An ASC’s laparoscopic cholecystectomy patients were prone to pain and nausea after surgery. There had to be a solution that would achieve both effective pain management and less nausea. A quality improvement team gathered to find that solution.
The resulting pain management intervention won a 2018-2019 Innovations in Quality Improvement Award from the Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement in April.
“It seemed the more medication we gave patients for pain, the more the treatment increased their nausea, and they got sick and hurt worse,” says Lisa Leathers, BSN, RN, administrator and director of nursing at CSA Surgical Center in Columbia, MO.
The quality improvement committee focused on what the scientific literature showed might benefit gallbladder surgery patients. The answer appeared to be IV Tylenol administered preoperatively. But that solution came with logistical problems.
“The problem with IV Tylenol is that it’s very expensive,” Leathers explains. “In a surgery center, when you’re trying to provide patients with a product they can afford to purchase, it’s cost-prohibitive.” An even bigger obstacle was that IV Tylenol was on backorder and difficult to obtain consistently. “IV Tylenol was not a reliable product available for routine purchase,” Leathers laments. “The last thing we wanted to do was to implement something that was available only part of the time.”
One of the quality committee’s surgeons came up with a solution: Just use oral Tylenol. After obtaining buy-in from anesthesia providers, the surgery center began to administer Tylenol one hour before surgery to patients, except those with liver toxicity or other problems prohibiting the use of Tylenol, Leathers explains.
“We talked about the need to make sure patients received Tylenol within a reasonable interval, meaning not eight hours before surgery or five minutes before surgery,” Leathers says. “Patients should be given Tylenol roughly one hour before surgery.”
The intervention has worked. Prior to implementing the Tylenol quality project, about 42% of patients had a length of stay (LOS) related to pain that was longer than two hours. When measured after implementation, patients with a pain-related LOS longer than two hours dropped to 7%. Later, the quality committee re-measured the results to make sure the intervention was still working. They found that no patients on the Tylenol regimen stayed longer than two hours.
Another positive outcome was that narcotic usage sharply declined with the intervention. In the six months before implementing the Tylenol intervention, only 7.6% of postanesthetic care unit (PACU) patients required zero narcotic pain medication. In the six months after implementing the intervention, nearly 22% of PACU patients required zero narcotic pain medication.
Nurses at the surgery center were excited with the intervention within weeks of making the change. “They said, ‘We can’t stop doing this.’ They no longer had to manage patients coming out of surgery in pain and nausea,” Leathers says.
Gallbladder patients’ reported pain scores improved so significantly that the surgery center decided to use the pre-op Tylenol intervention on all general surgery patients that typically experience pain during recovery. They receive two 500 mg tabs of Tylenol one hour before surgery, Leathers says.
AAAHC’s accreditation process involves directing surgery centers to undergo improvement projects, measure their quality, and evaluate it through completing 10-step quality studies, Leathers says.