A North Carolina hospital’s trauma service created a multidisciplinary team that substantially reduced opioid prescriptions for patients by standardizing the approach to pain control, according to a new study.
The Wake Forest Baptist Medical Center’s multidisciplinary team implemented a pain management protocol (PMP) for trauma patients that improved pain management and patient satisfaction while reducing opioid use, the researchers reported at the 2017 annual meeting of the American Association for the Surgery of Trauma (abstract 42).
The key to the success of the team’s efforts was to focus on patients’ pain medication from the moment they enter the hospital’s trauma center all the way through to discharge and beyond, said Jessica L. Gross, MD, the lead author and assistant professor of trauma surgery, Wake Forest University School of Medicine, in Winston-Salem.
The study compared the amount of opioid medication (in morphine milligram equivalents [MME]) prescribed at discharge and in clinic follow-up before and after implementation of the protocol.
The study found that during a two-year period, from Jan. 1, 2015, through Dec. 31, 2016, 498 patients were managed by the team’s advanced practice providers, with 249 patients receiving care before PMP initiation on Dec. 14, 2015, and 249 getting care after the initiation.
The results showed that prior to the PMP, the average MME per person was 2,421, and that after the implementation, there was a significant reduction to 1,242 MME per person (P<_0.0001).
Additionally, the trauma unit where these patients stayed was recognized for the most improved patient satisfaction and the most improved pain control after the PMP began on the trauma service, the researchers said.
Dr. Gross cited figures from the CDC that 91 Americans die every day from an opioid overdose, and nearly half of these deaths involve a prescription opioid. The researchers said sales of prescription opioids had increased fourfold from 1999 through 2014 nationally, but there had not been an overall increase in the amount of pain reported by Americans.
Because of concern about these issues, the hospital’s trauma service developed the PMP with the goals of adequate pain control while using fewer opioids in the post-discharge setting. The trauma service’s existing multidisciplinary team, which already reviewed each patient’s care daily, was enhanced to include members from trauma surgery, orthopedic surgery, psychiatry, acute pain anesthesia, chronic pain anesthesia, pharmacy, addiction counselors and information technology.
Under the new protocol, through increased education and communication, pain medication prescriptions became part of the daily discussion, Dr. Gross said. Prior to the creation of the PMP, pain control on the trauma service was not standardized, and included oxycodone and intravenous opioids as needed. With the PMP, the multidisciplinary trauma team transitioned pain medicine from simply oxycodone to formulations with acetaminophen.
Dr. Gross said the PMP provided a stepwise approach to pain control:
- acetaminophen or ibuprofen for mild pain;
- 5 mg oxycodone/325 mg acetaminophen every six hours as needed for moderate pain and 10 mg oxycodone/650 mg acetaminophen for severe pain (maximum eight tablets/24 hours); and
- tramadol (50-100 mg) every six hours as needed for breakthrough pain
The medications were staggered to allow administration of oral pain medications every three hours as needed, the study authors said. “If pain was not adequately controlled on these short-acting agents, long-acting oral opioids, such as extended-release oxycodone or extended-release morphine, were added and titrated as necessary.”
Asked to comment on the study, Oscar Guillamondegui, MD, MPH, trauma medical director of ACS Level 1 trauma center, Vanderbilt University Medical Center, in Nashville, Tenn., praised the authors for changing the paradigm in pain management. He said the study was “the next generation of enhanced recovery after trauma and pain perception modification.” He said, “Dr. Gross and the multidisciplinary group at Wake Forest have presented compelling evidence to help alleviate this growing tragedy” of opioid deaths.
“The PMP was implemented on a day-to-day basis by our advanced practice providers,” Dr. Gross said. “We performed a review of patients that were then seen in follow-up by these same advanced practice providers.” She said all medical personnel treating trauma patients, including residents and the nursing staff, were also included in her informational and educational efforts to maintain focus on the PMP.
The team also set pain management expectations using an informational handout as part of the patient’s admission packet. “One of our biggest focuses was to set pain medication expectations basically upon admission,” Dr. Gross said. “How you are going to control their pain medication upon admission would have downstream effects on how much is prescribed at day of discharge.”
The emphasis on pain management continued with information on pain medication weaning at discharge. Prior to the PMP, Dr. Gross said, there was very little focus on how much and how often pain medication was provided as well as how the patient would start weaning off the medication without guidance. “Instead of giving everyone a script for a significant amount of pills, we give post-discharge instructions on how to wean.”