A Pain Control Optimization Pathway to Reduce Acute Postoperative Pain and Opioid Consumption Postoperatively: An Approach to Battling the Opioid Epidemic

Practice Problem: Healthcare providers worldwide are working to battle the opioid epidemic and reduce opioid-related harm to patients. Utilizing evidence-based acute pain management methods to reduce opioid consumption is critical to combat the problem. PICOT: The PICOT question that guided this project was: In opioid-naïve adult patients undergoing general anesthesia for out-patient, minimally invasive abdominal wall hernia surgery, how does the implementation of an evidence-based, preventative Pain Control Optimization Pathway (POP) using a multimodal, opioid-sparing acute pain management technique and standardized procedure-specific opioid prescribing, compared to standard treatment, affect postoperative pain scores and opioid consumption, upon discharge from the recovery room and 72 hours postoperative? Evidence: Evidence supported utilizing a multimodal, opioid-sparing acute pain management technique, patient counseling, and opioid prescribing guidelines to improve outcomes among opioid-naïve patients undergoing abdominal surgeries. Intervention: In this preand post-intervention evaluation, N = 28 patients received the POP care process during the perioperative period. Outcome: Results showed the mean pain score at discharge from the recovery room decreased from 4.8 to 2.82 on the 10-point Numeric Rating Scale post-intervention (p< 0.001). Also, provider compliance with prescribing a procedure-specific opioid prescription increased from 73% to 100%, thus reducing opioid exposure and access. Conclusion: This project provided evidence that utilization of the innovative POP care process provided optimal pain control and decreased opioid consumption, consequently reducing the risk of new persistent opioid use. PAIN CONTROL OPTIMIZATION PATHWAY 4 A Pain Control Optimization Pathway to Reduce Acute Postoperative Pain and Opioid Consumption Postoperatively: An Approach to Battling the Opioid Epidemic The purpose of this DNP scholarly paper is to discuss an evidence-based change project that implemented an innovative Pain Control Optimization Pathway (POP) developed by Michigan Opioid Prescribing Engagement Network (OPEN) for reducing acute postoperative pain and opioid consumption as an effort to fight the opioid epidemic. The opioid epidemic is complex and multifactorial; therefore, managing acute perioperative pain becomes imperative as acute pain experiences are often the gateway for new persistent opioid use (OPEN, 2020). A strong body of scientific evidence supported using opioid-sparing acute pain management techniques, patient counseling, and procedure-specific opioid prescribing guidelines to improve outcomes for opioid-naïve patients undergoing out-patient, minimally invasive abdominal wall hernia surgery. Kotter’s 8-Step Change Model guided implementation of the preventative POP care process, which focused on preoperative and postoperative patient education and engagement, functional recovery goals, and opioid prescribing recommendations. Intraoperative anesthesia and postoperative care used a multimodal, opioid-sparing protocol as first-line treatment for acute pain, thus utilizing evidence-based techniques from Enhanced Recovery after Surgery, or ERAS (OPEN, 2020). The intervention provided uncompromising pain management, reduced opioid consumption, and showed patient satisfaction. This interdisciplinary approach to transforming perioperative surgical care has the potential to aid in curbing the opioid epidemic. Significance of the Practice Problem The opioid epidemic is a global problem that is tragically resulting in increased morbidity and mortality. It has evolved from a rise in opioid prescribing to control acute and chronic pain, the prevalence of misuse and diversion, and illicit and prescription opioid overdose-related PAIN CONTROL OPTIMIZATION PATHWAY 5 deaths (Clark & Schumacher, 2017). While once described as an epidemic in the United States, the opioid crisis is transitioning to a worldwide phenomenon resulting in disease burden and premature mortality (Degenhardt et al., 2014). Globally, in 2018, it was estimated 35.6 million individuals suffered from an opioid use disorder, and 0.5 million deaths were attributed to drug usage (World Health Organization [WHO], 2018). The United States is often blamed for starting the opioid epidemic and had a death rate reaching over 69,000 in 2019 (Centers for Disease Control and Prevention [CDC], 2019). The state of Michigan is not spared from the tragedy surrounding the opioid epidemic. In 2018, the death rate from overdose was over 2,500 compared to only 115 reported deaths in 1999 (Michigan Department of Health and Human Services [MDHHS], 2020). At the local level, Oakland County has seen a 267% increase in opioid-related deaths from 2009 to 2015 (Access Oakland, 2017). While the opioid epidemic is complex, managing acute postoperative pain is a critical component to reduce the risk of long-term opioid use. The problem is cyclical. Healthcare providers have an ethical responsibility to provide safe and high-quality acute postoperative pain management, but there is a link between prescribing opioids for acute pain and long-term use, even in opioid-naïve patients (OPEN, 2020). In the United States, nearly 50 million inpatient and outpatient surgical procedures are performed annually (Gan, 2017; Hah et al., 2017). More than 80% of patients receive opioids because they are the primary method of acute postoperative pain management (Hah et al., 2017). Unfortunately, up to 10% of opioid-naïve patients continue filling their opioid prescriptions one year following surgery (OPEN, 2020). Acute postoperative pain is devastating for the patient, family, healthcare system, and society. Patients with postoperative pain have an increased risk of suffering, morbidity and mortality, emotional complications, and delayed healing (Pogatzki-Zahn et al., 2017; Ramia et PAIN CONTROL OPTIMIZATION PATHWAY 6 al., 2017). There is an increased risk of negative physiologic effects, such as myocardial supply and demand mismatch, interruption of normal respiratory function, activation of the sympathetic nervous system, reduction in gastric motility, and coagulopathy (Bajwa et al., 2017). Emotionally, pain may lead to anxiety, depression, sleep disturbances, and even inhibit a patient’s ability to return to work and obtain an income (Bajwa et al., 2017). The anticipation of pain is a major source of preoperative anxiety for the patient and family. Additionally, an increasing number of outpatient surgeries are being performed, placing the burden of pain management and opioid weaning on patients and caregivers. Families routinely have questions for providers regarding postoperative pain management and counseling becomes vitally important. When acute postoperative pain is not managed appropriately, patient and family satisfaction is reduced, which is an important quality metric in healthcare (Ramia et al., 2017). Postoperative pain may prolong hospitalization and increase re-admission rates, which increases costs to the healthcare system. The American Academy of Pain Medicine (2019) estimated that pain costs society 560-635 billion dollars annually. Therefore, combating opioid abuse is a state and federal priority. In 2017, the state of Michigan signed a multi-bill to fight the epidemic, focusing on patient counseling, along with prescribing and dispensing regulations for providers

