title: A prospective time-series quality improvement trial of a standardized analgesia protocol to reduce postoperative pain among neurosurgery patients.
abstract: OBJECTIVE The inclusion of the pain management domain in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey now ties patients' perceptions of pain and analgesia to financial reimbursement for inpatient stays. Therefore, the authors wanted to determine if a quality improvement initiative centered on a standardized analgesia protocol could significantly reduce postoperative pain among neurosurgery patients. METHODS The authors implemented a 10-month, prospective, interrupted time-series trial of a quality improvement initiative. The intervention consisted of a multimodal, interdepartmental, standardized analgesia protocol with process improvements from preadmission to discharge. All neurosurgical-floor patients participated in the quality improvement intervention, with data collected on a systematically randomly sampled subset of 96 patients for detailed analysis. Patient-reported numeric rating scale pain on the first postoperative day (POD) served as the primary outcome. RESULTS Implementation of the analgesia protocol resulted in improved preoperative and postoperative documentation of pain (p < 0.001) and improved use of multimodal analgesia, including use of NSAIDs (p < 0.009) and gabapentin (p < 0.027). This intervention also correlated with a 32% reduction in reported pain on the 1st POD for all neurosurgical patients (mean pain scale scores 4.31 vs 2.94; p = 0.000) and a 43% reduction among spinal surgery patients (mean pain scale scores 5.45 vs 3.10; p = 0.036). After controlling for covariates, implementation of the protocol was a significant predictor of lowered postoperative pain (p = 0.05) on the 1st POD. This reduction in pain correlated with protocol compliance (p = 0.028), and a significant decrease in the monthly number of naloxone doses suggests improved safety (mean dose ± SD 1.5 ± 1.0 vs 0.33 ± 0.5; p = 0.04). Furthermore, a significant and persistent reduction in the pain management component of the HCAHPS scores suggests a durability of results extending beyond the life of the study (72.1% vs 82.0%; p = 0.033). CONCLUSIONS The implementation of a standardized analgesia protocol can significantly reduce postoperative pain among neurosurgical patients while increasing safety. Given the current climate of patient-centered outcomes, this study has broad implications for the continuum of care model proposed in the Affordable Care Act. Clinical trial registration no.: NCT01693588 ( clincaltrials.gov ).
authors.affiliation: Departments of 1 Neurosurgery.|Harvard School of Public Health, Harvard University, Boston, Massachusetts; and.
authors.forename: W Lee
authors.initials: WL
authors.lastname: Titsworth
authors.affiliation: Nursing and Patient Services.
authors.forename: Justine
authors.initials: J
authors.lastname: Abram
authors.affiliation: Nursing and Patient Services.
authors.forename: Peggy
authors.initials: P
authors.lastname: Guin
authors.affiliation: Anesthesiology.
authors.forename: Mary A
authors.initials: MA
authors.lastname: Herman
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Jennifer
authors.initials: J
authors.lastname: West
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Nicolle W
authors.initials: NW
authors.lastname: Davis
authors.affiliation: Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bushwitz
authors.affiliation: Anesthesiology.|Psychiatry.|Neurology, and.|Orthopedic Surgery and Rehabilitation, University of Florida, Gainesville, Florida.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hurley
authors.affiliation: Departments of 1 Neurosurgery.|Anesthesiology.
authors.forename: Christoph N
authors.initials: CN
authors.lastname: Seubert
mesh_terms: D000698:Analgesia / Q000592:standards*; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D065186:Interrupted Time Series Analysis; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D059408:Pain Management / Q000379:methods*; D010149:Postoperative Pain / Q000517:prevention & control*; D011446:Prospective Studies; D058996:Quality Improvement
keywords: BMI = body mass index; EHR = electronic health record; HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems; NRS = numeric rating scale; OME = oral morphine equivalent; PDSA = Plan-Do-Study-Act; POD = postoperative day; PROMIS = Patient Reported Outcomes Measurement Information System; analgesia; postoperative pain; postsurgical pain; quality