The effect of guideline implementation on discharge analgesia prescribing (two years on)

Abstract

The provision of appropriate discharge analgesia can be challenging and is often prescribed by some of the most junior members of the medical team. Opioid abuse has been considered a growing public health crisis and physician overprescribing is a major contributor. In 2015 an initial audit of discharge analgesia at the Royal Perth Hospital led to the development of discharge analgesia guidelines. Compliance with these guidelines was assessed by a follow-up audit in 2016, which showed improved practice. This audit assesses discharge analgesia prescribing practices two years following guideline implementation. Dispensing data were obtained for analgesic medication over a three-month period from April to July 2017 and 100 unique patients were chosen using computer generated randomisation. Patients' medical records were assessed against the hospital's Postoperative Inpatients Discharge Analgesia Guidelines. The data collected were then compared with equivalent data from the previous 2015 and 2016 audits. Overall 83.4% of the 170 discharge analgesia prescriptions written were compliant with guidelines. The highest overall compliance rates were achieved for paracetamol (100%, up from 95.9% in 2016), celecoxib (96%, down from 100% in 2016), and oxycodone immediate release (IR) (74%, down from 88.9% in 2016). The quantity of oxycodone IR given on discharge complied with quantity guidelines in only 56% of cases. Overall there has been a significant and sustained improvement in appropriateness of discharge analgesia prescribing since 2015, though the results from 2017 show less compliance than 2016 and that achieving compliance with quantity guidelines is an ongoing challenge. This demonstrates the challenge of obtaining high adherence to guidelines over a longer time period.

Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge

“…Educating junior hospital doctors and hospital pharmacists improved discharge opioid prescribing in terms of reducing the numbers of opioids prescribed, particularly slow release opioids, and improving the frequency of providing de‐prescribing recommendations for GPs. These findings are in line with those of a number of studies that found similar programs to be beneficial 7,15 . The principles of opioid stewardship should therefore be promoted and applied in all Australian hospitals; currently, there are still significant shortcomings in achieving this goal 16 …”

“…The underlying principles of opioid stewardship are the identification of risk factors for misuse, the assessment of analgesia requirements, the provision of appropriate but limited amounts of discharge opioids, and communication with the patient and, importantly, their general practitioner. The overall process should be governed by a hospital opioid discharge policy or guideline 7 …”

Post-surgical opioid stewardship programs across Australia and New Zealand: Current situation and future directions

“…7,8 Whilst the factors relevant in the United States do not necessary apply directly to Australia and New Zealand, suboptimal opioid handling has been demonstrated in our region. 9,10 Local measures are being developed at a national regulatory level, 11 and also at the individual health service or state level. 12, 13 However, current stewardship measures relating to prescribed opioids after surgical care across our region are unknown, and likely highly variable.…”

The processes of hospital discharge and recovery after blunt thoracic injuries: The patient’s perspective

“…For these participants, the reality of self‐management in the early post‐discharge period was different to what they had expected. Providing greater information on safe opioid use and weaning advice could negate the risk of complications associated with unsafe opioid self‐management (Bartels et al., 2016; Feinberg et al., 2018; del Portal et al., 2016; Stewart et al., 2019).…”