The comparison was standard treatment, which manages acute pain with standard opioid and non-opioid analgesics. Treatment is based on provider experience and expertise, patient's hemodynamic status, and level of pain, free from consideration of a POP care process. Evidence supported a standard treatment regimen for opioid-tolerant patients; however, it has shown to be a precursor for long-term opioid use among opioid-naïve patients (Hah et al., 2017;OPEN, 2020).
The outcomes included acute postoperative pain scores, opioid consumption variables, and patient satisfaction with the acute pain management process. The Numerical Rating Scale (NRS) was utilized to assess acute pain. The NRS allows the patient to rate their pain with 0 representing "no pain" and 10 representing the "worst pain imaginable." In literature, the NRS is shown to be valid, reliable, easy to utilize, and simple to audit clinically (Bendinger & Plunkett, 2016;Ozgur et al., 2018). Opioid consumption variables were described by the project leadership team and included utilization of a standard procedure-specific opioid prescription, opioid consumption, opioid disposal, and overall satisfaction with the pain management technique.
The timing was reasonable for the intervention and considered results in the scientific literature (Bingener et al., 2015). Pain scores were obtained at discharge from the recovery room and 72 hours postoperatively. Time of discharge showed immediate effectiveness of a multimodal, opioid-sparing anesthetic technique on acute pain. Seventy-two hours was a realistic time for acute pain to begin subsiding after minimally invasive abdominal wall surgery and opioid consumption variables to be evaluated. This allowed appropriate evaluation of the synergistic effect of a multimodal, opioid-sparing pain management plan and opioid requirements.

Evidence-Based Practice Framework and Change Theory
The change theory that served as the foundation for the project was Kotter's 8-Step Change Model as it is an appropriate framework to develop and implement deliberate and sustainable change (Applebaum et al., 2012). The first step was to create a sense of urgency by assisting key stakeholders in realizing the need for timely change (Applebaum et al., 2012;Small et al., 2016). Then a powerful guiding coalition was established, including key stakeholders and leadership within the organization. The powerful guiding coalition (project leadership team) created a vision for change to communicate and ensure "buy-in" from all providers involved in the perioperative change project (American Association of Nurse Anesthetists [AANA], 0219, p. 8). Next, the frontline providers were empowered as the project leadership team implemented broad-based actions by identifying and removing potential or actual barriers to developing and implementing the project (AANA, 2019; Small et al., 2016). To continue the process of change, short-term goals were created to fuel and generate momentum during the project, and then energy from quick-wins was used as a foundation to continue change (AANA, 2019). Lastly, the changes were anchored into the organization and team culture through recognition, orientation, and recruiting (Small et al., 2016).
The quality improvement framework that guided the development and implementation of the change project was the Plan-Do-Study-Act (PDSA) model as it is a problem-solving model to improve processes and sustain change (Taylor et al., 2014). This is a formative evaluation process that utilized a stages approach through the scientific process of experimental learning with ongoing testing of changes (Knudsen et al., 2019;Sylvia & Terhaar, 2018). During the "planning" phase, the project leadership team was identified, opportunities for improvement acknowledged, and plans were made (Sylvia & Terhaar, 2018). It was of utmost importance the project leadership team understood the intervention, goals, measurement strategy, and measures of success based on the analysis of organizational processes. During the "do" phase, the project was executed, data collected, and displayed (Sylvia & Terhaar, 2018). The "study" phase required interprofessional collaboration as the team members worked together to evaluate the intervention outcomes and assess if outcomes were desirable (Sylvia & Terhaar, 2018). Lastly, during the "act" phase, a decision was made to implement the intervention as the cycle had been completed successfully. The model was well suited to provide a process and communication flow to ensure compliance with the POP care process.

Evidence Search Strategy
The evidence search strategy was guided by the PICOT process to ensure evidence-based and clinically significant literature was used to guide the project. The EBSCO host interface for the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database, PubMed database, Cochrane Library, and Google Scholar were searched for the PICOT question's major elements with natural language, subject, and medical subject headings (MeSH). In the CINAHL database, the search mode was refined to "Boolean/Phrase" to ensure exact phrase searching. To execute the search, separate advanced searches were performed related to the population, intervention, and outcomes then combined using the search history. Related to the population, . The initial search yielded over 14,000 articles, so the search was refined by adding limiters to focus the results, including peer-reviewed, evidence-based practice, randomized controlled trials (RCTs), all adult population, publication date within ten years, and English language. This produced 146 articles. Subject major headings were added, including postoperative pain, analgesics, non-opioids, and opioids. Titles were reviewed for relevance to the PICOT question, followed by a review of abstracts for inclusion and exclusion criteria.
Inclusion criteria included Johns Hopkins evidence-based level one through five and quality grades A through C evidence (Dearholt & Dang, 2018). Exclusion criteria included: (a) open surgical procedures not on the abdominal wall, (b) primary outcome comparing multimodal techniques, (c) lack of multimodal anesthesia technique utilized, (d) comparing regional techniques, (e) comparing local anesthetics, and (f) population of chronic opioid users. Articles not available in the full-text were requested by inter-library loan. Also, hand searches were conducted using the reference lists of appropriate articles. Fifty-two complete articles were reviewed.
In the PubMed database, an advanced search of the keywords above yielded over 40,000 articles, so a refined search was carried out. These keywords included: (a) ["enhanced recovery after surgery" [MeSH] OR (ERAS) OR "multimodal anesthesia"], (b) [("minimally invasive surgery") OR ("abdominal wall surgery")], (c) [("postoperative pain management") OR ("postoperative pain")], and (d) [("opioid consumption" OR "opioid use")]. Terms were combined with the connector word "AND." After applying filters published in the last 10 years, humans, English, and adult (nineteen or older), 168 articles were yielded. Titles were reviewed for relevance to the PICOT question, duplicates removed, the similar articles function used, and abstracts were reviewed for inclusion and exclusion criteria. Hand searches of reference lists were conducted and thirteen additional articles were reviewed. To ensure a comprehensive evidence search, the Cochrane Library and Google Scholar were searched using natural language "enhanced recovery after surgery", "enhanced recovery minimally invasive surgery", "multimodal opioid-sparing surgery", and "acute postoperative pain management" resulting in five additional articles. Collectively, 25 full articles were relevant to the PICOT question.

