








































Anesthesia eJournal
Volume 4 - Issue 1 2016

AEJ

Educated Hand Publishing LLC 
“The Science Behind the Art”  

Anesthesia eJournal - Online
ISSN 2333-2611

Page 34

An Anesthesia Quality Improvement Project to Improve Postoperative Pain Outcomes 
After Hysterectomy

MAJ Jacob L. Deeds1,2,3   DNP, CRNA, ANC, USA
MAJ Priscilla N. Shaw2  DNAP, CRNA, ANC, USA
LTC Aaron R. Elliott1 DNP, CRNA, ANC, USA
Brett T. Morgan3  DNP, CRNA

Affiliation:
1 William Beaumont Army Medical Center, Fort Bliss, TX
2 United States Army Graduate Program in Anesthesia Nursing, Fort Sam Houston, TX
3 Duke University, Durham, NC

Funding/Conflict of Interest Disclosure: 
None

KEYWORDS: Preemptive, preventive, gabapentin, intravenous acetaminophen, postoperative pain

INTRODUCTION
Background

Each year, over 100 million inpatient and outpatient surgeries occur,1,2 with over 80% of these patients complaining 
of postoperative pain.3 Eighty-six percent of these patients will describe their pain as moderate, severe, or extreme.3 
Ineffective control of pain after surgery prevents early mobilization, increases side effects related to treatment, lengthens 
post-anesthesia care unit (PACU) stay, increases hospital admission rates, delays discharge home, and decreases patient 
satisfaction.4,5 The effect on health care costs is dramatic. Hospital stays in the United States cost $1960 per day, on 
average.6 Poor early postoperative pain management not only increases a patient’s length of stay but is reported to be 
a primary cause of chronic pain,7 now costlier on an annual basis than treatment of cancer, heart disease, or diabetes.8 
Moreover, opioids, the mainstay of postoperative pain management,9 have demonstrated efficacy but their use potentially 
contributes to these escalating costs. Oderda et al4 demonstrated that 2.7% of patients experience an opioid-related 
adverse event resulting in significant increases in length of stay (0.53 days) and an additional $840 in hospital costs per 
event.

Postoperative pain is nondiscriminatory, affecting patients across the surgical spectrum. However, women who undergo 
hysterectomies are a uniquely vulnerable population. Each year, 500,000 hysterectomies are performed in the United 
States, making this the second most common major surgery for women.10 Minimally invasive techniques, such as vaginal 
or laparoscopic hysterectomies, have been shown to decrease overall complication rates, the length of hospital stay, and 
pain, when compared with abdominal hysterectomy.11 Nevertheless, high ratings of pain occur even when minimally 
invasive techniques are used, with patients rating their pain as moderate to severe.12,13

Abstract
An anesthesia quality improvement initiative implemented an evidence-based, preemptive, preventive multimodal 

analgesic regimen to improve perioperative pain outcomes for women undergoing hysterectomy. Although statistical 
significance was not achieved, clinically significant decreases in post-anesthesia care unit (PACU) narcotic usage, pain 
ratings, time in the PACU, and opioid-related side effects were observed. This analgesic regimen was easily implemented, 
readily modifiable, and suitable for expansion to multiple surgical populations to supplement customary anesthesia 
perioperative care.



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Volume 4 - Issue 1 2016 Page 35

An ideal anesthesia analgesic regimen is safe, inexpensive, 
rapidly administered, and effective.14 Unfortunately, effective 
analgesic techniques, such as epidurals or spinals, carry intrinsic 
risks, are time-intensive, require special postoperative monitoring, 
and do not always appeal to patients.5 The American Association 
of Nurse Anesthetists (AANA) Standards for Nurse Anesthesia 
Practice15 and the American Society of Anesthesiologists (ASA) 
Practice Guidelines for Acute Pain Management in the Perioperative 
Setting16 recommend utilization of preemptive,15 multimodal15,16 
pain management regimens when possible. Preemptive analgesia 
is the administration of an analgesic prior to noxious stimuli 
with the goal of decreasing acute pain upon insult and decreasing 
pain-related modulation of the central nervous system, thereby 
inhibiting postoperative pain.17 Multimodal analgesia is the 
administration of 2 or more different agents that act by different 
mechanisms to provide better analgesia than single modalities 
and minimize analgesic-associated side effects.8 This quality 
improvement project was undertaken to implement an evidence-
based, preemptive, multimodal analgesic regimen to improve 
perioperative pain management outcomes in patients undergoing 
hysterectomy in a local setting where 5 to 10 hysterectomies are 
performed monthly.
Local Problem

