2026 Southeastern Residency Conference

Evaluation of Postoperative Outcomes and the Impact of an Enhanced Recovery Pathway in Patients Who Have Undergone a Laparotomy Procedure

Mackenzie Winter Waters, Melissa Bagwell, Leborah Cole Lee, Courtney Reliford, Kayla Brown

Abstract
Purpose: Utilization of an enhanced recovery pathway (ERP) perioperatively has shown benefit in reducing postoperative symptoms, complications, length of stay, and readmission rates, but it is not widely utilized at our institution. The purpose of this study was to supplement current literature regarding the clinical impact of an ERP on patient outcomes following surgical procedures by retrospectively assessing patients’ postsurgical outcomes as it relates to ERP utilization compared to those who received standard of care. The hypothesis of this study is that implementation of an ERP would result in a reduction in opioid consumption and a decrease in postoperative complications.

Methods: This single-center, retrospective chart review was approved by the Institutional Review Board at East Alabama Medical Center (EAMC) and evaluated the impact of an ERP after the following elective open laparotomy surgical procedures: gynecologic-oncologic, colorectal, and/or hysterectomy. The primary outcome was total morphine milliequivalents (MME) utilized during inpatient hospitalization stay (IHS). Secondary outcomes included average pain scales, adverse drug events related to narcotics, prescribed narcotic(s) on discharge, incidence of postoperative ileus, incidence of acute kidney injury, adherence to the ERP postoperative analgesic medication regimen (> 75% scheduled doses received), average daily dose of narcotics (in MME) and non-narcotic medications (in mg) used for pain management, length of IHS, 30- and 90-day hospital readmission, and 90-day mortality. Patients were identified using the electronic medical record and assessed for the following inclusion criteria: ≥19 years of age and hospitalized for previously defined elective surgical procedures between May 1, 2024, and May 31, 2025. Exclusion criteria included pregnancy, prisoners, males, length of IHS <24 hours, patients admitted with a bowel obstruction or ileus prior to surgery, and patients who received a patient-controlled analgesia pump for pain management. Criteria were assessed to obtain at least 50 patients in the ERP group and 50 patients in the non-ERP group. Data analysis was conducted using a Chi-square, Fisher’s exact test, Student’s t-test, or Mann-Whitney U test dependent on data type and distribution. All statistical analyses were performed in IBM SPSS Statistics version 30.0.0.0 (IBM Corp., 2024).

Results: There were 1,582 patients screened for inclusion, with 50 patients in each group meeting inclusion criteria. Patients within the ERP group used a lower amount of total MME compared to the non-ERP group (median 766.3 versus 935, P = 0.046). The ERP group had a lower average daily MME utilization (median 242.5 versus 316.7, P = 0.005), lower average pain scales (median 3.4 versus 5.5 (on a 10-point scale), P < 0.001), and a higher average daily utilization of APAP in mg (median 2066.7 versus 1175, P < 0.001). Differences in narcotics prescribed at discharge showed statistical significance (P < 0.001), and post-HOC analysis was performed with the adjusted P value for significance set at < 0.008. Oxycodone was prescribed more frequently in the ERP group (68% versus 28%; P < 0.001) and oxycodone-APAP prescribed more frequently in the non-ERP group (50% versus 10%; P < 0.001). All other secondary outcomes did not show statistical significance.

Conclusion: Utilization of an ERP perioperatively resulted in clinically and statistically significant reductions in narcotic utilization and average pain scales throughout hospitalization. One strength is this study included evaluation of pain outcomes in invasive surgical procedures, which are associated with higher pain scores and longer length of inpatient hospital stay compared to non-invasive surgeries. One limitation of this study was that men were excluded due to the nature of procedures that utilized an ERP. In the future, our organization plans to expand the use of an ERP to other surgical areas, including colorectal surgeries and cesarean deliveries.