Evidence Search Results and Evaluation
The search strategy detailed above utilized the EBSCO host interface for the Cumulative Index of Nursing and Allied Health Literature (CINAHL) database, PubMed database, Cochrane Library, and Google Scholar for the major elements of the PICOT question. The search results included 25 research articles presented in a primary research evidence table and a summary of systematic reviews (see Appendix A and Appendix B). Figure 1 is a PRISMA model describing the identification, screening, and eligibility processes.
The Johns Hopkins nursing evidence-based practice level and quality grade model was utilized to determine the strength of evidence (Dang & Dearholt, 2018). The 25 articles included three meta-analyses and four systematic reviews with level one evidence and a quality grade A (high-quality results). Two randomized control trials (RCTs) had level one evidence and a quality grade A. Also included were nine cohorts and one case-control study with level two to three evidence and a quality grade B (good quality results). Lastly, six literature reviews with level five and quality grade B evidence supported the PICOT question.

Themes
A thorough evaluation of literature guided by the PICOT question revealed several common themes that revolved around the importance of utilizing a multimodal, opioid-sparing program to control acute postoperative pain and prevent long-term opioid use among opioidnaïve patients. Reoccurring themes included: (a) enhanced recovery after surgery (ERAS) is an evidence-based, multimodal, and opioid-sparing program to improve outcomes for a variety of abdominal surgeries, (b) multimodal, opioid-sparing programs adequately control postoperative pain, reduce postoperative opioid consumption, improve outcomes, and enhance patient satisfaction, (c) procedure-specific standardized prescribing guidelines are associated with reduced postoperative opioid consumption, and (d) preoperative and postoperative patient counseling are beneficial components of opioid-sparing programs.
Compared to standard care, an ERAS program is associated with improved outcomes for abdominal surgery, including decreased length of hospitalization, adequate postoperative pain management, reduced opioid consumption, decreased overall costs, reduced adverse events, and improved quality of life. Of 11 good and high-quality articles, three specifically addressed ERAS for minimally invasive abdominal, gynecology, or urogynecologic surgery and consistently published improved outcomes. The articles reliably showed a reduced length of stay (LOS), decreased pain scores, fewer opioids, reduced adverse events, and decreased costs with ERAS and minimally invasive surgery, or MIS (Chapman et al., 2016;Trowbridge et al., 2019). A retrospective case-control study by Chapman et al. (2016) evidenced ERAS with MIS increased postoperative day one discharge from 60% to 91%, reduced average costs from $15,649 to $13,771, and decreased opioid use by 30%. The percentage of patients discharged by noon doubled when ERAS is combined with MIS, thus reducing costs and improving perioperative productivity (Chapman et al., 2016;Trowbridge et al., 2019). Trowbridge et al. (2019) had similar outcomes reducing the LOS by 2.07 hours, yet only reported a slight reduction in mean pain scores, 4.49 versus 4.26 out of 10. Nonetheless, total morphine equivalents were significantly reduced and patient satisfaction statistically higher (Trowbridge et al., 2019).
Five studies had similar positive outcomes with ERAS and open procedures on the abdomen related to LOS, costs, improved functional recovery, and adverse events (Harryman, 2019;Li et al., 2019;Majumder et al., 2016;Smith et al., 2016;Wijk et al., 2019). Length of stay reduced by 50% with lowered overall costs of hospitalization Majumder et al., 2016). Enhanced recovery after surgery improved physical functioning, health-related quality of life, and fatigue scores in multiple studies, along with reducing adverse events Wijk et al., 2019). On the contrary, one RCT revealed no statistical difference with open surgery and MIS of the abdomen related to fatigue, physical and mental health. Still, the authors noted significantly reduced LOS and no difference in complications (Kennedy et al., 2014). Overall, evidence emphasized MIS has a statistically significant synergistic effect with ERAS related to LOS, costs, opioid use, and adverse events (Chapman et al., 2016;Harryman, 2019;Kalogera et al., Li et al., 2019;Majumder, 2016;Smith et al., 2016;Spanjersberg et al., 2015;Trowbridge et al., 2019;Wijk et al., 2019;Zhao et al., 2016. A multimodal, opioid-sparing perioperative pathway, when compared to standard care, is associated with reduced postoperative pain scores, decreased opioid consumption, enhanced patient satisfaction, and improved patient-reported outcomes (PROs). Of seven articles, one meta-analysis provided evidence that multimodal analgesia with regional anesthesia significantly reduced pain scores (p<0.001) and improved patient satisfaction (Zhou et al., 2017). Opioid use decreased by 72% with an opioid-sparing pathway and opioid-naïve patients experienced positive outcomes with high satisfaction (Hallway et al., Meyer et al., 2018;Zhou et al., 2017). Specifically, evidence showed an opioid-sparing pathway reduced median postoperative opioid use to ten pills or less (average of four pills) in 98% of patients (Hallway et al., 2019).
Opioid-sparing techniques may also result in no postoperative opioid use when patients utilize a combination of acetaminophen and ibuprofen (Hallway et al., 2019). One narrative review found multimodal techniques significantly improved postoperative pain scores but specifically showed opioid-free analgesia had the highest patient and surgeon satisfaction (Nassif & Miller, 2018).
Echeverria-Villalobos et al. (2019) evidenced opioid-sparing analgesia had optimal analgesia, improved patient safety, and fewer adverse events. Also, the authors linked short-term exposure to long-term use (Echeverria-Villalobos et al., 2019). This was similar to two narrative reviews discussing the negative effects of long-term opioid use after surgery among opioid-naïve patients (Hah et al., 2017;Kumar et al., 2017). Surgical patients present a challenge to balancing pain management and limiting opioid use; therefore, multimodal, opioid-sparing pathways are advocated in literature and proven effective in reducing postoperative opioid consumption.
Six articles discussed procedure-specific standardized prescribing guidelines are associated with reduced postoperative opioid consumption among surgical patients. Two systematic reviews reported patients had unused opioids, low pain scores, and poor knowledge or plan for proper opioid disposal (Bickett et al., 2017;Feinberg et al., 2018). Opioid oversupply is reported as high as 67% to 92% with low anticipated or actual proper disposal (Bickett et al., 2017). Feinberg et al. (2018) reported a lack of education and awareness among patients regarding proper disposal and advocated for education among providers to transition to procedure-specific and standardized prescribing. One retrospective cohort study reported an ERAS program increased the utilization of opioid-free anesthesia from 17% to 58% (Brandal et al., 2017). On the contrary, opioid prescriptions at discharge did not decrease significantly (85% to 78%), thus showing the need for education on prescribing practices (Brandal et al., 2017).
Provider training on evidence-based best practices for pain management and standardizing prescribing guidelines have significantly reduced the number of opioid pills and oral morphine equivalents prescribed after outpatient surgery (Stepan et al., 2019).
Provider education and knowledge regarding procedure-specific prescribing and multimodal, opioid-sparing techniques are important in reducing postoperative opioid use.
However, patients must be appropriately counseled Soffin et al., 2017). Key components of preoperative and postoperative patient counseling include addressing the risk of opioid therapy, the danger of sharing opioids, the risk of long-term use, safe disposal methods, and expectations of pain management Soffin et al., 2017).
Counseling regarding the advantages of preemptive analgesia, utilizing multiple components of the ERAS program, and regional anesthesia are valuable in setting patient expectations regarding the acute pain management program.
This literature synthesis is good to high quality and directly related to the components of the PICOT question. Evidence supported implementing an evidence-based, opioid-sparing POP care process for managing acute postoperative pain after minimally invasive, abdominal wall hernia surgery on opioid-naïve patients. The intervention, outcomes, and key findings support the program's success in controlling acute postoperative pain, reducing postoperative opioid consumption, and improving patient-reported outcomes.

