You Can Do the Impossible When You Try
By Lynn D. Martin, MD, MBA
Like a proud father, I have decided it is time to brag about my kids or actually, my partners in the Bellevue Surgery Center (BSC) at Seattle Children’s. For the last ten years, my team and I have worked very hard to develop and maintain a culture that pursues perfection with the use of Plan-Do-Study-Act (PDSA) continuous improvement methods, democratized data, and consensus decision-making.
Using these tools and a mindset that embraces change as the only means to get better, this team was able to reach outcomes I personally thought were previously unachievable (See Franz AM, Martin LD, Liston DE, et. at. In Pursuit of an Opioid-free Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. April 10, 2020 doi: 10.1213/ANE.0000000000004774). Let me describe how this was accomplished.
Anesthesiologists and nurse anesthetists follow standardized anesthesia care protocols at BSC. This consistent practice leads to reliable and predictable outcomes in care with few complications and low costs. The team regularly reviews the outcomes of our protocols and comes up with ideas to add value (i.e., similar or better quality and safety outcomes with lower costs). One central tenet of our protocols from the beginning has been the use of multimodal analgesia, including regional anesthesia, to minimize post-operative pain and opioid use. Despite these efforts, most patients received an opioid as part of their balanced anesthetic (84% in our baseline measurement).
Our established anesthetic protocol for tonsillectomy included IV acetaminophen, a higher cost, non-opioid analgesic. With the goal of increasing the value of our highest volume procedure at BSC, the team opted to conduct a QI trial replacing IV acetaminophen with dexmedetomidine, a highly selective α-2 agonist that decreases anesthetic requirements, reduces emergence delirium, and provides analgesia with minimal risk of respiratory depression (Mahmoud M, Mason KP: Dexmedetomidine: Review, Update, and Future Considerations of Pediatric Perioperative and Periprocedural Applications and Limitations. Br J Anaesth. 2015;115:171-82).
Ultimately, through a series of PDSA cycles, the team was able to not only replace acetaminophen with dexmedetomidine, but also replace the administered opioid (morphine) with IV ketorolac. This new opioid-free protocol resulted in no change in mean maximum pain scores in recovery; a reduction in post-operative analgesia rescue (25% to 20%); and a reduction in postoperative nausea and vomiting treatment (3.6% to 0.5%) without any change in total anesthesia or recovery time (Franz AM, Dahl JP, Huang H, et al: The development of an Opioid Sparing Anesthesia Protocol for Pediatric Ambulatory Tonsillectomy and Adenotonsillectomy Surgery – a Quality Improvement Project. Pediatr Anesth. 2019;29:682-9).
Around the same time, two new factors in the environment came in play. First, was the growing awareness of the magnitude of the national opioid epidemic and the potential detrimental contributions of the healthcare system via perioperative opioid exposure. Second was a new national shortage of IV opioids with concerted efforts to conserve limited supplies.
These two new factors, along with our initial success with an opioid-free tonsillectomy anesthetic protocol, led the team to trial in rapid succession over the next six months duplication of the opioid-free anesthesia protocol for the 12 most common procedures at BSC. Finding very similar outcomes, the team made the leap of faith and eliminated opioids from all of our remaining anesthesia protocols. What did we see 12 months later?
- Reduction of opioid vial use from 84% to 8% of patients
- Reduction of post-operative analgesia rescue from 11% to 6% of patients
- No change in mean maximum recovery pain scores (2.45 and 2.66)
- Reduction in PONV treatment (1.4% to 0.9% of patients)
- No change in total anesthesia time (60.9 versus 58.9 minutes)
- No change in total recovery time (62.4 versus 63.5 minutes)
- Annual analgesia cost saving of $73,000 (approximately $19 per patient)
Using our cultural norm of continuously improving our standard practice with easily accessible and actionable data and consensus decision making, this team has achieved something that 12 months ago I would have thought impossible – the development of an opioid-free anesthetic for all of our approved procedures. This was the first critical step in creating an opioid-free surgery center. I now believe in that audacious goal.
What will be required to achieve this ambitious target? First, we need to eliminate opioids during surgery and in recovery. Next, we must work with our surgical colleagues to reduce and then eliminate post-discharge opioid use for analgesia. Finally, we need to expand and modify as needed these practices for more complex (non-ambulatory) surgeries in both children and adults.
Rather than fearing the change, we all should be eagerly pursuing this impossible dream. Will you join us?
I want to congratulate my collaborators on this project (Amber Franz, MD; David Liston, MD, MPH; Gregory Latham, MD; Michael Richards, MD, MRCP and Daniel Low, MD). I also would like to express my gratitude and appreciation to all of the surgeons, anesthesiologists, nurses and technicians at the Bellevue Surgery Center for their assistance in making the future better for the patients and families we serve.