Title: Acute Pain Management in Patients with Opioid Use Disorder: Evaluating Practice and Outcomes Within a Tertiary Care Facility

Authors: Breanna Wright, Mary Beth Brinkman, Justin Gruca
TriStar Centennial Medical Center – Nashville, TN

Background: Chronic pain is reported by 20.5% of Americans within the United States. Chronic pain is defined as pain that lasts beyond three months and extends past normal tissue healing time. Although hospitalized patients are treated for chronic pain, they may also require acute pain management in instances such as moderate to severe fractures or post-surgical pain. These instances may lead to undertreated pain by physicians due to fear of cognitive, respiratory, and psychomotor side effects which may be exaggerated with short-term opioid use. It is important to maintain adequate pain management, especially in patients with opioid use disorder (OUD) because undertreated pain has been shown to result in poor health outcomes, including early discharges, negative stigma, and overall mistrust of the healthcare system. Opioid use disorder is defined as a pattern of opioid use associated with a range of consequences, and with increased mortality leading to significant impairment or distress. The American Society of Addiction Medicine (ASAM) have published guidelines for the treatment of OUD, but there is still a lack of consensus among providers as it relates to acute pain management. In this study, we aimed to describe characteristics of acute pain management in patients on chronic opioid therapy within our institution.

Methods: This is a single-center, retrospective cohort study conducted through chart review from January 1, 2025 through July 1, 2025. Patients were identified via a computerized report using a clinical surveillance platform, generated by searching for buprenorphine medication orders. Patients admitted to our facility with acute pain and identified as being on chronic opioid therapy or receiving buprenorphine for opioid use disorder were included. Exclusion criteria consisted of oncology patients, nonverbal patients, patients admitted to the intensive care unit (ICU), patients receiving methadone inpatient or outpatient, and patients undergoing surgery during their admission. The primary endpoint was the average number of as needed (PRN) pain medication orders. Secondary endpoints included pain scale reduction, psychiatric provider consultations, naloxone administrations, methylnaltrexone administrations, and number of unplanned readmissions or emergency department (ED) visits.

Results: A total of 65 patients were screened; 27 patients met inclusion criteria and 38 patients were excluded. Less than half of the patients included within the study were male, and 85% of patients had a prior history of substance use disorder. Twenty-two of 27 patients had a medication-assisted treatment (MAT) regimen prior to index admission to our facility. The average number of PRN pain medication orders was 1.9, with an average of 0.5 PRN opioid orders and 1.4 PRN non-opioid orders. On average, pain scores decreased from admission to discharge by 0.5. Naloxone and methylnaltrexone were not administered to patients included in this study during the index admissions. 4 patients (14.8%) were readmitted within 30 days, while 8 patients (29.6%) visited the emergency department following their index admission.

Conclusion: Pain is a complex condition that can be challenging to manage, both acutely and chronically. This study’s assessment of acute pain control in patients with chronic pain demonstrated outcomes comparable to those reported in prior studies and highlighted the importance of effective acute pain management within this population. Patients had a similar average of PRN analgesic orders to those in prior studies and experienced modest reductions in pain scores from admission to discharge. Increasing the availability of PRN pain medications may further improve pain control in patients with chronic pain.
This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Title: Systematic Use of the MORE Tool to Reduce Opioid-Related Adverse Events at a Community Teaching Hospital 
Authors: Mariam Diaby, Kimm Freeman  

Background: Opioids are widely used for the management of moderate to severe pain in hospitalized patients; however, their use is associated with significant risk of opioid-related adverse drug events (ORADEs), including respiratory depression, oversedation, delirium, gastrointestinal complications, and increased morbidity and mortality. ORADEs have been linked to prolonged hospital length of stay, higher healthcare costs, and poorer clinical outcomes. 

In response, opioid stewardship has become a major focus of inpatient quality improvement initiatives. Numerous stewardship efforts have emphasized multimodal analgesia, dose optimization, avoidance of high-risk medication combinations, and enhanced monitoring of sedation and respiratory status. Pharmacists play a critical role in these initiatives by conducting medication reviews, identifying inappropriate opioid prescribing, mitigating high-risk regimens, and implementing safety-focused interventions. However, sustaining consistent and standardized opioid stewardship practices within routine clinical workflow remains challenging. 

The Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) tool was developed as a structured framework to standardize opioid stewardship efforts among pharmacists. The MORE tool prompts systematic evaluation of opioid therapy, including assessment of risk factors, optimization of analgesic regimens, reassessment of safety parameters, and patient education. 