Practice Recommendations
A rigorous review of literature has validated implementing a program encompassing an evidence-based, multimodal, and opioid-sparing acute pain management technique and standardized opioid prescribing for opioid-naïve patients undergoing out-patient, minimally invasive abdominal wall hernia surgery. The intervention has proven to reduce pain scores, decrease opioid consumption, enhance patient satisfaction, improve PROs, reduce LOS, and decrease costs (Chapman et al., 2016;Trowbridge et al., 2019). Utilization of a standardized care process encompassing evidence-based aspects of ERAS such as a multimodal, opioid-sparing perioperative course for first-line treatment, preoperative and postoperative patient counseling regarding an opioid-sparing perioperative course, and procedure-specific postoperative opioid prescribing guidelines are recommended to improve patient outcomes based on good and high-quality evidence (see Appendix A and Appendix B).
Although no study specifically addresses the POP care process, it is an evidence-based program developed by Michigan OPEN. The program addresses patient counseling, best practices, and provider education, all interventions are supported in the literature (OPEN, 2020). Michigan OPEN is supported and affiliated with the Michigan Department of Health and Human Services, Institute for Healthcare Policy and Innovation, and Blue Cross Blue Shield of Michigan to combat the opioid epidemic (OPEN, 2020). Figure 2 provides an overview of the recommended POP perioperative care process. The project leadership team recognized there were no data collection tools specifically designed for the Michigan OPEN POP care process yet created a tool that may serve as a foundation for future projects.
Utilization of the POP care process for minimally invasive abdominal wall surgery addressed the practice problem of reducing acute postoperative pain and opioid consumption among opioid-naïve patients to reduce the risk of long-term use and associated side effects. It introduced the perioperative team to an evidence-based strategy that standardized an innovative, opioid-sparing acute pain management plan, tailored to the surgical procedure. The program also highlighted central concepts in the postoperative pain management clinical practice guidelines, which emphasized the importance of preoperative education, perioperative pain management planning, use of multimodal therapies, peripheral regional anesthesia, and organizational structure and policy (Chou et al., 2016).
Michigan OPEN POP recommendations (unless contraindicated) includes the preoperative use of acetaminophen one gram by mouth, intraoperative use of local anesthetics, ketorolac 30 milligrams intravenously at closing, or postoperative ketorolac 30 milligrams intravenously if not administered intraoperatively (OPEN, 2020). Preoperative counseling occurs at the surgical or preoperative consult. The patient receives education regarding pain expectations and norms, schedule for non-opioid medication plan, alternative pain management modalities, appropriate use of opioids, adverse effects, and safe disposal (OPEN, 2020). Also, the intraoperative and postoperative acute pain management plan is addressed (OPEN, 2020).
Postoperative counseling includes written communication of a consistent message regarding functional pain management goals and non-opioid adjuncts (OPEN, 2020). The over-the-counter medication regimen at discharge is acetaminophen 650 milligrams every six hours, alternating with ibuprofen 600 milligrams every six hours by mouth (OPEN, 2020). Standardized procedurespecific prescribing of opioids for abdominal wall hernia repair is zero to ten pills and left to provider discretion (OPEN, 2020). Patients are notified opioids are utilized for only breakthrough pain during the first 24 to 48 hours (OPEN, 2020).
Based on scientific evidence, it was recommended to implement the preventative POP care process described by Michigan OPEN into the perioperative protocol at the organization for opioid-naïve patients undergoing minimally invasive, out-patient abdominal wall hernia surgery.
The POP program is based on best practices adopted from ERAS programs supporting an evidence-based, multimodal, opioid-sparing acute pain management program, preoperative and postoperative patient counseling, and standardized procedure-specific opioid prescribing. It was anticipated to reduce acute postoperative pain scores, decrease opioid consumption, and enhance patient satisfaction at discharge and after 72 hours.

