Are You Overprescribing Opioids? Read This
NO PAIN The study's authors provided surgeons with "reasonable" guidelines for opioid prescriptions and also recommended advising patients to manage post-operative pain using non-narcotic painkillers.

Are you overprescribing opioids to help patients manage their post-operative pain? If so, the authors of a new study say making surgeons more aware of the issue may help facilities do their part to curb the nation's deadly opioid epidemic.

Educational interventions helped surgeons at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., decrease opioid prescriptions for certain outpatient procedures by more than half, according to the study, which was published in a recent issue of Annals of Surgery. The authors' goal: to prevent the long-term use of opioids by patients and also to block the diversion of these painkillers to illegal users.

When the authors analyzed the medical records of 642 patients who underwent breast surgery, hernia repairs and cholecystectomy in 2015, they found that opioids were greatly overprescribed, with only 28% of the pills being consumed. In May and June 2016, they proposed "reasonable" guidelines to dramatically cut the number of opioids for these procedures, while still satisfying 80% of patients' analgesic requirements. This included the recommendation that surgeons advise patients to manage their pain with non-narcotic painkillers such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen.

In October 2016, the authors identified all Dartmouth-Hitchcock patients who underwent 5 outpatient operations of interest &mash; partial mastectomy, partial mastectomy with a lymph node biopsy, gallbladder removal and 2 different kinds of hernia repair &mash; between June 1, 2016, and Sept. 30, 2016. A follow-up survey of 224 patients showed that the total number of opioids prescribed dropped from 6,170 before the education initiative to 2,932 afterward — a 53% decline. Only one patient requested a prescription refill.

Also, 85% of the post-education patients used either an NSAID or acetaminophen. The authors suggest more patients will not require opioids if given both acetaminophen and an NSAID. Citing the Cochrane Database of Systematic Reviews, the authors found that 200 mg of ibuprofen and 500 mg of acetaminophen relieved pain in 69% of patients, while 400 mg of ibuprofen and 1,000 mg of acetaminophen relieved pain in 73% of patients.

Bill Donahue

Wisconsin 'Black Box' Law Would Require Cameras in Every OR
EYE IN THE SKY Video cameras installed in ORs would help investigators determine why adverse events happen.

Wisconsin may become the first state in U.S. that requires surgical facilities to have video and audio recording capability. The "black box" proposal would give patients the right to insist that any surgery that involves anesthesia be captured on video.

Wade Ayer intends to work with Wisconsin lawmakers to reintroduce legislation inspired by the death of his sister, Julie Ayer Rubenzer, 38, a Wisconsin native who died of a massive amount of propofol during a breast enhancement surgery performed at a Florida cosmetic surgery center in September 2003. She slipped into a coma and died months later. Oral surgeon Kurt Dangl, MD, the physician who performed the surgery despite not being certified for the procedure, lost his medical license, but was not criminally charged. Dr. Dangl also operated without having an anesthesiologist or nurse present.

In 2015, Mr. Ayer worked with Wisconsin State Representative Christine Sinicki to introduce the "Julie Ayer Rubenzer Bill," which would have required all surgical facilities in the state to place video cameras in ORs to capture time- and date-stamped recordings of procedures. Mr. Ayer says hospital and surgery center lobbyists helped kill the bill before it was brought up for vote in the state assembly.

"There are many wonderful surgeons, nurses and staff members who care about patient safety, but there needs to be more oversight of what they do in the OR," says Mr. Ayer.

The planned renewal of the legislation in Wisconsin is part of a growing interest in using black box technology to protect patients first introduced by Teodor Grantcharov, MD, PhD, who created a platforms that mimics what flight data recorders document during mid-air disasters. Dr. Grantcharov's platform captures video from the surgeon's imaging equipment and from a wall-mounted camera in the OR. It also captures audio recordings of the procedure, the patient's vital signs, data from the anesthesia machine and how many times the room's door is opened during a case.

Dr. Grantcharov believes black box technology can be used to analyze adverse events or assess new procedures, technology and techniques.

"If it's done well and used constructively, the potential to enhance patient safety is significant," says Dr. Grantcharov. "This is not about the surgeon or the surgical team. Everything that's going on in the OR is about the patient."

Daniel Cook

Check out the American College of Surgeons' New SSI Guidelines
BLOOD COUNT Glucose levels above 150 mg/dL may promote SSIs, says the American College of Surgeons.

To reduce SSIs, all patients, not just diabetics, should have their blood glucose levels monitored and controlled during the perioperative process, says the American College of Surgeons, which recently released new and updated SSI-prevention guidance.

Calling the broadened recommendation the most notable change in the new guidelines, the ACS says the SSI risk for all patients can be lowered through "better short-term perioperative glucose control in the 110 to 150 mg/dL range."

The new guidelines also diverge from previous guidelines in recommending that antibiotics typically be discontinued once incisions are closed, instead of sometime over the following 24 hours.

There's no evidence, says the ACS, that antibiotic administration after incision closure decreases SSI risk across a range of procedures, including clean, clean-contaminated, and contaminated wound classes. However, there may be exceptions, it says, as optimal duration of antibiotic therapy remains unknown for total joints, implant-based breast reconstruction, and cardiac procedures.

The guidelines also say that better data is still needed in several areas, including surgical attire (but "conducting high-quality research in this area might not be feasible"), topical and local antibiotics and post-operative wound management.

Jim Burger

InstaPoll: Mandatory Double-Gloving?

Should surgeons be required to double-glove? What about staff? Tell us in this week's InstaPoll.

Most (35%) of the 127 respondents to last week's poll say their surgeons wear a Level 3 gown, but the results were pretty evenly distributed:

My surgeons most often wear a Level ___ gown.

  • 1 20%
  • 2 21%
  • 3 35%
  • 4 24%

Dan O'Connor

News & Notes
  • Anesthesiologist says prescriptions are fake The chief medical officer at Massachusetts Eye and Ear Infirmary testified last week that he never signed or approved several prescriptions that the head of the New England Compounding Center (NECC) submitted to state regulators in response to a 2012 complaint. Testifying in the second-degree murder trial of Barry J. Cadden, anesthesiologist Sunil Eappen, MD, also said that several other prescriptions NECC submitted couldn't have been written by the doctors named on the forms because they wouldn't be using the drug being dispensed. Dr. Eappen was the final prosecution witness in a trial that began nearly 2 months ago. The case could go to the jury this week.
  • Florida ASCs get one step closer to hosting overnight patients Patients may soon be allowed to stay overnight in Florida ambulatory surgical centers, as House Bill 145 last week received the support of the Florida House of Representatives' Health Care Appropriations Subcommittee. If approved, patients would be permitted to stay at a licensed ASC for up to 24 hours, as of July 1. The bill is now with the House's Health & Human Services Committee for review.
  • Fee-for-service vs. salaried doctors Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting, according to a, according to a new study in JAMA Surgery, suggesting that doctors sometimes opt for surgery because they get reimbursed for it.