Between June 2014 and September 2014, at the author’s local 
institution, data were prospectively collected on 25 consecutive 
hysterectomies demonstrating that women undergoing 
hysterectomies experience moderate to severe postoperative 
pain. Data collected included (1) the amount of analgesics 
(morphine equivalents) administered in the PACU, (2) pain 
ratings every 15 minutes (on an 11-point numeric rating scale, a 
validated pain assessment tool,18 with 1-3 indicating mild pain, 
4-6 moderate pain, and 7-10 severe pain), (3) the incidence of
opioid-related adverse events, and (4) time spent in the PACU. 
The median time in the PACU was 72 minutes, determined by
PACU admission time until discharge criteria were achieved, and
the total median analgesic dose administered in the PACU, in
morphine equivalents, was 7.5 mg. Opioids administered during
the data collection period were exclusively fentanyl, morphine, 
and hydromorphone. A median pain rating of 5 was reported
on admission, 6 after 15 minutes, 5 after 30 minutes, 5.5 after
45 minutes, and 5 after 60 minutes. No preemptive analgesia
was observed and 20% of these patients had analgesic regimens
that were non-multimodal and consisted entirely of opioids. 
The incidence of opioid-related adverse events was 20%, with
4 patients complaining of nausea and 1 patient experiencing
respiratory depression.
Intended Improvement

This quality improvement project aimed to utilize a preemptive, 
multimodal analgesic regimen for 100% of patients undergoing 
hysterectomy to decrease postoperative opioid use, opioid-related 
adverse events, PACU pain scores, and time in the PACU.
Quality Improvement Question

The primary question addressed was, “In women undergoing 
hysterectomy, will the addition of an evidence-based preemptive 
analgesic regimen improve pain control, decrease the requirement 
for opioid pain medications, decrease opioid-related adverse 

events, and decrease the time spent by patients in the PACU 
compared to customary analgesic regimens?”
METHODS

Ethical Issues
No protected health information was logged for this project. 

All data were retrieved from the patient’s electronic medical 
record on the day after surgery and recorded in an SPSS (IBM 
Corp) dataset for analysis. The data collected during this quality 
improvement project did not include information that would 
allow any person to identify the participants. The SPSS dataset 
was saved on a Department of Defense secure server in a 
password-protected folder.

The project was submitted to the local Institutional Review 
Board (IRB) for a quality improvement study determination 
and did not satisfy the definition of “research” under US Code 
of Federal Regulations 32 CFR 219.19 The IRB application 
stated the project was aimed at “improving local systems of care 
utilizing an accepted multimodal approach to perioperative 
analgesia in accordance with practice guidelines” (M Abel, 
unpublished memorandum, April 1, 2014). Subsequent to local 
IRB determination, the project was also submitted to the Duke 
University IRB, which concurred with the local determination.
Setting

The setting was a military treatment facility located in the 
southwestern United States serving over 100,000 beneficiaries 
who receive care within the military health system. Beneficiaries 
of this military health system include all age groups and consist 
primarily of active duty service members and families, National 
Guard/Reserve members, and retired service members and 
families.20 The surgical department comprised 10 operating 
rooms, encompassing approximately 800 surgeries per month, of 
which 5 to 10 were hysterectomies performed by the obstetrical-
gynecological surgical service (E Leiter, personal communication, 
March 20, 2014). The anesthesia staff consisted of 23 certified 
registered nurse anesthetists (CRNAs) and 9 physician 
anesthesiologists.
Planning the Intervention