Project Setting
The project setting was Michigan's largest health care system, with eight hospitals, 145 outpatient locations, and over 38,000 employees (Beaumont, 2020). It is a not-for-profit and teaching organization, Magnet Recognized, and affiliated with three local medical schools and graduate medical education (Beaumont, 2020). The organization's mission is to provide compassionate and extraordinary care based on a foundation of safety, patient and familycenteredness, and transparency regarding the quality of care and success (Beaumont, 2020). The vision is to be a leader in delivering high-value care through compassion, innovation, and education (Beaumont, 2020). The culture embraces a caring partnership, community outreach, and care delivery model of patient and family-centered care. The organization is a newly merged health system and the organizational structure includes a President & Chief Executive Officer and Board Chair who oversee the health board, executive team, and senior leadership (Beaumont, 2020).
A combination of best practice in literature, legislation, and a desire to combat the opioid epidemic established the organizational desire to implement an acute postoperative pain management program for opioid-naïve patients undergoing minimally invasive hernia surgery (C. Schmidt, personal communication, March 6, 2020). There is strong evidence a standardized program encompassing evidence-based aspects of ERAS, preoperative and postoperative patient counseling regarding an opioid-sparing perioperative course, and procedure-specific opioid prescribing results in improved patient outcomes. Also, in 2017 the state of Michigan signed a multi-bill package to combat the opioid epidemic (OPEN, 2020). Lastly, there are financial incentives to using the POP program as surgeons may report modifier 22 for an additional 35% reimbursement (OPEN, 2020).
Organizational support was confirmed by personal communication with the Director of Anesthesia Services, anesthesiologists, and general surgeons. Collectively, the perioperative providers desired an intervention considering best practices to combat the opioid epidemic. The Checklist to Assess Readiness for Implementation (CARI) was utilized to assess the healthcare organization's capacity to support the change project and ensure success (Barwick, 2011). The organization showed the highest scores related to staff desire and readiness for practice change, leadership acknowledging the importance of the problem and value in the intervention, and the organizational mission supporting innovative and evidence-based practice (Barwick, 2011). The plan for stability is multifactorial, beginning with aligning the project short-and long-term goals with the organizational goals. Also, continuously engaging key stakeholders through effective communication via multiple channels and providing on-going education to the perioperative providers regarding the intervention and outcomes.
Stakeholders include anesthesiologists, certified registered nurse anesthetists (CRNAs), Director of Anesthesia Services, surgeons, surgery office staff, preoperative care unit nurses, post-anesthesia care unit (PACU) nurses, quality and patient safety department, billing and coding departments, and the patient. Interprofessional collaboration among stakeholders was maintained by considering Interprofessional Education Collaborative (IPEC) core competencies, including creating a climate of shared values and respect, role identification, accountability, and transparency (IPEC, 2016). These competencies were integrated and applied to the quality improvement framework and change theory guiding the project, along with continuous communication and feedback driving the processes.
A SWOT analysis was performed related to the current state of the organization (See Figure 3 for the SWOT analysis for this project). Strengths included support from leadership, teamwork capability, the volume of cases, and experience of providers. Weaknesses were a lack of protocols for acute postoperative pain management and lack of provider training regarding standardized procedure-specific opioid prescribing. Opportunities were strong scientific evidence, key stakeholders' motivation to implement the POP pathway, improvement in acute postoperative pain scores, improved PROs, decreased LOS, and reduced postoperative opioid use. Threats were organizational production pressure, time constraints, costs, and resistance to change.

Project Overview
This project's mission was to implement and sustain an evidence-based acute perioperative pain management program for opioid-naïve patients undergoing out-patient, minimally invasive abdominal wall hernia surgery to reduce pain and decrease opioid use. The vision was to advocate for the patient and center the intervention around providing respectful, patient-centered, and high-quality acute pain management. This is congruent with the organization's mission and vision focusing on leading innovative care, safety, and patientcenteredness.
Multiple short-term objectives were identified to implement the POP care process for managing acute postoperative pain. First, 95% perioperative provider compliance with utilizing an opioid-sparing, multimodal technique as the first-line treatment for acute pain management.
Ninety-five percent perioperative provider compliance with preoperative and postoperative patient counseling. Ninety-five percent compliance with the utilization of standardized procedure-specific opioid prescribing. Average patient pain score at discharge from PACU with opioid-sparing, multimodal technique less than four on a 10-point VRS and less than two after 72 hours. Average patient postoperative opioid use at or below the prescribed number of pills after 72 hours.
The long-term objectives were to ensure compliance with on-going provider education, maintain interprofessional communication, and sustain the program. The goal was to avoid risk and unintended consequences during the project; however, there is potential for provider resistance to changing opioid practices, increased costs related to educating providers, and increased time related to patient preoperative and postoperative counseling.

Project Plan
The change model that guided this evidence-based change project was Kotter's 8-Step Change Model as it is appropriate to create a culture for change, engage and empower providers, develop and implement the intervention, and sustain the change with continuous quality improvement (Applebaum et al., 2012;Small et al., 2016). The implementation plan involved the collaboration of an interprofessional project leadership team, including the project manager (DNP student), key stakeholders, and project champions. It was of utmost importance the leadership team exhibited transformational leadership skills and focused on changing the status quo through communicating a vision and fostering inspiration within the group (Longest & Daar, 2008). As this intervention involved multiple phases of the perioperative process, the project was divided into smaller elements with a strategic communication plan to ensure coordination of care. The interprofessional leadership team communicated face-to-face monthly and via email weekly, or as appropriate. The project champions maintained communication between the project leadership team and perioperative providers as appropriate. The project manager oversaw the entire process. Table 1 shows each team member's responsibility.
The intervention was a POP care process based on best practices during three perioperative phases, including (a) preoperative counseling, (b) operative management, and (c) postoperative counseling (see Figure 2). The interprofessional project leadership team collaborated to develop provider educational materials and resources based on high-quality evidence, systemic reviews, and practice guidelines to successfully implement the intervention.
Provider education and resources included best practices for the pain control optimization pathway, prescribing recommendations, and patient counseling materials (see Appendix C).

Create a Sense of Urgency
Establishing a sense of urgency involved guiding others to see the need for immediate change (Applebaum et al., 2012;Mindtools, 2020;Small et al., 2016). The Director of Anesthesia Services and DNP student recognized the need for implementing an acute postoperative pain management pathway to control pain and reduce opioid consumption during the perioperative period. Consideration of the risks surrounding opioid use motivated practice change. Also, the practice problem's significance was viewed as an opportunity to improve patient outcomes and satisfaction. A sense of urgency was conveyed to key stakeholders during a face-to-face meeting with consideration of best practices in scientific literature, desire to improve patient outcomes, and recent legislation in Michigan to reduce opioid consumption. The momentum to move forward with the intervention was immediately established among key stakeholders. To transition this sense of urgency to perioperative providers, the leadership team developed a brief verbal and nonverbal overview of the project mission and vision to encourage interprofessional collaboration, motivation, and engagement (AANA, 2019).

