Note: The NHRMC system has earned seven 2019 Touchstone Awards from Atrium Health. Each of the initiatives will be profiled in blogs in advance of Atrium Sharing Day on August 7.
According to one 2015 study, Wilmington ranked as the top city in the country for opioid abuse. Wilmington was first in the percentage of individuals who were prescribed opioids (11.6%) and fourth in prescriptions abused (53.8%), driving the need for action and improvement. As a result, New Hanover Regional Medical Center (NHRMC) faced an increase in the number of perinatal patients experiencing substance abuse disorder. Multiple critical patients were admitted with problems linked to substance abuse such as cardiac complications, fungal infections, pre-term labor, fetal demise, and other medical issues related to lack of prenatal care. Additionally, NHRMC was treating a high number of newborns with withdrawal symptoms, and the number of referrals to the Department of Social Services was evident.
The NHRMC Women’s & Children’s Hospital established goals to reduce the number of opioids given to this vulnerable population.
NHRMC formed a committee to focus on how to best manage pain while reducing the use of opioids. The issue is complex as pain after giving birth can disrupt mother-baby bonding and feeding, while the use opioids can lead to concerns over breastfeeding and increase the risk of addiction.
Reducing the use of opioids during and after childbirth can reduce the risk of substance abuse while positively impacting the experience of mom and baby. Further, the risk of subsequent pregnancies with substance abuse and newborn exposure may be reduced significantly.
The team used evidence-based research and employed pain management protocols that eliminated or reduced opioids.
The team, with the guidance of NHRMC Lean Strategies, used the Plan-Do-Study-Act methodology. The strategy for pain reduction included scheduled non-opioid pain relievers, opioids reserved for breakthrough pain, and other measures that did not involve medication. These included abdominal binders for all C-section mothers, along with Dermoplast (numbing spray for pain relief), Tucks pads, ice packs, and early ambulation. The team also agreed to carefully monitor patient satisfaction scores related to pain to ensure the reduction of opioid use was not negatively impacting patient experience.
The quality coordinator worked with NHRMC’s informatics team to build a report that tracks opioid usage after childbirth. The team measured the percentage of patients receiving oral opioids during after childbirth and the average number of tablets per patient per hospital stay. The Act phase included some modifications to the project implementation, mainly order sets and education. As this was a shift in culture and not just a singular change of a care plan, staff buy-in was important. This was accomplished by reinforcing the project implementation and changes through education, huddles, and team meetings.
The analysis compared 4,501 vaginal and cesarean delivery patients from 2017 to 1,354 patients in the post-implementation group (October 2018 – January 2019) to determine if the total doses of oral opioids per hospital stay and opioid prescription rates were reduced as a result of the protocol change.
The average dose of opioids prescribed for cesarean deliveries was reduced by 38%, from 10.2 tablets to 6.3 tablets. Additionally, the change resulted in a 17% reduction in opioid prescriptions to C-section mothers.
Mothers who delivered vaginally experienced an even more significant reduction, from 34% to 14%. And the average number of oral opioids dropped to 0.6 tablets per patient, a 64 percent decrease. While results have conclusively shown that the postpartum opioid reduction protocol has significantly reduced all outcomes measures, data collection and monitoring will continue until December 2019 for continuous process improvement.
Simultaneously, our teams identified an enhanced patient experience specifically concerning communication about pain. Before the change, 78.3% of patients gave NHRMC an excellent rating; after the change, 90.9% of patients reported an excellent score.
The Touchstone Award considered dates through January 2019. The team’s goal, however, was to change the culture, and the results continue to reflect that.
Through May, the number of oral opioid tablets taken by patients who delivered vaginally has decreased to 0.46 per patient. Additionally, the percentage of C-Section mothers who received an oral opioid remained below the goal of 80 percent for April and May of 2019.
- Dr. Jeffrey Stinson, Medical Director, OB Dept., Betty H. Cameron Women’s & Children’s Hospital
- Pamela Vest, DNP, Clinical Education Specialist II
- Robbie Pettit, RN, Labor and Delivery/High Risk Antepartum Manager
- Suzie McCabe, RN, Director, Betty H. Cameron Women’s & Children’s Hospital
- Ann Quinlan-Colwell, PhD, Pain Management Clinical Nurse Specialist, Consultant and Educator
- Hannah Brownlow, RN, Coordinator of OB Quality and Perinatal Bereavement Services
- Michael Mirrielees, Research Statistician