Table 3 Structural, process, and outcome quality indicators across the patient perioperative journey

Preoperative

(Bardiau et al. 1999)

(Fields et al. 2019) (Lee et al. 2017) (Neuman et al. 2019)

Patient education

Presence of preoperative patient education materials on perioperative pain and pain management, risks of opioids

(Bongiovanni et al. 2020)

(Hopkins et al. 2020)

Staff education

Presence of multi-professional education materials for staff on opioid stewardship and need for multimodal analgesia

(Brat et al. 2018) (Cron et al. 2017)

(Fields et al. 2019)

(Gan et al. 2020) (Hilliard et al. 2018) (Truong et al. 2019)

Preoperative identification and optimization for patients with opioid tolerance

Opioid tolerant definition: if opioids used for more than 7 days in the 60 days prior to surgery/any opioid use in 12/12 prior to surgery, any opioid medication on admission meds list

System to identify preoperative opioid use in elective population

Specialist pain referral pathway to enable opioid weaning and perioperative analgesic planning for preoperative optimization in opioid tolerant population

(Brummett et al. 2017)

(Clarke et al. 2014) (Fields et al. 2019) (Jiang et al. 2017) (Lee et al. 2017) (Macintyre et al. 2014) (Stafford et al. 2018)

Identification of patients at greatest risk of persistent postoperative opioid use (PPOU)

Opioid Risk Tool (ORT), Screener for Opioid Assessment and Patients with Pain (SOAPP) and Brief Risk Interview (BRI) may be of use in acute pain setting

Presence of screening tool to identify risk factors for persistent postoperative opioid use (PPOU) defined as use of opioids at 90–180 days postoperatively

Identified prevalence of PPOU risk

(Minkowitz et al. 2014)

Identification of patients at risk of opioid-related adverse drug events (ORADEs)

Presence of screening tool to identify preoperatively those at greater risk of postoperative opioid-related adverse drug events (ORADEs)

(Felling et al. 2018) (Yap et al. 2020)

Use of multimodal analgesia

Presence of protocol to reduce perioperative opioid use with preoperative multimodal analgesia

(Lee et al. 2017) (Macintyre et al. 2014)

Concept of ‘universal precautions’ in the use of perioperative opioids

Adoption of ‘universal precautions’ when initiating perioperative opioids

Intraoperative

(Bardiau et al. 1999) (Brandal et al. 2017)

(Cheung et al. 2009)  (Felling et al. 2018) (Keller et al. 2019) (Mujukian et al. 2020), (Neuman et al. 2019) (Stafford et al. 2018)

(Thiele et al. 2015) (Truong et al. 2019)  (Wick et al. 2017)

(Yap et al. 2020)

Use of multimodal analgesia

Presence of opioid-sparing protocol for intra operative use including minimally invasive surgery, regional blocks and multimodal analgesia

Adherence to intra-operative opioid sparing protocol

Recovery

(Fields et al. 2019)

Identification of patients at greatest risk of PPOU

Presence of review/re-screen with new risk factors for PPOU including formation of a stoma

(Bardiau et al. 1999) (Brandal et al. 2017) (Cheung et al. 2009)  (Felling et al. 2018)

(Keller et al. 2019) (Mujukian et al. 2020)  (Neuman et al. 2019)  (Stafford et al. 2018)  (Thiele et al. 2015) (Truong et al. 2019)  (Wick et al. 2017) (Yap et al. 2020)

Use of multimodal analgesia

Presence of opioid-sparing protocol for recovery/immediate postoperative use including regional blocks and multimodal analgesia

Adherence to recovery/immediate postoperative opioid sparing protocol

Postoperative

(Bardiau et al. 1999) (Brandal et al. 2017)

Access to acute pain service

Availability of an acute pain service

Delivery of a daily pain review

(Bardiau et al. 1999) (Brandal et al. 2017) (Cheung et al. 2009)  (Felling et al. 2018) (Gan et al. 2015)  (Keller et al. 2019) (Mujukian et al. 2020) (Neuman et al. 2019)  (Stafford et al. 2018)  (Thiele et al. 2015) (Truong et al. 2019) (Wick et al. 2017) (Yap et al. 2020)

Use of multimodal analgesia

Presence of opioid-sparing protocol for postoperative use including regional blocks and multimodal analgesia

Adherence to postoperative opioid sparing protocol

Rate of postoperative ileus

(Keller et al. 2019) (Kessler et al. 2013) (Lee et al. 2010) (Oderda et al. 2013)

(Tsui et al. 1996)

Presence of ORADEs

Scoring of frequency, severity, and distress of opioid-related side effects as 0 to 60 on the Perioperative Opioid-related

Symptom Distress scale

Presence of review for ORADEs

Rate of ORADEs, severity of ORADEs detected, impact of ORADEs on length of stay

(Greco et al. 2014)