Form a Powerful Guiding Coalition
Forming a powerful guiding coalition created an interprofessional project leadership team to drive the perioperative providers to effective and sustainable change (Applebaum et al., 2012;Small et al., 2016). The leadership team included the project manager, key stakeholders, and champions selected from specialties including anesthesia, surgical office staff, and perioperative nursing. The champions played an important role in facilitating education and communication among their specialty to increase knowledge, awareness, and sustainability of the pathway. Four champions were selected based on their ability to: (a) discuss the value of the intervention, (b) inspire and direct perioperative team, (c) foster trust in the process, (d) build and sustain professional relationships, and (e) communicate effectively (Applebaum et al., 2012;Small et al., 2016). This stage represented the "plan" phase of the PDSA model.

Create a Compelling Vision for Change
Once the powerful guiding coalition was formed, the mission and vision of the project were finalized. The leadership team collaborated and considered the SWOT analysis (see Figure   3 for the SWOT analysis for this project) and CARI tool outcomes. These results were the strategic basis for creating a vision and a successful change process. The vision was clear enough that the perioperative providers recognized their positive impact on the outcomes (Applebaum et al., 2012;Small et al., 2016). The collaboration created clarity regarding the change project, role identification, accountability, and transparency (Small et al., 2016).
The vision considered the intervention and necessary resources including information and knowledge, the communication plan, perioperative providers, time, equipment, and costs (AANA, 2019;Small et al., 2016). For knowledge acquisition, provider resources described the care process, including preoperative patient counseling, intraoperative management, postoperative counseling, and standardized procedure-specific prescribing (see Figure 2 and Appendix C). The communication plan included verbal and visual materials and the frequency of oral and written communication channels, all based on project leadership team preferences.
Connections were made between the vision and perioperative providers to facilitate a commitment to the change process. Equipment and costs were identified at the onset and continuously assessed to ensure availability. A summary of the vision and strategic plan was developed into a brief verbal and visual presentation and presented to champions (Mindtools, 2020).

Communicate a Compelling Vision for Change
Champions communicated the change project's mission and vision to perioperative providers in a brief verbal and nonverbal overview, which stimulated a climate for change (Applebaum et al., 2012;Small et al., 2016). During this phase, "buy-in" from the perioperative providers was of utmost importance (AANA, 2019). The champions served as communication lines between the project leadership team and perioperative providers during staff meetings.
Concerns and fears were openly addressed, constructive feedback encouraged, and the communication plan described and followed. The goal was motivation by preparation, making the process rewarding, and valuing providers' work.

Empower Action, Remove Obstacles
During this phase, the care process was introduced into practice. The "do" phase of the PDSA model was also executed. Obstacles were preemptively identified to ensure the perioperative providers' success (Applebaum et al., 2012;Small et al., 2016). The project leadership team addressed challenges and provided support to the perioperative providers, thus facilitating empowerment and motivation to move forward. The project's staff-related barriers were provider resistance to change, the time required for patient counseling, communication, collaboration inefficiencies among the team, and lack of skills or competencies (AANA, 2019).
To address provider resistance to change, formal training was offered with verbal and visual educational resources focusing on scientific evidence supporting the change and the dire need to overcome the opioid epidemic. Patient-related barriers included health literacy, understanding engagement, and overcoming bias related to opioid-sparing techniques (AANA, 2019). To overcome this barrier, education took place during the three perioperative phases with both verbal and visual materials. Facility-related barriers included local changes in policy and procedures, staffing changes, ability to maintain continuous staff education, and availability of opioid-sparing medications (AANA, 2019). The strong interprofessional leadership team and strategic implementation plan were aimed at overcoming these obstacles.

Create Short-Term Wins
Setting short-term goals allowed for clear and visible wins, thus creating momentum in the project (Applebaum et al., 2012;Mindtools, 2020;Small et al., 2016). The goal was to increase providers' confidence in the program and potentially gain support from late adopters (Small et al., 2016). To implement this step, weekly emails were sent by the project manager to the project leadership team with the project status, including outcomes, provider compliance, and recognition of teams and individuals for their efforts. This phase entered the "study" phase of the PDSA model. These weekly emails also facilitated and encouraged interprofessional communication and feedback.

Consolidate and Build on Change
The momentum from short-term wins was utilized to build on positive aspects of the project and identify areas in need of improvement (Applebaum et al., 2012;Small et al., 2016).
To execute this step, the leadership team collaborated face-to-face monthly and considered outcome data, process measures, and feedback from perioperative providers to determine whether the outcomes were desirable. This information was communicated to perioperative providers by champions and included in weekly emails from the project manager.

Anchor Changes into Organization and Team Culture
To anchor the change into the organization, ongoing recognition, recruiting, and staff education was vital (Applebaum et al., 2012;Small et al., 2016). To execute this step, the champions continued to discuss the project at staff meetings and new employees were oriented to the process. The pathway is currently being formalized and translated into other surgical specialties. This coincided with the "act" phase of the PDSA model. This evidence-based change project was developed, implemented, evaluated, and disseminated over 45 weeks and a detailed project schedule is presented in Appendix D. There were minimal costs to the organization for the project as the DNP student volunteered her time to formally train the interprofessional leadership team during the normally scheduled educational time, no staffing coverage was necessary at the practice setting, and statistician costs were paid for by the DNP student. Communication between the champions and perioperative providers took place during staff meetings requiring no staffing coverage. A monthly meeting of the interprofessional leadership team was during regularly scheduled surgical service departmental meetings. Table 2 presents the final budget with consideration of direct and indirect costs.

