2025 Southeastern Residency Conference

OPIOID CONSUMPTION: THE IMPACT OF REVISIONS TO AN INPATIENT OPIOID ORDER SET
Eisha Ludtke, Lisa Scott, MaryAnn Birch
HCA Florida West Hospital-Pensacola, FL

Background/Purpose:
Investigate the impact of revisions made to an inpatient opioid order set on overall opioid consumption amongst hospitalized patients and education given to providers regarding the new order sets.

Methodology:
This single-center quasi-experimental study conducted at a 515-bed academic hospital with data collection beginning September 2024 and was continued until March of 2025. Patients were excluded if admitted to the labor and delivery unit, the intensive care unit, palliative care, or to the operating room. Patients with active malignancy, opioid use disorder, opioid reversal prior to admission, opioid tolerance, scheduled opioid use, pain management consults, contraindications or allergies to study drugs, incomplete pain scale documentation by nursing, or non-numerical pain scale orders were also excluded from this study. Cohort 1 consists of patients prescribed both opioids and non-opioids (acetaminophen or ibuprofen) outside the opioid order set. Cohort 2 includes patients prescribed analgesic medications from the revised opioid order set. Cohorts were identified through facility surveillance software reports. The study evaluates the frequency of opioid administration. The primary endpoint of this study evaluated the average MME administered per 24 hours of a patient's stay, while secondary endpoints included the number of times the available MME increased, the percentage of patients with breakthrough pain orders, the number of times an opioid for breakthrough pain was given divided by the inclusion time, the percentage of patients with a scheduled acetaminophen order, and the frequency a non-opioid was given for analgesia divided by inclusion time.

Results:
Baseline demographics between both cohorts, including age, sex, race, BMI, Charleston Comorbidity Index, surgical patient status, prior opioid use, presence of adjunctive pain medication, and length of stay, showed no statistical differences. For the primary endpoint, there were no statistical differences between cohort 1 and cohort 2 regarding the mean MME consumed by hospitalized patients per 24 hours of their stay, the number of times the MME increased throughout the stay, or the number of times an order for breakthrough pain was given, divided by the inclusion time (p-values: 0.9952, 0.5572, and 0.1121, respectively). The implementation of the order set increased the percentage of patients with a breakthrough pain order from 31% to 60%, demonstrating a statistically significant difference between pre- and post-intervention groups (p-value: 0.0031). An increase in the percentage of patients with a scheduled acetaminophen order from 19% to 88% post-intervention was observed (p-value: <0.0001). Lastly, there was a statistically significant increase in the frequency of either acetaminophen or NSAID administration for analgesia, divided by inclusion time, indicating more administrations of non-opioids in the post-intervention group (p-value: 0.0453).

Conclusions:
Despite the addition of a breakthrough pain (BTP) order, there was no statistical difference in average morphine milligram equivalents (MME) per day, although the number of BTP orders increased significantly. This increase was anticipated due to the prechecked BTP order in the new set, which physicians could uncheck if desired. Concerns about increased opioid consumption were unfounded, as BTP orders involved lower potency opioids compared to those for moderate or severe pain. The unchanged MME, combined with significant BTP order results, indicates that standardizing the order set improved overall pain control. While there was no statistical difference in early opioid administration, offering a lower potency BTP opioid may theoretically reduce early administrations due to uncontrolled pain. Scheduling acetaminophen led to better around-the-clock pain control and increased use of opioid-sparing agents. The prechecked scheduled acetaminophen order encouraged non-opioid analgesia. Limitations include a restricted sample size due to the time required for implementation and education, and some providers' preference for custom order sets. A larger sample size and proper use of the new order set could demonstrate lower opioid use and greater utilization of opioid-sparing agents. Further data collection is needed to assess these outcomes. Potential confounders include cognitive issues and drug-seeking behavior, which could affect pain perception and reporting.

