Madeleine robinson, dr alan mcshane, dr neil mcdonald Clinical Audit: The effectiveness of analgesia prescribing in the acute postoperative setting Madeleine robinson, dr alan mcshane, dr neil mcdonald

Scope Currently no feedback on efficacy of analgesia orders Are postoperative analgesia orders spot on, or off the mark? Little robust evidence to shape current guidelines1 – are they used? The aim of this audit is to measure the effectiveness of perioperative analgesia orders by reviewing the types of prescription as well as the administration rates among the sample population, thereby concluding if a review of best prescribing practice is required among anaesthesiologists. 1. Gordon DB, de Leon-Casasola OA, Wu CL, Sluka KA, Brennan TJ, Chou R. Research Gaps in Practice Guidelines for Acute Postoperative Pain Management in Adults: Findings From a Review of the Evidence for an American Pain Society Clinical Practice Guideline. J Pain. 2016;17(2):158-66. At present, anaesthesiologists at SVHG have no feedback as to the efficacy of their postoperative analgesia orders. Write order, move onto next patient, Are postoperative analgesia orders spot on, or slightly off the mark? The current guidelines for postoperative analgesia orders are based on very little robust evidence. Due to the fact that acute postoperative pain is a common occurrence among patients, further research has been deemed necessary in order to provide strong evidence to lay the foundations for potential guidelines to shape a prescribing pathway for anesthesiologist stakeholders. The aim of this audit is to measure the effectiveness of perioperative analgesia orders by reviewing the types of prescription as well as the administration rates among the sample population, thereby concluding if a review of best prescribing practice is required among anaesthesiologists.

Methodology Snapshot over a single week at SVPH. All patient MRNs whose postoperative stays were 24h hours or more. 64 patients in total. Drug kardexes and perioperative anaesthesiologist and nursing notes were reviewed for each patient. Data was compiled and analysed using Microsoft Excel. Post-PACU/recovery room analgesia data was used only.

At a glance… 35 open surgeries, 29 endoscopic Most frequently ordered: Paracetamol (98.4%) Least commonly ordered: NSAID (71.9%) Most likely to be prescribed as regular: Paracetamol (47.6%) Least likely to be prescribed as regular: Opioids (19.7%) Best compliance to regular order: Opioids (95.8%) Worst compliance to regular order: NSAID (46.7%) – see chart

A few key points from the data… Out of the full sample, no patient required more analgesia than was originally ordered by the anaesthesiologist. Only one patient received the maximum dose of PRN opioid amongst the sample population, yet no further analgesia was required. A few key points

A few key points from the data… Paracetamol compliance does not affect requirement for opioids NSAIDs: poorest compliance Regular opioids most likely prescribed for orthopaedic procedures Anti-Emetics: prescribed in 100% of sample More than one anti-emetic prescribed in 84.4% of patients Administered in 26.6% of cases; 3.1% required > 1 dose Ondansetron most frequently administered (76.5%) Cyclizine (23.5%) administered more frequently than Prochlorperazine (11.8%) Prescribing regular paracetamol, or indeed administering the maximum daily dose of PRN paracetamol, had no notable effect on the amount of PRN opioid required by patients Analysis of NSAID prescribing portrayed that compliance to regular orders fell behind that of paracetamol and opioids, and requirement of PRN NSAIDs fell short of the maximum daily dose across the majority of the population. Regular opioids were prescribed primarily for orthopaedic procedures. In fact all but one patient who was prescribed both regular paracetamol and regular opioids had undergone orthopaedic surgery.  Anti-emetics were prescribed across the population but used in just over a quarter, mostly one dose only. Ondansetron was the most commonly prescribed, followed by Prochlorperazine, however Cyclizine was the second most administered anti-emetic.

Summing up… SVPH anaesthesiologists performed excellently, and accurately predicted the amount of pain relief required in the acute postoperative patient. Scope for further analysis: Expand the sample size to verify the accuracy of our findings Interview patients at time of discharge to ask their views on analgesia and nausea treatment and/or prevention SVPH anaesthesiologists performed excellently, and accurately predicted the amount of pain relief needed in the postoperative patient. Scope for further analysis: Expand the sample population to ensure universal effectiveness. Interview patients post-discharge about their pain management experience. Ideally this would be done close to the time of discharge in order to ensure that they are able to accurately recall their experiences. - Expand sample size to verify accuracy of our findings - Interview patients at time of discharge to ask their views on the analgesia and nausea treatment and/or prevention.