Anesthesia and analgesia · 2026
Impact of a Multidisciplinary Institution-Wide Enhanced Surgical Recovery Framework on Perioperative Opioid Use: A Retrospective Cohort Study of 49,394 Patients.
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Whalen Alison A, Brethauer Stacy A, Halm Kimberly, Brower Kristin I, Pervo Valerie, Abdel-Rasoul Mahmoud, Shah Tejen, Shabsigh Ahmad, Humeidan Michelle L
Аннотация
BACKGROUND: Enhanced surgical recovery (ESR) programs aim to support opioid-sparing care through patient education and multimodal analgesia (MMA) with pharmacologic and regional anesthesia approaches. Few studies have evaluated longitudinal, institution-wide ESR implementation across multiple surgical specialties.
METHODS: We completed a retrospective cohort analysis of patients with eligible surgical procedures 2 years prior to ESR implementation (base) and after implementation (ESR) for ambulatory and inpatient surgeries at a large academic medical center, covering a 10-year span. Patients were grouped by discharge disposition (same day discharge, postoperative day [POD]. 1discharge, and POD ≥ 2 discharge) and by individual protocol. We examined the association between ESR adoption and use of MMA, opioid consumption, and patient-reported pain scores. Oral morphine equivalency (OME) was compared for periprocedural (inpatient OME per day) and post-discharge (total outpatient OME prescribed within 30 days) phases of care. Utilization of multimodal analgesia (MMA use), including specific procedural (regional blocks with local anesthesia or intrathecal morphine) and pharmacologic contributors (administration of at least two periprocedural non-opiate pain medication adjuncts), was also examined, in addition to maximum pain score.
RESULTS: Among 49,394 patients (14,607 Base; 34,787 post-ESR), ESR implementation was associated with meaningful reductions in opioid use for all discharge dispositions, with the most significant decreases observed among patients having surgery associated with longer postoperative stays (median [IQR], POD ≥ 2 discharge: Inpatient OME per day: Base 50.5 [27.3-83.7], ESR 36.3 [20.0-60.5], P < .0001; total outpatient OME: Base 300.0 [150.0-600.0], ESR 150.0 [90.0-225.0], P < .0001)). Utilization of non-opioid analgesics and regional analgesia varied by discharge disposition but was consistently observed to increase for ESR patients, with largest gains shown in the POD ≥ 2 discharge group (MMA use: same day discharge, base 50.1%, ESR 61.5%, P < .0001; POD 1 discharge, base 77.4%, ESR 89.1%, P < .0001; POD ≥2 discharge, base 70.6%, ESR 89.0%, P < .0001). Segmented regression analyses identified downward trends in opiate use beginning during the planning phase of ESR with additional decreases temporally aligned with protocol initiation. The models showed significantly increased MMA in all discharge groups since the start of ESR. Maximum pain scores before and after ESR implementation remained stable.
CONCLUSIONS: System-wide implementation of an ESR framework was associated with lower perioperative opioid use without compromising pain control. Variation in MMA approach across individual protocols and discharge disposition groups highlights the value of multidisciplinary ESR programs in promoting effective and standardized, yet also customized, perioperative pain management practices.
METHODS: We completed a retrospective cohort analysis of patients with eligible surgical procedures 2 years prior to ESR implementation (base) and after implementation (ESR) for ambulatory and inpatient surgeries at a large academic medical center, covering a 10-year span. Patients were grouped by discharge disposition (same day discharge, postoperative day [POD]. 1discharge, and POD ≥ 2 discharge) and by individual protocol. We examined the association between ESR adoption and use of MMA, opioid consumption, and patient-reported pain scores. Oral morphine equivalency (OME) was compared for periprocedural (inpatient OME per day) and post-discharge (total outpatient OME prescribed within 30 days) phases of care. Utilization of multimodal analgesia (MMA use), including specific procedural (regional blocks with local anesthesia or intrathecal morphine) and pharmacologic contributors (administration of at least two periprocedural non-opiate pain medication adjuncts), was also examined, in addition to maximum pain score.
RESULTS: Among 49,394 patients (14,607 Base; 34,787 post-ESR), ESR implementation was associated with meaningful reductions in opioid use for all discharge dispositions, with the most significant decreases observed among patients having surgery associated with longer postoperative stays (median [IQR], POD ≥ 2 discharge: Inpatient OME per day: Base 50.5 [27.3-83.7], ESR 36.3 [20.0-60.5], P < .0001; total outpatient OME: Base 300.0 [150.0-600.0], ESR 150.0 [90.0-225.0], P < .0001)). Utilization of non-opioid analgesics and regional analgesia varied by discharge disposition but was consistently observed to increase for ESR patients, with largest gains shown in the POD ≥ 2 discharge group (MMA use: same day discharge, base 50.1%, ESR 61.5%, P < .0001; POD 1 discharge, base 77.4%, ESR 89.1%, P < .0001; POD ≥2 discharge, base 70.6%, ESR 89.0%, P < .0001). Segmented regression analyses identified downward trends in opiate use beginning during the planning phase of ESR with additional decreases temporally aligned with protocol initiation. The models showed significantly increased MMA in all discharge groups since the start of ESR. Maximum pain scores before and after ESR implementation remained stable.
CONCLUSIONS: System-wide implementation of an ESR framework was associated with lower perioperative opioid use without compromising pain control. Variation in MMA approach across individual protocols and discharge disposition groups highlights the value of multidisciplinary ESR programs in promoting effective and standardized, yet also customized, perioperative pain management practices.