The analgesic regimen instituted consisted of preoperative 
administration of 600 mg oral gabapentin and 1 g intravenous 
(IV) acetaminophen. The regimen was derived from the
ASA Practice Guidelines for Acute Pain Management in the
Perioperative Setting recommendations,16 the AANA Standards
for Nurse Anesthesia Practice,15 a review of the literature, and
anesthesia staff experience with multimodal regimens in other
institutions similar to the author’s. There was much discussion
on whether to utilize oral versus IV acetaminophen. Owing to
a lack of evidence comparing the 2 routes, we selected the IV
formulation secondary to the varied absorption rates of oral
acetaminophen prior to surgery,21 increased peak plasma levels
of IV acetaminophen,22 increased cerebral spinal fluid levels of
IV acetaminophen,22 and the preference for IV over oral by our
anesthesia providers.

The sample and inclusion criteria consisted of (1) patients 
scheduled for hysterectomy (total laparoscopic, laparoscopic 
assisted, vaginal, or transvaginal), (2) 20-55 years of age, and 



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Volume 4 - Issue 1 2016 Page 36

(3) physical status score of I-III, representing patients without
severe systemic disease processes. Exclusion criteria consisted of
(1) hypersensitivity to gabapentin or acetaminophen, (2) renal
insufficiency, or (3) liver disease. No patients were required to
be excluded. Patients were identified 5 days prior to surgery via
the operating room schedule. On the day of surgery, patients
followed the normal protocol, arriving at the hospital at least 2
hours in advance of their surgery. Upon arrival to the preoperative
holding area, approximately 1 hour before the start of surgery, 
the patient received 600 mg gabapentin with a small sip of water, 
administered by the preoperative holding area nurse or anesthesia
staff. Approximately 30 minutes prior to the start of surgery, 
1 g IV acetaminophen was administered over 15 minutes. The
administration of IV acetaminophen and gabapentin at these
times was important, as their respective peak effects coincided
with the onset and cessation of the surgery, respectively. Any
additional analgesics required were determined in the customary
way by the assigned anesthesia provider to that surgical case. 
Assessment in the PACU was done in standard PACU fashion
(pain assessments, pain interventions, and traditional modified
Aldrete scoring every 15 minutes) with no additional assessments
required by the PACU staff.
Planning the Study of the Intervention

The project aimed to improve postoperative analgesic outcomes 
following hysterectomy. Analysis of the outcomes consisted of a 
pre/post design with a period of pre-implementation (customary 
analgesic regimens) data collection, a period of instruction to 
applicable staff (surgeons, anesthesia providers, PACU nurses) 
regarding implementation of the quality improvement project, 
and a period of post-implementation (preemptive multimodal 
regimen of IV acetaminophen and gabapentin supplemented by 
our customary analgesic regimens) data collection. Quantitative 
data collected by the PACU nurses for every hysterectomy patient 
in the recovery room were used to evaluate the aims. Additionally, 
age, weight, duration of surgery, type of hysterectomy, and the 
presence of preoperative chronic pain were collected as baseline 
variables. These items were predetermined by the gynecological 
and anesthesia staff as possible variables that could affect the 
outcomes independent of the analgesic regimen.

Methods of Evaluation
Data evaluating the aims of this project were collected directly 

from the patient’s chart by the author and input into an SPSS 
dataset on the day after surgery. Prior to data collection, the 
author analyzed the patient’s electronic medical record and 
ensured the designated regimen had been performed in the 
proposed manner. Primary outcomes were reflective of the 
aims of the project, whereas secondary outcomes provided 
additional analysis. Primary outcomes were (1) pain assessment 
on admission to the PACU, and at each 15-minute subsequent 
assessment, using an 11-point verbal rating scale; (2) PACU 
total opioid use converted to morphine equivalents; (3) time 
from PACU admission to the time at which criteria were met 
for discharge; and (4) absence or presence of opioid-related 
adverse events defined as nausea, vomiting, respiratory depression, 
dizziness, or sedation. The secondary outcomes were (1) 
intraoperative opioid use converted to morphine equivalents; (2) 
time from the end of surgery to removal of the endotracheal tube 
(extubation); and (3) time to first analgesic administration in the 
PACU.
Analysis