Methods: This retrospective observational study evaluated implementation of the MORE tool on 3 North Telemetry and 3 South Renal units at Wellstar Cobb Medical Center from December 22, 2025, to January 16, 2026. Adult patients admitted to study units who received at least one opioid medication during hospitalization were eligible. Patients admitted for hospice or comfort measures only, those hospitalized for less than 24 hours, and those who received naloxone for indications unrelated to opioid overdose were excluded. 

The primary objective was to quantify and characterize the types of medication-related interventions documented during daily MORE tool utilization. Secondary analysis evaluated potential associations between documented MORE tool interventions and the root causes of naloxone administration during the study period. 

Interventions were identified through pharmacist-documented I-Vents within the electronic medical record. Data collected included patient demographics, hospital length of stay, opioid administration records, sedation and risk assessment scores, naloxone administration events, and interventions. Descriptive statistics were used to summarize intervention frequency and type. Comparative analyses were performed to explore associations between MORE tool interventions and naloxone events. 

Results: A total of 108 interventions were documented across 67 patients. Of the 108 interventions, 88 were accepted and 20 were rejected. The most common intervention was the conversion of intravenous opioids to oral opioids, which accounted for 33 interventions with 27 being accepted by the provider.  Other frequently implemented interventions included the addition of opioid-induced constipation (OIC) prophylaxis (32 interventions), scheduling of Tylenol (4 interventions), and the discontinuation of benzodiazepines (4 interventions). 

The overall rate of accepted interventions was 81.5%, with the highest acceptance rates seen in optimizing OIC prophylaxis (100%) and converting intravenous opioids to oral opioids (81.8%). Notably, there were no NARCAN (naloxone) administration events documented during the study period. 

Conclusion: The systematic use of the MORE tool in this study demonstrated a high acceptance rate of opioid stewardship interventions, with 81.5% of the documented interventions being implemented. The tool effectively prompted appropriate adjustments in opioid management, particularly in optimizing OIC prophylaxis and converting IV opioids to PO opioids. During the study period, there were no naloxone administration events, suggesting that ORADEs may have been effectively mitigated through this proactive approach. These findings highlight the potential value of utilizing structured tools like the MORE tool in reducing ORADEs and optimizing opioid therapy, thus contributing to improved patient safety and clinical outcomes. Further research with larger cohorts is needed to confirm these findings and assess the long-term impact of such interventions.

Contact: [email protected]

Impact of Opioid-Sparing Multimodal Pain Management Order Set on Opioid Use and Clinical Outcomes in Thoracic Surgery Patients

Authors: Kylie Michot, Michael Ezebuenyi, Monica Campbell, Jennifer Jones, Greggory Davis

