Abstract
Summary
Narcotic administration within the inpatient setting is highly variable any may benefit from the implementation of standardized multi-modal pain management protocols.
Introduction
Total joint arthroplasty (TJA) candidates have historically received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid prescribing documentation and implementing narcotic-sparing pain protocols into TJA integrate care pathways (ICP). Despite these efforts, there are few technological platforms designed to curtail excessive inpatient narcotic administration. Here we present an early iteration of an inpatient narcotic administration reporting tool which normalizes patient narcotic consumption as an average daily morphine milligram equivalence (MME) per surgical encounter (MME/day/encounter) among total hip arthroplasty (THA) recipients. This information may help orthopaedic surgeons visualize their individual granular inpatient narcotic prescribing habits individually and compared to other surgeons, while taking into consideration patient and procedure specific variables.
Material and Methods
A query of our electronic data warehouse, was performed for patients undergoing elective primary THA between January 1, 2016 to April 30, 2017. Patient demographics; inpatient and surgical factors; and inpatient narcotic administration were retrieved. Narcotic type, route and dose were converted into total Morphine Milligram Equivalences (MMEs;) on a patient encounter basis (MME/day/encounter). MME/day/encounter were subsequently used determine mean and variance of narcotics prescribed by healthcare providers. A secondary analysis of regional distribution of inpatient narcotic consumption was determined by patient's zip codes.
Results
In total, 4020 primary THAs were included. The institutional average narcotic dose administered for a single surgical encounter was 24.44±52.09 MME/day/encounter. Average surgeon narcotic prescribing ranged from 13.02 to 40.70 MME/day/encounter. Similarly, intra-surgeon variability of narcotic prescribing habits varied from ±21.24 to ±91.94 MME/day/encounter. Further evaluation of patient breakdown did not demonstrate a trend towards increased narcotic administration or variability for surgeons when compared to patient race or insurance type. Moreover, regional distribution of narcotic administration appeared to visually correlate with median household income, whereby less affluent areas demonstrated increased MME/day/encounter.
Discussion
Narcotic administration in the inpatient setting among orthopaedic surgeons at the same academic institution is highly variable as evidenced by the differences in mean MME/day/encounter. Although patient and operative characteristics may vary among THA recipients a more comprehensive understanding of narcotic prescribing patterns may enable healthcare organizations to develop multimodal pain management pathways tailored to the patient's needs.
