Implementation of Intravenous Lidocaine Infusion Order Set in Military Medical-Surgical Unit

Abstract

Problem/Purpose: The current opioid epidemic is not only a problem in the outpatient setting but also an inpatient problem that has brought great concerns to hospitals. Despite new medications and minimal invasive surgeries, the use of opioids continues to be one of the basic modalities for pain management. Opioids can provoke side effects including nausea and vomiting, ileus, and post-administration cognition dysfunction, leading to longer hospital stays, increase risk of complications and negative quality of life, function and recovery. The host organization noted an increased use of opioid medications among medical-surgical patients with daily ranges between 120-150 morphine milligram equivalents (MME) per patient over six months. The purpose of this quality initiative is to determine if the use of a standardized electronic intravenous lidocaine infusion (IVLI) order set would be associated with a lower amount of opioid use, increase order set compliance, and consequently a decreased-on length of stay without impacting acute and chronic pain management. Methods: A pre- and post-implementation study was conducted on adult acute and chronic pain patients consulted by the Acute Pain Service department on a medical-surgical unit at a large military medical center. The electronic health record IVLI order set included baseline electrocardiograms (ECG), baseline laboratory studies, medication verification by nurses, medication dosages for various conditions, supportive care for adverse events, and monitoring of vital signs, pain scores and sedation scores. The primary endpoint was the difference in opioid use between the post-implementation of IVLI order set patients and the pre-implementation opioid group. Secondary endpoints included hospital LOS and compliance rate of the order set. Results: The six patients included in the pre-implementation phase were patients consulted on who received opioid patient-controlled analgesia (PCA) for various conditions. Double was completed 82% of the cases (28 times out of 34 possible opportunities). Sedation scores were documented only on 3% of the cases (3 out of 94 possible opportunities). Baseline vital signs were documented 100% but only 17% at the expected times post-initiation (1 out of 6 patients). There was a decrease of pain scores at 4-, 8-, 12-, and 24-hour after initiation with the greatest decrease at 8 hours post initiation (83% decrease). The average length of stay for patient on opioids was 12.9 days. Conclusions: Electronic order sets have the potential to decrease medication errors, increase application of evidence-based care, and decrease nursing workflow. There was a low compliance on the documentation of ordered vital signs (post-initiation), and sedation scores on the opioid PCA order sets potentially increasing the length of stay and consequently hospital costs.