a guideline for preoperative and postoperative pain medication management. The intervention period was 10/1/2019-3/31/2020. We utilized the preceding year's data (October 1, 2018-September 30, 2019) as the pre-intervention control group. We also compared results between local and distant sites to see if personal connection to surgeons influenced the results.
A total of 1785 appendectomies were performed during the study period at participating hospitals. The average number of prescribed narcotics decreased from 23.6 doses during the control period to 14.2 during the intervention (p < 0.001). There was no change in the number of total narcotic prescriptions (8.9 vs 7.9%, p = 0.52). Overall, the average number of narcotics prescribed decreased by 40% with similar decrease in average prescribed narcotics for local and distant hospitals, respectively (47.7% vs 42.1%). Average narcotic dose during the first 2 months of intervention at the local hospitals was 9.7 and 11.1 for the last 2 months of intervention (p = 0.69). Average narcotic dose during the first 2 months of intervention at the distant hospitals was 19.5 and 13.4 for the last 2 months of intervention (p = 0.005).
A multimodal pain regimen combined with a monthly narcotic prescription report provided to prescribers decreases the average number of narcotic prescriptions after laparoscopic appendectomy. Local sites demonstrated immediate decrease in narcotic utilization compared to distant sites whose change occurred more gradually.
阑尾炎是住院手术的常见指征。单纯性阑尾炎通常采用手术干预治疗，最常见的是腹腔镜阑尾切除术。与许多手术一样，术后疼痛控制的麻醉药物使用在外科医生之间差异很大。随着阿片类药物的流行以及过度开具阿片类药物处方与依赖和成瘾之间的明显联系，减少这些药物的使用比以往任何时候都更为重要。我们假设围手术期多模式镇痛策略结合每月比较医院麻醉药物处方习惯的反馈报告，将减少（甚至在某些情况下消除）腹腔镜阑尾切除术后成人门诊使用麻醉药物。
启动了一项质量改进项目，每月向腹腔镜阑尾切除术后的外科医生提供麻醉药物处方习惯的反馈。创建了一个多医院数据库，其中包括被诊断为急性阑尾炎、接受腹腔镜阑尾切除术和术后 48 小时内出院的成年患者。该数据库提供了出院时开具的麻醉药物剂量数目的信息。参与医院选择了一名现场冠军，负责分发每月的处方报告。为参与地点制定了一份方案，并分发了一份关于术前和术后疼痛药物管理的指南。干预期为 2019 年 10 月 1 日至 2020 年 3 月 31 日。我们利用前一年的数据（2018 年 10 月 1 日至 2019 年 9 月 30 日）作为干预前的对照组。我们还比较了当地和远程地点的结果，以了解与外科医生的个人联系是否会影响结果。
在研究期间，参与医院共进行了 1785 例阑尾切除术。在对照组中，平均开具的麻醉药物剂量从 23.6 剂减少到干预组的 14.2 剂（p<0.001）。麻醉药物总处方数没有变化（8.9%对 7.9%，p=0.52）。总体而言，平均开具的麻醉药物数量减少了 40%，当地和远程医院的平均开具的麻醉药物数量也分别减少了（47.7%对 42.1%）。在当地医院的干预前 2 个月，平均麻醉药物剂量为 9.7，在干预后的最后 2 个月为 11.1（p=0.69）。在远程医院的干预前 2 个月，平均麻醉药物剂量为 19.5，在干预后的最后 2 个月为 13.4（p=0.005）。
多模式疼痛方案结合每月开具麻醉药物处方报告，可减少腹腔镜阑尾切除术后的平均麻醉药物处方数量。与当地医院相比，远程医院的麻醉药物使用率变化较为缓慢，而当地医院的麻醉药物使用率则立即下降。