Evaluation Results
This pre-and post-intervention evaluation was deemed an evidence-based practice change project by The University of St. Augustine for Health Sciences Evidence-Based Practice Review Council; the Beaumont Nursing Evidence-Based Practice, Quality, and Research Council; and the Beaumont Institutional Review Board.
Efforts to implement ethical practices throughout the intervention included the protection of the safety and rights of participants by de-identification of data. Secure computer programs and equipment were used to protect personal health information and contact information (phone numbers). All de-identified data was kept in a regulatory binder in a locked office (see Appendix E and Appendix F). Also, digital information was kept safe in a password-protected computer in a facility approved SharePoint per policy. Necessary information was destroyed after use and no conflicts of interest were noted. Furthermore, the project manager stored all data and directly obtained missing information from the secure EHR or patient. No recruited participants were removed from the project. The approaches used to determine how effectively the intervention impacted the practice problem included selecting quality outcome measures, a link between the intervention and practice problem, and utilization of appropriate statistical analysis to compare pre-and postintervention data. The primary outcomes evaluated were postoperative pain scores and opioid consumption variables, since these are driving forces in the opioid epidemic.
Postoperative pain scores were the key data source evaluated pre-and post-intervention to assess the practice change's effectiveness during the perioperative period. Upon discharge from the PACU, pain scores were collected from a chart review in the EHR and after 72-hours through a phone call (see Appendix E). The instrument utilized to collect pain scores was the 10point NRS (see Figure 4), which is validated in the literature (Sylvia & Terhaar, 2018). Other primary outcomes included the prescription of a standard procedure-specific opioid, opioid consumption details, and patient satisfaction with the POP care process. This data was collected 72-hours after discharge and documented with an internally designed tool by the project leadership team (see Appendix E). The survey asked four "yes or no" questions, and there is no current test for reliability and validity. However, the intention was to develop the tool for future projects. To ensure the data collection process's consistency and accuracy, the project manager directly obtained the data using facility approved protocols and data collection tools.
Simple random sampling was used to collect pre-intervention baseline data retroactively from the EHR for 4 weeks before the intervention. The pain scores on a 10-point NRS scale at discharge from PACU averaged 4.8 pre-intervention. Also, 73% of eligible patients have prescribed a standard procedure-specific opioid prescription. Post-intervention data was collected for pain scores over the intervention period and presented as a 30-day mean, 31-60 day mean, and 0-60 day mean. Post-intervention data regarding procedure-specific opioid prescriptions were collected and presented for the entire time period.
Twenty-eight opioid-naïve adult patients undergoing general anesthesia for out-patient, minimally invasive abdominal wall hernia surgery received the opioid-sparing acute pain management technique, and procedure-specific opioid prescribing. For primary outcome data (postoperative pain scores at discharge from the PACU), a two-tailed one-sample z-test was used to evaluate pre-intervention and post-intervention data and analyze whether mean pain scores would be produced by a probability distribution with a mean of 4.8 (baseline). Furthermore, the Shapiro-Wilk test was conducted to assess whether the post-intervention data could have been produced through normal distribution.
Thirteen patients received the intervention during the first 30 days and the mean pain score at discharge from the PACU was 2.62. Results of the two-tailed one-sample z-test were significant based on an alpha value of 0.05, z = -15.56, p <0.001; results are presented in Table 3. Note. N = 13.
The Shapiro-Wilk test was also significant based on an alpha value of 0.05, W = 0.63, p< 0.001, suggesting the data was not normally distributed.
During days 31 to 60, 15 patients received the intervention and the mean pain score at discharge from the PACU was 3.0. The results were significant based on an alpha value of 0.05, z = -9.22, p< 0.001 and are presented in Table 4. Note. N = 15.
The Shapiro-Wilk's test results were also significant based on an alpha value of 0.05, W = 0.82, p = 0.007, signifying the normality assumption violated.
Collectively, the data from days zero to 60 related to pain scores at discharge from the PACU were analyzed. The post-intervention mean score was 2.82, nearly half of the baseline mean score of 4.8. This is an analysis from a two-tailed one-sample z-test, showing a statistically significant difference, p< 0.001 (see Table 5). Note. N = 28.
These results show a statistically significant reduction in mean pain scores at discharge from the PACU post-intervention.
Postoperative pain scores were also collected after 72-hours and compared to scores at discharge using a two-tailed paired samples t-test for the entire 60-day intervention period. The mean pain score at discharge was 2.82 and 1.68 at 72-hours. Results were statistically significant (p< 0.001), indicating the mean pain score at discharge was significantly higher than after 72hours (see Table 6). Note. N = 28. Degrees of Freedom for the t-statistic = 27. D represents Cohen's d.
The Shapiro-Wilk test was significant, p = 0.002, showing differences were unlikely to result from a normal distribution. However, Levene's test was not significant, p = 1.000, suggesting homogeneity of variance was met. Together, evaluation of this outcome data suggests the intervention reduces pain in the immediate postoperative period and provides a care process to continue controlling pain over the next 72-hours (see Figure 5).
Outcome data related to opioid prescribing, consumption, and satisfaction was obtained 72-hours after the patient was discharged via a four-question phone survey and descriptive statistics used to summarize the data (see Table 7). Frequencies and percentages were calculated based on each question: (a) Were you prescribed a standard procedure-specific opioid prescription? (b) Did you consume your entire prescription? (c) Did you properly dispose of extra opioid pills, and (d) Were you satisfied with your acute postoperative pain management technique? Post-intervention results showed that 100% of patients were prescribed a standard procedure-specific opioid, which is a significant increase from the pre-intervention 73% compliance. Eighty-two percent of patients did not consume their entire opioid prescription, of which, 78.57% properly disposed of the opioids. Furthermore, 100% of patients were satisfied with the acute pain management technique. This data shows that the evidence-based change projected influenced providers' knowledge and behavior, increased compliance with procedurespecific opioid prescribing practices, and educated and empowered patients to be satisfied with opioid-sparing techniques. Ultimately, the results show that there should be an increased emphasis placed on the proper disposal of opioids.
While evaluating outcomes identified in the PICOT question showed statistical significance, it is more critical to consider the project findings' clinical and practical significance. Clinical significance is important in EBP projects since it reflects the impact and magnitude of the intervention and whether the outcomes are clinically important, making it prudent for patient care (Ranganathan et al., 2015). This EBP change project had practical significance since providers viewed the intervention as an effective and efficient care process for delivering safe and high-quality perioperative pain management, with no increased burden.
Additionally, the project leadership team has plans to continue the implementation since the adherence to the POP care process has met most pre-intervention goals, the feedback was positive, and patients' behaviors have shown proactive change.
The intervention had clinical significance as it improved health outcomes for patients in the short-and long-term. The intervention immediately controlled acute postoperative pain, improved patient knowledge regarding non-opioid pain control, focused on functional recovery goals, and produced satisfactory pain management. The new practice also reduced patient opioid use and decreased opioid supply in the community. Each of these outcomes facilitates patient engagement and empowerment, which are key factors in delivering patient-centered care. As for long-term effects, this intervention contributes to reducing the risk of long-term opioid misuse or overdose, making it critical in mitigating the opioid epidemic. The intervention is also clinically significant since it did not present documented adverse patient events and reduced side effects associated with opioid use.
Descriptive statistics were used to analyze population measures, including gender, age, the American Society of Anesthesiology (ASA) classification, and body mass index (BMI), and race (see Appendix E). Summary statistics were calculated for interval and ratio variables, while frequencies and percentages were calculated for each nominal variable. Results for nominal variables (race and gender) are presented in Table 8.