The aims of this project were to improve analgesic outcomes 
as evidenced by decreased opioid administration, pain ratings, 
opioid-related adverse events, and time in the PACU. Descriptive 
statistics were used to summarize the data and comparisons 
were made between the pre-implementation and post-
implementation groups to determine if the aims were achieved. 
We further compared the groups by using inferential statistics, 
as determined by the distribution of the data and assumptions 
of proposed statistical tests. For interval and ratio level data that 
met assumptions, a two-tailed independent t-test was utilized 
(time in the PACU). Mann-Whitney U tests were conducted if 
assumptions were not met (PACU morphine equivalents, pain 
ratings). Categorical secondary outcomes (absence or presence of 
opioid-related adverse events) were analyzed by using Pearson’s 
chi-squared test. Relationships between variables were further 
investigated by using a Pearson or Spearman’s correlation. 
Analysis was executed by using SPSS Statistics version 21 (IBM 
Corp).



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Volume 4 - Issue 1 2016 Page 37

RESULTS

Outcomes
There were no significant differences in baseline characteristics between the pre- and post-implementation groups. Each group was 

similar in age, weight, duration of surgery, preexisting chronic pain, and type of hysterectomy (Table 1).

Compared with patients in the pre-implementation group, patients in the preoperative gabapentin and IV acetaminophen 
group showed improvements in all primary outcomes and in all but one of the secondary outcomes (Table 2). PACU analgesics in 
morphine equivalents were reduced 33%, and time in the PACU (minutes) was reduced by 13%. In both groups, the opioids utilized 
were exclusively fentanyl, morphine, and hydromorphone. Secondary outcomes showed similar improvements for 2 of the outcome 
measures, whereas 1 of the outcomes slightly worsened. Comparing patients in the pre-implementation group with those in the post-
implementation group, intraoperative analgesic administration was reduced in morphine equivalents by 21% and time to first analgesic 
administration was delayed 5%, whereas the time from the end of surgery to extubation was prolonged by 6.2%.

Table 1. Baseline Characteristics of the Groupsa

Pre-QI Implementation 

Data (n= 25)

Post-QI Implementation 

Data (n=25)

P Value

Age, years (± SD) 39.32 ± 6.16 41.16 ± 7.69 0.36

Weight, kg (± SD) 86.08 ± 18.37 79.34 ± 17.61 0.19

Duration of surgery, min 103 110 0.15

Preexisting chronic pain (yes/no) 1/24 5/20 0.19

Type of hysterectomy, trans/TVH/TLH/

LAVH (number of each performed)

5/17/1/2 7/15/1/2 0.93

Abbreviations: LAVH, laparoscopically assisted vaginal hysterectomy; QI, quality improvement; TLH, total laparoscopic hysterectomy; trans, 
transvaginal hysterectomy; TVH, total vaginal hysterectomy.
aThe pre-implementation group did not receive preoperative gabapentin and IV acetaminophen. The post-implementation group received 600 mg 
preoperative gabapentin and 1 g IV acetaminophen. There were no significant differences between the pre-implementation and post-implementation 
groups.

Table 2. Primary and Secondary Outcomes Before and After Implementationa

Pre-QI Implementa-

tion Data (n=25)

Post-QI Implementa-

tion Data (n=25)

P Value Percentage 

Change
PACU analgesics, mor-

phine equivalents

7.5 5 0.62 33% reduction

Time in PACU, min (± 

SD) 

75.12 ± 32.81 65.12 ± 22.01 0.21 13% reduction

Intraoperative analge-

sics, morphine equiva-

lents

31.67 25 0.14 21% reduction

Time to extubation, 

min (± SD), from end of 

surgery

5.8 ± 3.10 6.16 ± 5.12 0.77 6% increase

Time to first analgesic in 

PACU, min (± SD)

19.83 ± 13.16 20.79 ± 13.02 0.83 5% increase

Abbreviations: PACU, post-anesthesia care unit; QI, quality improvement.
aPre-implementation group received customary care decided by anesthesia provider. Post-implementation group received preoperative gabapentin 
and IV acetaminophen in addition to typical care as determined by anesthesia provider.