Background: Multimodal analgesia optimizes postoperative pain management while reducing opioid use and associated risks. Pain management is achieved by optimizing the synergistic effects of non-opioid medications with complementary mechanisms of action. The Enhanced Recovery After Surgery (ERAS) Society recommends multimodal analgesia over scheduled opioid therapy for thoracic surgery postoperative pain management. While current evidence highlights the benefits of multimodal strategies, further research is needed to evaluate opioid-sparing effects and clinical impact after thoracotomy. This study evaluates whether implementation of a postoperative multimodal analgesia regimen within an ERAS protocol reduces opioid utilization among thoracic surgery patients undergoing thoracotomy compared to traditional opioid-based postoperative pain management.
Methods: This single-center, retrospective chart review evaluated patients admitted to FMOL Health – Our Lady of the Lake between March 2017 and September 2025 who underwent thoracotomy and received postoperative analgesics from a standardized order set. Patients were excluded if they were younger than 18 years or older than 80 years of age, receiving renal replacement therapy, pregnant, receiving comfort care, or had a documented allergy to a medication included in the order set.
The primary outcome was three-way comparison of opioid utilization, measured in morphine milligram equivalents (MMEs), in patients receiving a multimodal pain management protocol versus usual care with opioids for pain management after a thoracotomy on post-operative day (POD) 0, POD 1-3, and total postoperative length of stay (LOS). Secondary endpoints included chest tube duration, post-operative ventilator duration, intensive care unit (ICU) LOS, hospital LOS, average pain control score on POD 1 and POD 3, time to first dose of opioids after surgery, and opioid prescriptions upon discharge.
Results: A total of 156 patients were included in this study with 78 patients in each group. Regarding baseline characteristics, the majority of the multimodal group had a higher American Society of Anesthesiologists (ASA) Physical Status Score (ASA score >3, 17% vs. 46%; P < 0.001), an overall lower number of female patients (67% vs. 44%, P = 0.004), and patients over the age of 60 (median age, 60 vs. 66; P = 0.005). No difference in inpatient opioid consumption was seen between groups on POD 0 (17 vs. 20; ratio, 1.2; 95% CI 0.68 to 2.05; P = 0.78). There was a statistically significant reduction in inpatient opioid consumption between groups on POD 1-3 (83 vs. 20; ratio, 0.19; 95% CI, 0.11 to 0.34; P < 0.001) and total postoperative LOS (130 vs. 55; ratio, 0.38; 95% CI, 0.24 to 0.62; P < 0.001). Multimodal analgesia reduced pain score on POD 1 (median pain score, 4.6 vs. 3.5; P = 0.003) but had no difference in pain score on POD 3 (median pain score, 3.8 vs. 3.0; P = 0.07). Additionally, multimodal analgesia was associated with decreased chest tube duration (median chest tube days, 3.1 vs. 2.2; P = 0.003), and decreased hospital LOS (median LOS, 4 vs. 3; P = 0.010). There was no difference in discharge opioid prescription MMEs (median discharge MMEs, 225 vs. 300; P = 0.89).
Conclusion: Among patients undergoing thoracotomy, a multimodal analgesia regimen with an ERAS protocol was associated with significant reductions in opioid utilization during POD 1-3 and total postoperative hospitalization but did not demonstrate a difference on POD 0. Limitations include the retrospective nature of this single site study and the inability to access opioid usage data from patient-controlled analgesia (PCA) pumps.
Contact Information: [email protected]

Title: Evaluation of intraoperative intravenous methadone administration for cardiothoracic surgery analgesia 
Author(s): Anna Carlson, Nevena Mihalovich, Ethan Gerrald, Zachary Klick, Paige Behr, Madison Fielding, Akshara Patel; Atrium Health Wake Forest Baptist, Winston Salem, NC 

Objective: To evaluate the efficacy and safety of intravenous (IV) methadone as adjunctive analgesia in cardiothoracic surgery (CTS)
  
Background:  Post-operative opioid stewardship has been a focus of national and state level initiatives to curtail the prescribing of excessive opioid analgesics. The use of multimodal analgesics is recommended by the Society of Thoracic Surgery (STS) to reduce morphine milligram equivalents (MME). Pain following CTS is typically most severe within the first 24 hours postoperatively but may persist for several days. To effectively manage postoperative pain, methadone has been used intraoperatively due to its favorable pharmacokinetic profile, including its long half-life of 24-36 hours. Previous studies comparing methadone with shorter-acting opioids suggest reductions in pain scores and MME requirements in patients receiving intraoperative IV methadone. However, studies vary among types of surgery performed, reported opioid-related adverse events, and postoperative day (POD) study follow-up duration. Additional research is warranted to quantify the impact of intraoperative IV methadone and support practice optimization. 

Methods: This was a retrospective, single-center, cohort study utilizing electronic health record (EHR) data of patients undergoing CTS, including coronary artery bypass graft (CABG), aortic valve repair (AVR), isolated mitral valve repair or replacement (MVR/MVr), aortic root repair or replacement, or other combinations thereof. Data was collected utilizing an EHR report to identify CTS performed from March 2024 – August 2025. Patients were categorized into two groups: intraoperative IV methadone administration for adjunctive analgesia or standard of care. Key exclusion criteria are preoperative gastrointestinal obstruction (including ileus), mechanical circulatory support after index surgery, continuous infusion opioids within 48 hours prior to CTS, or active or prior opioid use disorder. The primary endpoint was average cumulative MME requirements through POD four or discharge, whichever comes first. Secondary endpoints include difference in daily MME requirements, incidence of naloxone rescue administration, intraoperative MME requirements, percentage of patients extubated within 6 and 24 hours, incidence of postoperative ileus, incidence of opioid-related adverse effects, and opioids prescribed at discharge in MME.  
Baseline characteristics assessed were age, sex, comorbidities, and type of CTS performed, as well as use of antiarrhythmic medications, glucagon-like-peptide-1 receptor agonists, and opioid, including methadone, use within 30 days. Results were analyzed utilizing descriptive statistics, with means or medians reported for continuous variables as appropriate. Categorical endpoints were analyzed using Fisher’s exact or chi-square test for normally distributed data.  
 