Table 8
Frequency The most frequently observed race was white (n=22, 79%), while the most prominent gender was male (n=24, 86%). Summary statistics for interval and ratio variables averaged to an age of 65.11, ASA classification 2.82, and BMI 28.39 (see Table 9). Note. This indicates the statistic is undefined due to constant data or insufficient sample size.
The descriptive statistics were collected to summarize and describe the data and understand whether patient-specific demographic variables influenced pain and opioid use with the multimodal, opioid-sparing acute pain management technique; no significant relationships were observed. Therefore, this data serves as a foundation for understanding the population and aids in transitioning to additional populations or generalizing to larger populations. Balancing measures included ensuring the rate of unintended hospitalization and readmission rates, neither of which increased. Therefore, it may be assumed this evidence-based change did not negatively impact other areas within the organization. Financial measures included provider education and training costs, which were minimal and covered by the DNP student. Sustainability measures were embedded into the evidence-based change project, emphasizing compliance with on-going training of providers, patient counseling, and compliance with procedure-specific opioid prescribing.

Impact
Assumptions based on scientific evidence that implementation of the POP care process for opioid-naïve patients undergoing minimally invasive, out-patient abdominal wall hernia surgery would decrease pain scores and reduce opioid consumption was supported in this evidence-based change project. Results showed the POP care process, which utilizes an opioidsparing acute pain management technique, preoperative and postoperative patient counseling, and standardized procedure-specific opioid prescribing, positively impacted patient outcomes and is an important step in battling the opioid epidemic. It alters practice by providing an alternative care process for acute postoperative pain that reduces side effects associated with opioids, reduces the risk of persistent opioid use, and provides adequate pain relief using multiple pharmacological and non-pharmacological treatment modalities.
The POP care process has a significant impact on nursing and healthcare, as it supports interprofessional collaboration and strong patient-provider relationships. It engages and empowers both providers and patients to participate in combating the opioid epidemic by focusing on an opioid-sparing perioperative course, functional recovery goals, and standardized procedure-specific opioid prescribing. The care process provides safe and effective acute postoperative pain control but considering the linkage between acute and long-term opioid use, it is vital to reduce the risk of opioid misuse, diversion, and overdose-related deaths.
As this change project provided a reliable cause-and-effect relationship between intervention and outcome, the project leadership team is devoted to continuing future intervention. To ensure the intervention's sustainability, the project leadership team is working with information technology to implement a clinical decision support tool with an alert for perioperative providers in the facility EHR to discuss opioid-sparing pain management options with patients. Also, written and verbal information regarding the POP care process is integrated into the organization's new employee orientation curriculum. Lastly, leaders within the organization have adopted the protocol and are implementing it within various surgical specialties. For ongoing evaluations, the Director of Anesthesia has volunteered to take the project manager role. The project leadership team will continue to meet monthly and communicate directly with the project champions.
To further improve the POP care process's effect on battling the opioid epidemic, the focus will be on transitioning to other surgical specialties, formalizing the facility EHR protocol, and improving the data collection tools. Limitations included a lack of data regarding the anesthetic technique and site-specific regional blockade. Recommendations for replicating this project include data collection on specific medications administered during the perioperative period and regional blockade documentation. The site-specific regional blockade should be documented, including the type of local anesthetic, concentration, dose, and site. This has the potential to greatly influence the longevity of pain management. Also, the exact number of opioid pills consumed should be documented, as zero to ten pills is a large range. Lastly, an emphasis should be placed on education regarding the safe disposal of opioids, including the importance of take-back events that prevent opioid abuse before it starts.

Plans for Dissemination
To share the evidence-based change project results within the organization, the project has been presented to the interprofessional leadership team and perioperative providers involved with the intervention. The providers were invited via email to the presentation during regular departmental meeting times and locations. Three separate presentations were given to the surgery office staff, the perioperative nursing team, and anesthesia providers at their designated locations. The presentation included a verbal overview, visual aids (poster), handouts, and interactive discussion time.
Moving forward, the leadership team will collectively prepare an abstract and poster to be presented at the organization's quality improvement conference. A presentation will also be given to the organization's research institute with anticipation to be reported in the 2020 accomplishments. This organization has reported quality and safety results that improve patient care and outcomes for over 50 years; therefore, it is anticipated the results of this change project will be valuable.
To share the results with the professional community, the change project will be archived at the University of St. Augustine for Health Sciences Scholarship and Open Access Repository (SOAR@USA) for student and faculty access. A poster will also be presented at the Spring 2021 Michigan Association of Nurse Anesthetists (MANA) conference virtually in Detroit, Michigan.
The American Association of Nurse Anesthetist Journal has been selected for publication. The journal has a peer-review process for submission; however, the interprofessional leadership team is also reviewing the manuscript before submission. This journal is published bi-monthly and delivers clinical practice information to anesthesia providers regarding innovations in nurse anesthesia practice, which is aligned with the goals of the intervention.

Conclusion
The POP care process developed by Michigan OPEN is an interdisciplinary and evidence-based approach to preventing harm and reducing long-term opioid use among surgical patients. It improves postoperative outcomes by providing an effective and efficient acute pain management plan, decreasing the surplus of opioids in the community, and educating patients. In      (2017). Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: A historicalprospective study. Anesthesia & Analgesia,125 (5)   Percent compliance with utilizing of standardized procedure-specific opioid prescribing The numerator is the number of opioid-naïve adult patients undergoing minimally invasive hernia surgery who received standardized procedurespecific opioid prescribing and the denominator is the total number of opioid-naïve adult patients undergoing minimally invasive hernia surgery within the same period of time. Data obtained by the project manager or leadership team member from EHR.