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Volume 4 - Issue 1 2016 Page 38

Percentage change in pain scores varied from a 5% to 10% reduction at admission, 15, 45, and 60 minutes in the PACU, although 
there was no difference in pain scores at 30 minutes. The incidence of opioid-related adverse events was reduced by 80% (Table 3).

Table 3. Comparison of Pain Ratings Before and After Implementationa

Numeric Rating Scale Pre-QI Implementa-

tion Data (n=25) 

Post-QI Implementa-

tion Data (n=25)

P Value Percentage Change

Admission 5 4 0.94 10% reduction
15 minutes 6 5 0.88 10% reduction
30 minutes 5 5 0.68 0% reduction
45 minutes 5.5 5 0.36 5% reduction

60 minutes 5 4.5 0.44 5% reduction
Opioid-related ad-

verse events, No. of 

episodes

Nausea (4)

Respiratory

depression (1)

Nausea (1) 0.20 80% reduction

aPre-implementation group received customary care as determined by anesthesia provider. Post-implementation group received preoperative 
gabapentin and IV acetaminophen in addition to typical customary care decided by anesthesia provider.

Numerous relationships were observed between 
variables. Morphine equivalents administered in the PACU 
and time in the PACU displayed a large, positive correlation 
[rs (48) = 0.528, P<0.000]. Additionally, pain on admission 
and time in the PACU had a moderate, positive association 
[rs (48)= 0.349, P<0.01]. Notably, the largest association with 
opioid-related adverse events (a small negative correlation) was 
with whether the patient received the preoperative analgesic 
regimen. Administration of the preoperative analgesic regimen 
was associated with fewer opioid-related adverse events [rs (48) = 
-0.25, P=0.085].

Statistical significance was not achieved for any inferential
statistical test. This was likely due to the small sample of the
quality improvement project. Given a medium effect size (0.50), 
alpha set to 0.05, and power set to 0.80, a sample size of 75 would
have been required in each group to achieve statistical significance
for a two-tailed independent t-test. This would have necessitated
15 to 30 months to complete at the author’s institution. Given
that this was a quality improvement study, utilizing analgesics
already supported by Category A1 evidence,16 a shorter duration
was preferred to achieve results consistent with the literature and
to assess successful implementation of the project.
DISCUSSION

Summary
Prior to this quality improvement project, there were

no existing preemptive analgesic protocols in this author’s
department and concerns existed that staff resistance may lead
to difficulty with implementation. However, this preemptive, 
multimodal project was well received by all anesthesia providers. 
The strength of this project was the simplicity with which the
regimen was instituted coupled with the documented efficacy

of the analgesic regimen. Postoperative opioid use and opioid-
related adverse events showed marked improvement, and all other 
primary objectives trended positively. Minor changes were made 
to the project during implementation. One change related to the 
timing of the gabapentin as patients arrived at the operating room 
holding area. Initially, patients were to receive the oral gabapentin 
upon arrival to the holding area. However, administration at this 
time resulted in the patients receiving the gabapentin 2 to 3 hours 
early for 2 of the first 5 patients in the post-implementation 
group. This was identified early and overcome by holding the 
gabapentin until physical confirmation of the previous operation 
nearing completion, as evidenced by the onset of suture closure of 
the surgical incisions.

