Although it is unrealistic to expect the opioid surplus to decrease to zero after implementation of the prescribing guideline, it is quite remarkable that 84% of patients in the post-implementation group reported a surplus of opioid at home despite the 51% to 78% decrease in discharge opioid prescribing. Previous research investigations have reported only a small fraction of patients discharged from acute care settings receive instructions about safe opioid disposal (Bartels et al., 2016). While patient education was beyond the scope of the project, future QI efforts should address patient education on methods of safe opioid disposal given our findings of a considerable opioid surplus after discharge.
The discharge opioid prescribing guideline was meant to be a point of care reference and not intended to be a strictly enforced protocol. The guideline encouraged flexibility and allowed room for adjustment based on clinical judgment of prescribing providers. The prescribing guideline's flexibility may have accounted for the difference in the actual and recommended opioid prescribing noted at the end of the implementation period. It is also noteworthy that at the time of this QI project, PDMP utilization was not yet mandated by the state of California (State of California Department of Justice, n.d.).
One limitation of the project was the absence of pre-implementation data on the post-discharge pain control adequacy. The post-implementation analysis would have been more meaningful if pre-implementation data on pain control adequacy after discharge were available for statistical comparison. The comparison might have offered some insights on the reason behind the high opioid surplus despite the significant decrease in discharge opioid prescribing.
It is important to note that obtaining data on prescription refill rate using state-administered PDMPs has limitations. These programs are not harmonized between states; thus, there is a remote possibility some opioid refills were uncaptured in cases when patients refilled their opioid prescription from a pharmacy in different state jurisdiction. This QI project's results may not apply to other patient populations due to the highly specific characteristics of project participants. The nature of the procedures included in the project resulted in participants with male predominance. Although other specialty surgery practices may be able to mirror the project design in similar QI initiatives, direct guideline application is not possible.
Urol Nurs. 2020;40(1):23-30. © 2020 Society of Urologic Nurses and Associates