Presentation Objective:
Review the impact of a revised analgesic order set on opioid consumption, non-opioid analgesic use, early opioid administrations, dose increases, and morphine equivalent increases, while also exploring how these changes influenced patient care and treatment preferences for moderate to severe pain.

Best Contact for Follow Up: Eisha Ludtke, eisha.ludtke@hcahealthcare.com

Survey of Healthcare Professionals’ Satisfaction and Perceived Impact on Quality of Care with Pharmacy Pain Management Services 
Alice Chang, Danny Basri, Jasmine Jones, Arielle Spurley 
 
 
Background/Purpose:   
Wellstar Kennestone Hospital (KH) initiated an inpatient pain management consult service to provide additional support for patients not managed by palliative care or anesthesia-led acute pain consult services. Previous studies have demonstrated that involvement of a pharmacy pain management service is associated with better pain control and functional improvement. There is limited research that describes healthcare professionals’ (HCP) perceptions on the impact of pharmacy pain management services. We evaluated HCP satisfaction with pharmacy pain management services and characterized their perceived impact on the quality of patient care. 
 
Methods:  
The survey was based on existing literature and prior feedback from HCPs. To enhance clarity, the survey was pretested with a multidisciplinary focus group including members of the KH Pain Assessment and Management Committee and external colleagues. The survey tool was updated based on respondents’ feedback. This study was conducted at Wellstar Kennestone Hospital from April 1, 2024, to July 31, 2024. A voluntary, anonymous survey using Microsoft Forms was distributed to prescribers (physicians and advanced practice providers), pharmacists, and nurses via email. Unit leaders also shared a link to the survey with their nursing staff during shift huddles. The study was approved by the Wellstar IRB, and informed consent was obtained from each respondent at the start of the survey to confirm their willingness to participate. 
 
Results:  
Of the 105 respondents, 86% agreed or strongly agreed the involvement of the pharmacy pain service improved patient care quality. Additional perceived benefits included professional confidence and efficiency: 82% felt increased professional confidence in their ability to provide quality care to their patients and 77% reported the pharmacy pain service allowed them to spend time on other patient care activities. Furthermore, 84% indicated improvement in the quality of communication between the treatment team and the patient and 86% noted the pharmacy pain service improves a patient’s understanding of the pain management plan and goals. Respondents expressed strong endorsement of the pharmacy pain management services in the comments section. However, while many comments suggested expanding the availability and scope of the pain consult service, only 68.6% preferred the pain management pharmacist independently make dose adjustments to currently ordered pain medications. 
 
Conclusion:  
The availability of pharmacy pain services resulted in a high level of satisfaction and perceived benefits amongst prescribers, nurses, and pharmacists. Most respondents reported that communication and patient understanding of their treatment were improved when the pharmacy pain management service was asked to assist in a patient’s care. Respondents supported expansion of pharmacy pain service availability. However, there was less support for pharmacists to be granted the authority to make independent medication adjustments. Further research is needed to explore differences in perceptions regarding advanced pharmacy practice roles to better understand the factors influencing HCPs’ views. 
 