Despite the minor adjustment to protocol, the project was 
successful and met its intended goals. Significant improvements 
were noted by the large decrease in narcotic analgesics 
administered in the PACU, the decreased time spent by patients 
in the PACU, and the substantial decrease in opioid-related 
adverse events.
Relation to Other Evidence

The project’s outcomes were consistent with the evidence 
appraised in the literature. Gabapentin and its effect on pain 
and pain-related outcomes have been studied extensively for 
both operative and nonoperative pain. Gabapentin, although 
similar in structure to gamma-aminobutyric acid (GABA), does 
not attach to the GABAA or GABAB receptors, but instead is 
an alpha-2 delta calcium channel blocker believed to exert its 
effect by decreasing neurotransmitter release.23 Gabapentin 
has a high volume of distribution (60 L in healthy individuals) 
and achieves its maximum plasma concentration (Cmax) in 3 
hours. Gabapentin is unbound to proteins and is cleared almost 
exclusively by the kidneys with an elimination half-life of 4.8-8.7 



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Volume 4 - Issue 1 2016 Page 39

hours.23 When administered 1 to 2 hours before hysterectomy, 
vaginal or abdominal, studies have reported a decrease in 
morphine consumption,24-31 a decrease in pain scores,24-26,28,31 and 
a decrease in nausea or vomiting.24,26,29

Although oral and rectal forms of acetaminophen have been 
available for over a century, the IV formulation is relatively new. 
IV acetaminophen was introduced in Europe in 2002 but was 
not approved for use in the United States until 2010, under 
the trade name OFIRMEV (Mallinckrodt Pharmaceuticals). 
IV acetaminophen is now found in many hospitals around the 
world.22 The exact mechanism of IV acetaminophen is unknown 
but it has been shown to exert its action both centrally and 
peripherally, possibly altering the action on NMDA, COX, and/
or serotonergic receptors.23 The Cmax for IV acetaminophen is 
twice that of oral administration, achieved in 15 minutes, and IV 
acetaminophen has a duration of action of approximately 4 to 6 
hours. IV acetaminophen has a volume of distribution of 69.2 L 
in healthy volunteers and does not bind extensively to proteins. 
It is metabolized extensively by the liver and has an elimination 
half-life of 2.7 hours.32 Preemptive IV acetaminophen utilized 
as an adjunct to pain management for hysterectomy has been 
reported to decrease narcotic requirements,33,34 decrease pain 
scores,33 and decrease opioid-related adverse events.33,34 When 
preemptive IV acetaminophen and gabapentin are combined, the 
decrease in narcotics and pain scores is significantly greater than 
placebo as well as when either drug is used independently.35,36

Limitations
With only 25 patients in each group, a greater number of 

disparities in practice among anesthesia providers for one group 
than the other may have affected the analgesic outcomes. For 
example, anesthesia providers interpret pain during surgery and 
treat it accordingly. Some providers may block the sympathetic 
response with nonanalgesic sympatholytics rather than analgesics, 
potentially leading to increased pain for patients while in the 
PACU until appropriate analgesia is achieved. The lack of 
controls regarding intraoperative actions by anesthesia providers 
was ultimately viewed as a strength of this quality improvement 
project, however, because altering individual anesthesia provider 
preferences would change the overall ability to determine this 
regimen’s application in the author’s setting.

Chronic pain is a common indication for hysterectomy and 
provides a unique postoperative pain management challenge 
owing to nervous system sensitization or tolerance to analgesics.37 
This factor was identified prior to implementation and 
comparisons were conducted to ensure homogeneity between 
groups. However, it was discovered after implementation had 
begun that the source for these data, the anesthesia preoperative 
assessment, was inconsistent with the surgeons’ history and 
physical examinations. Therefore, many of those with chronic 
pain may not have been identified. It is possible that with only 25 
patients in each group, one group may have included a statistically 
significantly greater number of patients with chronic pain, 
although this is unlikely.

The likelihood that observed outcomes would wane over time 
was considered possible if anesthesia providers abandoned the 
preemptive, multimodal nature of this intervention. Attempts 
were made by the author to maintain compliance over time. 

