Quality Improvement Project: Discharge Opioid Prescribing Guideline for the Urologic Surgery Patient Population

Christopher Acebedo, DNP, ACNP-BC, CCRN; Nancy Hung, PharmD; Cameron Heshmati


Urol Nurs. 2020;40(1):23-30. 

In This Article

Guideline Development

Following Institutional Review Board approval, the project commenced by conducting a needs assessment by retrospectively analyzing the Urological Surgery Department's postoperative pain data. The project team categorized the procedures according to invasiveness: a) cystourethroscopies, b) male reconstructive surgeries, c) male implantation surgeries, d) prostate procedures, e) percutaneous renal access procedures, and f) laparoscopic surgeries. The recommended procedure-specific discharge opioid regimen was calculated using the following steps:

  1. The total procedure-specific inpatient opioid consumption was converted to oral morphine milligram equivalent [MME] (see Table 1).

  2. The morphine equivalent daily dose (MEDD) was calculated by dividing the total MME by the patient's length of stay (LOS) (Fujii et al., 2018; Khater et al., 2017; Thiels et al., 2018; Tong et al., 2018; Xu et al., 2015).

  3. Using the MEDD, the 5-day opioid discharge regimen was calculated by incorporating a 25 % daily dose taper beginning on discharge day number one (Gedzior & Kwong, 2017; Scully et al., 2018).

  4. The 5-day opioid regimen was converted to the pharmacy supplied dose of hydrocodone/acetaminophen, oxycodone, or tramadol.

To identify if over-prescription existed and determine the extent of over-prescription, the median procedure-specific discharge opioid quantity (pre-guideline implementation) was compared to the calculated recommended quantity. The retrospective analysis showed a substantial gap between these quantities (see Table 2).

The created guideline utilized the recommended 5-day post-discharge MME. Non-opioid agents were incorporated into the pain regimen based on the procedure performed and patient factors, such as the presence of ureteral stents and baseline renal function. Non-steroidal anti-inflammatory drugs (NSAIDs) were not prescribed for patients with serum creatinine beyond the upper limit of normal. The guideline also encouraged utilization of PDMP before prescribing opioid agents at discharge. If the patient had been prescribed opioids prior to admission, the guideline outlines steps in addressing post-operative pain control after discharge (see Figure 1).

Figure 1.

Urologic Surgery Procedure-Specific Discharge Opioid Prescription Guideline

After guideline dissemination to prescribing providers through the organization's secure electronic mail, the project was implemented for 2 months. Simultaneous with guideline implementation, the project team collected data on post-implementation inpatient opioid requirement and discharge opioid prescription refill rate by reviewing the electronic medical record (EMR). Demographic data on age, gender, mean pain score, and LOS were also collected.