Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic

Abstract

Purpose Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage. Methods A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions. Results Thirty-seven patients met the highly selective eligibility criteria for “healthy patient, healthy anastomosis.” SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores. Conclusions In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.

Same day discharge following elective, minimally invasive, colorectal surgery

“…In May of 2020, after validation of the I-FEED scoring system to accurately predict sustained GI recovery, McLemore and colleagues initiated a quality improvement pilot program to implement and assess the safety and feasibility of SDD in healthy patients undergoing elective colorectal surgery as an alternative to postoperative hospitalization at Kaiser Permanente, Los Angeles Medical Center (KP LAMC) [ 48 ]. The KP LAMC multi-disciplinary ERP team met bi-monthly to review upcoming SDD cases, and the outcomes following prior SDD cases.…”

“…Data was obtained during the daily telephone remote visits on POD 1–7. Despite initially high pain scores on POD 1 and 2, patient opioid use was low with a mean number of five tablets used per patient during the entire postoperative recovery [ 48 ] (Color figure onlne) …”

Ambulatory Robotic Colectomy: Factors Affecting and Affected by Postoperative Opioid Use

“…3). SDD is a relatively new and still poorly studied approach to major colectomy surgery, and while opioid use and SDD have been investigated previously by Tran-McCaslin et al 14 with similarly low postoperative opioid usage, 15 here we present the largest sample size to date examining this question. The observed modest opioid usage despite early discharge may be at least partially enabled by the robotic surgery platform, whose precision reduces surgical tissue trauma and allows lower pneumoperitoneum insufflation pressures.…”

Preoperative Immunocyte-Derived Ratios Predict Postoperative Recovery of Gastrointestinal Motility after Colorectal Cancer Surgery

“…A larger sample size or prospectively acquired database may offer improved results. Another limitation concerns the insufficient clinical validation of the I-FEED score, considering its relatively recent introduction [34,36,37]. Although this score is an easy-to-use instrument with a potentially reasonable predictive power, there are other scoring algorithms, such as the one suggested by Van Bree et al, based on several clinical parameters and supported by the scintigraphic assessment of bowel transit, which may better predict the resolution of gastrointestinal motility [38].…”