Results: 200 patients in total were included (IV methadone n=100; standard of care n=100). Baseline characteristics were similar between the two groups aside from a statistically significant difference in incidence of depression. There were no significant differences in type of CTS or number of adjunctive analgesic agents used postoperatively. Cumulative POD 0-4 MME were significantly lower in the methadone group compared with standard of care (167 vs 209; mean difference 42; p=0.046). Reductions in MME requirements were most notable on POD 0 and POD 1 (mean difference 16 and 19, respectively; p=0.006). There were no observed differences in incidence of naloxone administration, extubation within 6 and 24 hours, postoperative delirium, or ICU length of stay. Mean MME prescribed at discharge was significantly lower in the methadone group (126 vs 135 MME; p=0.0047).  
 
Conclusions: Administration of intraoperative IV methadone significantly reduces postoperative MME requirements when compared to standard of care. 

Impact of Pharmacist Education on Opioid Stewardship Interventions in a Community Hospital 
Authors: Malena Pontrich; Will Stewart
Background:
Opioid stewardship is an important component of patient safety and therapy augmentation. The 2022 CDC Clinical Practice Guidelines for Prescribing Opioids for Pain endorse the use of collaborative efforts among a variety of clinicians, including pharmacists, for integrated pain management. This study is designed to evaluate the impact of pharmacist education on the average number of opioid stewardship clinical interventions per month. Secondary outcomes will include monthly averages of patients discharged with naloxone prescriptions after an opioid stewardship intervention occurred, and average morphine milligram equivalents (MMEs) received per day while inpatient.
Methods:  
This retrospective study was approved by the local Institutional Review Board. Patients admitted to Baptist Health Lexington were included if they were over the age of 18 and had a pharmacist-led opioid stewardship intervention documented during their admission. Subjects were excluded if they were incarcerated patients, pregnant patients, hospice patients, enhanced recovery after surgery (ERAS) patients, or patients with patient-controlled analgesia (PCA). Clinical pharmacists received education on internal opioid stewardship workflow guidelines including possible opioid stewardship intervention types, appropriate use of opioid stewardship interventions, and documentation in the electronic health record. Baseline data on the number of opioid stewardship interventions, naloxone prescriptions at discharge, and average inpatient MMEs was collected from the electronic health record for the six months preceding the intervention, March 2025 through August 2025. The same data was collected for the six months after the education occurred, September 2025 through February 2026. The findings from the pre- and post-intervention stages will then be evaluated.
Results:
Among the 142 interventions included in the final study, 74 were in the pre-intervention group and 68 were in the post-intervention group. Among both groups the breakdown of intervention subtypes in the pre-intervention and post-intervention cohorts, respectively, is as follows: alternative therapy 9 (12.16%) vs 16 (23.53%, discontinuation of opioid 38 (51.35%) vs 31 (45.59%), dose change 13 (17.57%) vs 6 (8.82%), drug information/consultation 7 (9.09%) vs 3 (4.41%), initiation of naloxone 2 (2.70%) vs 6 (8.82%), none selected 5 (6.76%) vs 6 (8.82%). For the primary objective, the pre- and post-intervention average monthly number of opioid stewardship interventions was 12.33 and 11.33 (p = 0.50), respectively. For secondary objectives, the average number of naloxone prescriptions written at discharge per month was 0.7 before pharmacist education and 2.0 after pharmacist education (p = 0.03). The average number of MMEs administered per patient per day while admitted was 57.82 and 51.86 (p = 0.50) pre- and post-intervention, respectively.
Conclusions:
There was no statistically significant difference in the average number of opioid stewardship interventions documented per month in the pre- and post-intervention groups (p = 0.50). There was a statistically significant increase in the average number of naloxone prescriptions written at discharge (p = 0.03). There was no statistically significant difference in the monthly average of inpatient MMEs administered per patient per day (p = 0.50). Pharmacist education did not significantly impact the average number of opioid stewardship interventions or the average number of MMEs administered per patient per day. The average number of naloxone prescriptions written at discharge was significantly increased after pharmacist education on opioid stewardship workflow. Limitations include a small sample size, the exclusion of a large portion of the initial sample population after applying exclusion criteria, staff turnover, and variation in hospital census. Outpatient opioid doses and length of stay were also not accounted for when quantifying administered MMEs for patients which may have impacted results. 