Title: Evaluation of Pharmacist-Led Opioid Stewardship Efforts in a Community Hospital 
Authors: Mia Passarelli, Amanda Herndon, Keith Johnson 
Background/purpose: Acute pain is a primary driver of hospital admissions in the United States, with opioids remaining the most used analgesics for management. However, the rise in opioid prescribing and consumption has significantly contributed to the ongoing opioid crisis. To address these concerns, the Centers for Disease Control and Prevention guidelines highlight the need for responsible opioid prescribing to reduce associated risks. Research on pharmacist-led opioid stewardship programs has shown improvements in both the safe and effective opioid utilization. This study seeks to evaluate the impact of pharmacist-driven opioid stewardship interventions on pain management safety and efficacy within a community hospital setting.   
Methodology: This study received Institutional Review Board exemption. Utilizing a quasi-experimental, retrospective, comparative design, this study evaluated opioid stewardship practices before and after the implementation of a pharmacist-led opioid stewardship protocol. Upon receiving opioid orders, pharmacists performed a comprehensive chart review to assess the need for medication-related interventions in accordance with a locally approved protocol. This review excluded orders for patients with chronic pain, cancer pain, those receiving palliative or hospice care, as well as cases involving acute postoperative pain and ischemic chest pain. This protocol served as a framework for selecting opioid analgesics and adjunctive therapies, ensuring a comprehensive approach to pain management. Pharmacists implemented a range of interventions, including converting intravenous opioids to oral formulations, adding analgesic orders for lower pain scales if omitted, prescribing naloxone for patients receiving more than 50 morphine milligram equivalents (MME) daily, and initiating bowel regimens for patients on scheduled opioid therapy. All pharmacist interventions were documented. The primary outcome was adherence to appropriate pain scale, defined as correspondence between the patient-reported pain scale and the administered medication’s ordered pain scale. Secondary outcomes included the incidence of analgesic order panel utilization, the incidence of oral opioid administration, incidence of methylnaltrexone administered for opioid induced constipation, and naloxone administration rates following the administration of an opioid analgesic.   
Results: A total of 2,878 patients were included, 1,419 in the pre-intervention group and 1,459 in the post-intervention group. For the primary outcome of incidence of adherence to appropriate pain scale, 77.9% of administrations were considered adherent in the pre-intervention group and 89.2% in the post-intervention group p < 0.001). Compared to the pre-intervention group, the incidence of analgesic order panel utilization was higher in the post-intervention group (25.5% vs. 38.2%; p < 0.001). The incidence of naloxone administration did not differ significantly between the pre- and post-intervention groups (0.21% vs. 0.14%; p = 0.63). Incidence of methylnaltrexone administered for opioid induced constipation occurred in 0.41% of the post-intervention group compared to 1.13% of the pre-intervention group (p = 0.02). Of all opioid administrations 60.01% were oral opioids in the post-intervention group compared to 63.27% in the pre-intervention group (p < 0.001).
Conclusions: The pharmacist-led opioid stewardship protocol significantly improved the adherence to appropriate pain scales and the utilization of available order panels. The protocol effectively implemented the initiation of bowel regimens, limiting the requirement for opioid induced constipation treatment.

Ttile: Impact of Liposomal Bupivacaine on Postoperative Opioid Consumption in Thoracic Surgery


Authors: Stefanie Pappas, Jordan Brooke Bibb, John Lazaar


Introduction: With advancements in multimodal and regional anesthesia, non-opioid pain management strategies have become increasingly popular. Local anesthetics can play a key role in minimizing opioid use and related complications; however, their effectiveness is often limited by a short duration of action. At Ascension Saint Thomas Hospital West (ASTHW), elastomeric infusion pumps were commonly utilized in thoracic surgery patients to deliver plain bupivacaine at the surgical site via an indwelling catheter. In June 2022, liposomal bupivacaine, a long acting formulation, was added to hospital formulary and replaced the use of infusion pumps. Research on liposomal bupivacaine has shown benefits such as reduced opioid use, lower pain scores, and shorter hospital stays, although results vary based on surgical site, technique, and intervention. The purpose of this study was to determine the impact on inpatient opioid consumption in thoracic surgery patients when utilizing a liposomal bupivacaine block compared to local infiltration of plain bupivacaine via an elastomeric infusion pump. 


Methods: This is a single-center, retrospective chart review of patients who underwent robotic lobectomy at ASTHW during two time periods: June 2021 through June 2022 and August 2022 through March 2024. Patients were included if they were at least 18 years of age and received either a single administration of liposomal bupivacaine or a continuous administration of plain bupivacaine via an elastomeric infusion pump. Patients with a history of substance use disorder, concurrent use of buprenorphine, methadone, naltrexone, were pregnant, or incarcerated were excluded. The primary outcome was to determine if there was a difference in postoperative morphine milligram equivalent (MME) usage between the two cohorts. Secondary outcomes included postoperative pain scores, hospital length of stay and incidence of post-operative wound infection.