(Neuman et al. 2019) (Syrowatka et al. 2021)

Protocolized opioid prescribing in hospital

Procedure-specific protocol for use of in-hospital opioids, promoting avoidance of long acting opioids

Electronic clinical quality measure (eCQM) to assess potentially inappropriate high dose postoperative opioid prescribing practices, e.g., an average daily dose

≥ 90 MME for the duration of postoperative opioid prescription in preoperatively opioid naïve patients

Discharge

(Brandal et al. 2017)  (Bromberg et al. 2021) (Chen et al. 2018) (Fields et al. 2019) (Fujii et al. 2018)  (Hill et al. 2017) (Hill et al. 2018) (Hopkins et al. 2020)  (Lee et al. 2017)  (Macintyre et al. 2014)  (Neuman et al. 2019) (Pruitt et al. 2020) (Thiels et al. 2017) (Wang et al. 2021) (Wick et al. 2017)

Protocolized opioid prescribing on discharge

Procedure-specific MME centiles to reduce inter-prescriber variation

Presence of a patient group specific guideline or algorithm for discharge opioid prescribing, opioid use in 24 h prior to discharge to guide opioids prescribed on discharge aiming at prescribing the lowest dose opioid possible for the shortest duration

Procedure specific post op prescribing guidelines to provide enough doses to cover 75% of patients

Procedure specific prescribing limits built into electronic patient record

Procedure-specific mean discharge MME prescribed

Total milligram of morphine equivalents (MME) consumed during 24 h prior to discharge

Opioid present on hospital discharge prescription

Frequency of slow-release opioids prescribed on discharge

Frequency of immediate-release opioids prescribed on discharge

Non-opioid adjuvant analgesia present on discharge prescription

(Brandal et al. 2017)

(Wang et al. 2021)

Review of inpatient opioid use

Presence of recording tool for opioids used during inpatient stay

Total milligram of morphine equivalents (MME) consumed during hospital stay

Procedure specific mean daily inpatient MME used

(Fields et al. 2019) (Hoang et al. 2020)

Identification of patients at greatest risk of PPOU

Use > 90th centile MME opioids, or equivalent of over 50 5 mg oxycodone prescribed at discharge as risk factor/flag for PPOU

(Hopkins et al. 2020) (Macintyre et al. 2014)

Opioid de-escalation and tapering

Presence of a de-escalation plan for opioids prescribed on discharge

Use of ‘reverse pain ladder’ to guide de-escalation

Pain management plan and tapering strategies clearly communicated to primary care team in a timely manner

(Bartels et al. 2016) (Fujii et al. 2018) (Lee et al. 2017) (Hill et al. 2017) (Macintyre et al. 2014) (Neuman et al. 2019)

Patient education

Provision of patient education on safe storage and disposal of unused opioids and avoidance of opioid diversion

Opioid-specific discharge advice, e.g., do not drive for up to 4 weeks until opioid dose is stable

(Macintyre et al. 2014)

Identification of patients at risk of ORADEs

Identify those at risk of ORADEs when prescribing opioids for use at home. Male, obese, over 65, greater comorbidities, pre-op opioid use, concurrent sedative medication use.

Follow up

(Agarwal et al. 2021) (Bartels et al. 2016) (Bromberg et al. 2021) (Howard et al. 2019) (Meyer et al. 2021) (Pruitt et al. 2020) (Roughead et al. 2019)

Review of opioids prescribed v used

MME prescribed and consumed

Presence of process to assess opioids prescribed v opioids used following surgical procedures to allow tailoring of opioid prescriptions to need for a patient group/specific procedure reduce unused opioid in the community

Post op prescription considered to have been given if opioids dispensed between 2–7 days following discharge

(Brat et al. 2018) (Clarke et al. 2014) (Fields et al. 2019) (Hill et al. 2018) (Pullman et al. 2021) (Roughead et al. 2019)

Identification of patients at greatest risk of or with PPOU

In primary care, detection of opioid misuse/PPOU after discharge, defined as at least one of the ICD-9 diagnosis code of opioid dependence, abuse, or overdose

Hospital analgesic policies include strategies to support post-discharge assessment and follow-up of patients at risk of becoming chronic opioid users

New or repeat opioid prescriptions within 30 days of discharge

Use of higher dosage of opioids at any time (> 50–60 MME)

PPOU: ongoing opioid use at 90–180 days post-discharge

Incidence of opioid-related re-admissions

Time to opioid cessation: a period without an opioid prescription equivalent to three times the estimated supply duration in preoperatively opioid naïve patients

(Pruitt et al. 2020)

Staff education

Staff education: prescribers sent quarterly reports on their prescribing v guidelines

(Macintyre et al. 2014)

Management of those with PPOU

Presence of plan/protocol if opioid abuse or misuse is detected