Evaluating Emergency Department Order Set in Sickle Cell Pain Management
Katherine Weller PharmD, Kanaan Shah PharmD, Christele Francois PharmD, BCPS, Tonya Hershman PharmD, BCPS, Karen Clarke, MD, Alexandra Arges MD, Mohamad Moussa MD, Yoo Mee Shin MD, Nicholas Kurtzman MD, Krista Dumkow PharmD, BCEMP, BCPS; Emory University Hospital, Atlanta, GA 

Background: 

Vaso-occlusive crises (VOC) in patients with sickle cell disease (SCD) occur because of adhesion of red blood cells to small vessel walls, leading to obstruction of blood flow, pain, and ischemia1. VOC is the most common complication of SCD. Patients often present to the emergency department (ED) for acute pain management when their home pain regimens fail to adequately control the crisis2. To manage acute crises, the American Society of Hematology Clinical Practice Guidelines on SCD recommend administering opioids within 60 minutes of arrival to the ED3. The guidelines further recommend a tailored opioid regimen that is reassessed every 30 to 60 minutes and multi-modal pain regimens with non-opioid therapies such as non-steroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants, or acetaminophen. This study aimed to assess the utilization of a guideline-based order set for acute pain management of patients with SCD presenting to the ED in a VOC.   


Methods: 

This was an Institutional Review Board-approved, single center, retrospective observational study of patients presenting to the ED with a diagnosis of VOC between January 1, 2024, and January 31, 2025. A total of 289 patients were identified and 181 met inclusion criteria of age >18, presentation during the study period, and a final diagnosis of VOC. Exclusion criteria included active infection, chronic or acute pain due to alternative diagnosis or other causes, history of substance abuse, left against medical advice, and pregnancy. The primary outcome was the incidence of analgesia administered within 60 minutes of ED arrival. Secondary outcomes included incidence of inpatient admission, time to initial dose of analgesia from arrival to the ED, time spent in the waiting room, pain re-assessment within 15-30 minutes of pain medication administration, dose escalation by 25% every 15-30 minutes until pain is adequately controlled, reduction in pain intensity measured by a pain scale, adverse events associated with opioid use, use of adjunctive NSAIDs, and ED length of stay. 



Results: 

Of the 181 patients that were included in this study, 37 patients had medications ordered utilizing the SCD order set in the ED. The primary outcome of incidence of analgesia administered within 60 minutes of ED arrival was not statistically significant (order set group, 10.8%; non-order set group, 11.8%; p-value=0.56). The use of NSAIDs was significantly higher in the orderset group (order set group, 43.2%; non-order set group, 16%; p-value=0.0003). Inpatient admission rates, pain assessment, dose escalation, and reduction in pain intensity were similar between groups, with no statistically significant differences. Operational metrics such as average time to analgesia, time spent in the waiting room, or average ED length of stay were not statistically significant. For adverse events associated with opioid use, there was no difference between groups (order set group, 8.11%; non-order set group, 1.39%; p-value=0.99). Of patients that had the order set used upon ED arrival, 70% had analgesics ordered through the order set panel.  



Conclusions: 

Implementation of the order set did not significantly improve the or timeliness of analgesia within 60 minutes of ED arrival.  The greatest barrier to receiving analgesia within 60 minutes of ED arrival was delays in appropriate room placement and IV placement. Strategies to address this barrier include prioritizing triage for patients presenting with VOC and implementing bed prioritization protocols to expedite rooming. The order set promotes guideline driven, multimodal VOC management while further optimization is needed to enhance timely analgesia, pain reassessment, and operational metrics. Future efforts should educate providers about the order set and refine the order set to improve its effectiveness, such as ensuring that analgesics are ordered through the order set and enhance timely nursing communications for pain scores and dose escalation.