Results: Sixty-two patients were included in the study (plain bupivacaine = 34; liposomal bupivacaine = 24). There was no statistically significant difference in postoperative MME usage between the plain bupivacaine group and liposomal bupivacaine group on day 1 (36.5  vs. 41.3; p = 0.92), day 2 (15 vs. 15; p = 0.84) or day 3 (2.5  vs. 3.25 ; p = 0.91).  The groups were also similar in postoperative pain scores, hospital length of stay, and incidence of wound infection.


Conclusion: 
In our study of patients undergoing robotic lobectomy, single administration of a liposomal bupivacaine block was comparable to local infiltration of plain bupivacaine for postoperative opioid consumption. Further research is needed to confirm any potential benefit; however, it appears that liposomal bupivacaine may be a similar and less invasive alternative for our thoracic surgery patients.

IMPACT OF PATIENT PREFERENCE ON INPATIENT ANALGESIA


Lauren Alaine “Lainey” LaMoyne, MaryAnn Birch, Lisa Scott


HCA Florida West Hospital – Pensacola, FL


Background/Purpose: Non-opioid analgesics are often underutilized as part of a multimodal approach. Additionally, patients may prefer non-opioids for moderate to severe pain, but these agents are often only prescribed for mild pain. In response, several changes were implemented to policy and an analgesic order set, and provider and nursing education was provided. The purpose of this study was to see if a pain management intervention consisting of usage of a standardized order set, new policy, and education will increase the usage of non-opioids administered for pain.


Methodology: This is a single center, quasi-experimental study conducted at a 515-bed academic hospital. Adult acute care inpatients were included if they were ordered a PRN (as needed) opioid pain medication and a non-opioid (acetaminophen or ibuprofen). Patients were identified using facility surveillance software reports. Patients were excluded if they had opioid use disorder, active malignancy, requirements of greater than 60 morphine milliequivalents per day before admission, contraindication or allergy to study drug, intravenous acetaminophen administration, incomplete documentation of pain scale, use of a scheduled opioid, and/or opioid reversal prior to inpatient status. Patients were also excluded if admitted to the labor and delivery unit, the intensive care unit, or palliative care. Cohort 1 consists of patients prescribed both opioids and non-opioids (acetaminophen or ibuprofen) without utilization of the revised opioid order set. Cohort 2 includes patients prescribed medications from the revised opioid order set. The primary outcome is the number of times a non-opioid was given for analgesia. The secondary outcomes are patient-reported pain scores and the number of times a non-opioid was given for moderate to severe pain per patient preference.


Results: One hundred and six patients were included in this study. The primary outcome of number of times a non-opioid was given for analgesia per length of days was 0.71 and 1.27 for cohorts 1 and 2, respectively (p=0.0362). The number of times a non-opioid was given for moderate to severe pain per length of days analyzed was 0.03 in cohort 1 and 0.2 in cohort 2 (p=0.0263). The number of times an opioid was given for moderate to sever pain per length of days analyzed was 1.3 in cohort 1 as compared to 1.3 in cohort 2 (p=0.8630). The mean non-opioid change in pain score was 1.4 in cohort 1 and -2.3 in cohort 2 (p=0.0818). The mean opioid change in pain score was -4.0 for cohort 1 as compared to -3.8 in cohort 2 (p=0.4879).
 
Conclusions: There was a statistically significant increase in the number of times non-opioids were administered for analgesia and a statistically significant increase in scheduled APAP utilization. There was also a statistically significant increase in the number of times opioids were given for breakthrough pain. Opioid administrations for moderate to severe pain did not result in a statistically significant difference, and there was no statistical difference in average daily MME between cohortss. Pain Scores could not be accurately assessed due to small sample size. Future studies with a larger sample size are warranted to further investigate the implications of patient preference.


This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.