28 Decreasing Discharge Opiates in Burn Patients

Abstract Introduction Burn injury, subsequent wound care and surgery cause significant pain. Management often requires opioids, potentially complicated by concomitant substance abuse and mental health issues. Inconsistent pain management is a common by-product. It results in challenges weaning patients from opioids. We undertook a Quality Improvement project, with the initial goal to decrease discharge opioid doses through improvements to inpatient workflow. Methods Adult, Non-ICU, opioid naïve burn patients treated conservatively or with a single operation were identified. We held focus groups (RNs, MDs, PharmDs, therapists) to identify factors contributing to inconsistent pain management. Based on their input, we generated an electronic survey sent to the entire burn team for anonymous replies. (Survey response rate was 65%.) From the data, we created standardized workflows for RN-Provider communication regarding daily pain management. The second change was a standardized checklist to track whether pain medication evaluation was discussed on morning rounds. Results The focus groups generated three themes: 1) Patients received too much or too little opioids during the inpatient stay, influencing discharge scripts (48.4%); 2) Patients were weaned from pain medications inappropriately due to a lack of communication regarding expected time of discharge 35.5%); 3) Discharge medications were not planned due to a lack of communication regarding expected time of discharge (16.1%). Prior to implementation patients were discharged with an average of 32.70 MMEs/day. (Morphine milligram equivalents) With our formalized communication structure, there was a decrease to 29.7 MME/day after 6 weeks. After implementation of the checklist, there was a further decrease to 27.82 MME/day. This resulted in a net decrease of 5MME/patient/day (or 7.5mg of oxycodone/patient/day at time of discharge). Conclusions The use of fundamental quality improvement methodology led to development of approaches for improved pain management. Through standardizing the communication and workflow for providers and use of a checklist, meaningful decreases in opioids can be obtained. Applicability of Research to Practice The next steps for this project include the development of a templated order set for pain management as well as a formal research project incorporating liposomal bupivacaine into an enhanced recovery after surgery (ERAS) pathway for burn patients.