Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol

Abstract

Background: Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis. Materials and methods: A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain. Results: Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED ( p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort ( p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group ( p < 0.001). Overall, there was no difference in postoperative pain related phone calls ( p = 1.0) or emergency room visits ( p = 1.0). Conclusions: An opioid-free discharge protocol can dramatically reduce opioid prescription at discharge following ureteroscopy for urinary calculi without affecting postoperative measures such as phone calls, clinic visits, or subsequent prescriptions.

Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better?

“…23 However, the benefits of a non-opioid post-ureteroscopy analgesic approach are evident, as Sobel et al found that patients who did not receive opioids did not have additional unexpected encounters to the emergency room or clinic, nor extra phone calls for pain. 24,25 And this opioid-free strategy is seen to be feasible in nearly 75% of patients. 24 In addition, robotic-assisted laparoscopic approaches or regional anesthetics and peripheral nerve blocks have been used as tools in other endourologic procedures (such as prostastectomies) to reduce intraoperative and postoperative opioid use.…”

“…26 These non-opioid approaches paired with patient education and counseling on expectations have further facilitated post-operative pain control. 25…”

Practice-Level Variation in Opioid-Free Discharge Following Surgery for T1 Renal Masses: A MUSIC-KIDNEY Analysis

“…10 Opioid-free discharge has been shown to be safe and feasible for a variety of urologic procedures. [11][12][13] However, there is limited knowledge on the safety and feasibility of opioid-free discharge following nephrectomy. The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement (QI) collaborative representing 46 diverse practices and over 260 urologists.…”

No-Opioid Discharge Following Artificial Urinary Sphincter Placement Does Not Significantly Increase Health Care System Burden

“…10,11 Following ureteroscopic procedures, implementation of an opioid-free discharge protocol did not lead to a significant increase in postoperative pain-related phone calls or emergency department (ED) visits. 9…”