During dissemination of the study results to the anesthesia 
department, time for discussion was afforded to allow the 
CRNAs and anesthesiologists the opportunity to provide 
critiques and identify barriers not detected by the author. 
Encouragingly, the anesthesia staff expressed an overwhelmingly 
positive attitude, and further plans have been made to expand on 
the success of this project. Ideally, the author would have observed 
the continued use of preemptive, multimodal pain management 
regimens that followed the formal implementation group of this 
project. Unfortunately, there was no additional time to achieve 
this outcome.
Interpretation

This quality improvement project resulted in clinically 
significant improvements in practice outcomes with the 
implementation of minor alterations of practice. Despite the 
effectiveness of the instituted regimen, some modifications to 
future regimens could be considered, including the addition of 
nonselective COX inhibitors, selective COX-2 inhibitors, and/or 
alpha-2 antagonists, among other minor adaptations. This project 
instituted a fixed regimen for all women having a hysterectomy 
and did not allow for flexibility by the anesthesia provider to 
alter the gabapentin dose or substitute a preemptive analgesic, 
as they might have otherwise. Ideally, analgesic regimens should 
be individually tailored for patients according to the anesthesia 
provider’s clinical expertise.

Hospital-costing practices can be highly variable and complex 
with differing methodologies resulting in difficulty performing 
a cost analysis for this analgesic regimen. Moreover, a cost 
comparison was not an intended outcome measure for this 
quality improvement project. However, a simple exploration of 
economic benefit was performed. For the author’s institution, the 
direct cost of the addition of the analgesic regimen of gabapentin 
and IV acetaminophen (OFIRMEV) was $12.39, $0.56 per 
600-mg dose of gabapentin and $11.83 per 1000-mg dose of
IV acetaminophen (OFIRMEV) (S Blessing, A Pangelinan, 
personal communication, April 20, 2016). Given the modest cost
of opioids and antiemetics, any financial benefit of the addition of
gabapentin and IV acetaminophen (OFIRMEV) was not likely
realized in drug cost-savings. Rather, the savings were more likely
observed in the avoidance of opioid-related adverse drug events
and the time and activity costs that are associated with them. 
In this project, opioid-related adverse events were reduced from
an incidence of 5 to 1 (Table 3). Oderda et al4 reported that for
every opioid-related adverse event, there is additional $840 in
hospital costs. Thus, the small increase in costs for the regimen
was quickly recovered.

Moreover, the cost of this regimen could be further reduced if 
the oral formulation of acetaminophen, costing $0.15 per 975-
mg dose (S Blessing, A Pangelinan, personal communication, 
April 20, 2016), was administered in place of the IV formulation. 
Although there is good pharmacokinetic theory supporting 
the claim that IV acetaminophen would provide better 
analgesia,21,22 there is limited evidence and much debate whether 
IV acetaminophen actually leads to better analgesic outcomes. 
Currently, multiple clinical trials are ongoing to compare the 2 
formulations and answer these clinical questions.38



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Volume 4 - Issue 1 2016 Page 40

Conclusions
In summary, the analgesic regimen was easily implemented, increased the incidence of multimodal regimens, and improved analgesic 

outcomes for women undergoing hysterectomy at the author’s institution. This regimen is easily modifiable, potentially cost-saving, 
and compatible for implementation with other patient populations. Future quality improvement projects of this kind would expand the 
regimen to other surgical populations and provide more flexibility in the analgesic regimen, particularly with regard to using additional 
preemptive analgesics, substituting analgesics when deemed appropriate, and increasing or decreasing doses as needed. Furthermore, 
future projects could thoroughly conduct a formal time-driven, activity-based costing algorithm to further explore the potential for 
cost-savings.

Summary of Key Points

-Easy-to-implement, evidence-based regimen consisting of preoperative gabapentin and IV acetaminophen

-Reduced opioid consumption, pain scores, opioid-related adverse events, and time in the PACU

-Cost-effective, easily modifiable, and appropriate to multiple populations across numerous surgical operations

Acknowledgments:  The primary author was a Duke University Doctor of Nursing Practice student throughout the QI Project.  

The authors would like to thank Julie A. Thompson, PhD, Duke University School of Nursing, for her statistical consultation 
throughout the creation of this manuscript.  The authors would also like to thank the incredible leadership and anesthesia staff of 
William Beaumont Army Medical Center for their commitment to Evidence-Based Medicine and best practices.

Disclaimer: The views expressed in this manuscript are those of the author(s) and do not reflect the official policy of William 
Beaumont Army Medical Center, the Department of the Army, or the United States Government.



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