Table 4 Full list of proposed quality indicators

Patient education

The site provides and delivers patient education materials in the preoperative period which cover expectations of perioperative pain and pain management options including the risks and benefits of opioids

The site provides and delivers patient education materials at discharge which cover the provision of patient education on safe storage and disposal of unused opioids in the community, the requirement to avoid opioid diversion, and opioid specific discharge advice, e.g., DVLA requirements

Staff education

The site provides and delivers multi-professional education materials on opioid stewardship

The site provides and delivers multi-professional education materials on the provision of multimodal analgesia at all stages of the patient journey starting in the preoperative setting

Percentage of prescribers who receive regular reports comparing their prescribing to hospital guidelines

The site provides and delivers educational materials on the need for a clear discharge pain management plan and tapering strategy

Preoperative patient optimization

The presence of a system to identify opioid tolerance preoperatively, defined as opioids used for 7 days or fewer in the 60 days prior to surgery.

The provision of a specialist pain service and referral pathway to enable opioid weaning and patient-specific analgesic planning for preoperative optimization for patients with opioid tolerance

The site uses a preoperative screening tool to identify patients with risk factors for persistent postoperative opioid use (PPOU)

Patient and procedure-specific prescribing and deprescribing

The site has an acute pain service with the ability to provide a daily pain review

The electronic record is used as a means to detect or highlight potentially inappropriate high-dose postoperative opioid prescriptions

Review takes place to evaluate the procedure-specific mean daily inpatient MME used

Use of higher dosage of opioids (> 50–60 MME per day) at any time during the perioperative journey is used as a flag for further review

The site has a perioperative analgesia protocol which includes regional blocks and multimodal analgesia

The presence of procedure-specific protocols for use of in-patient opioids specifically promoting the avoidance of long-acting opioids

The presence of a review postoperatively seeking new risk factors for PPOU identified including, e.g., formation of a stoma

The percentage of those who are still using opioids at 90–180 days postoperatively (where the denominator is patients undergoing major surgery for bowel cancer)

The use of protocolized opioid prescribing for hospital discharge:

The site has a system to guide prescribing

The site has a system to allow the review of the procedure-specific mean discharge opioids prescribed for a particular patient group

The site has a patient group-specific guideline or algorithm to guide discharge opioid prescribing

The electronic record is used to enable procedure-specific prescribing limits

Procedure-specific postoperative prescribing guidelines are used to provide enough doses at discharge to cover 75% of patients (where the denominator is all patients undergoing that procedure)

The site has a system in place to allow the discharge pain management plan and tapering strategy to be clearly communicated to primary care team in a timely manner

The opioid requirement, e.g., total consumed during the 24 h prior to discharge is used as a guide for opioids prescribed on discharge

The presence of a review process for opioid prescription at discharge, where the denominator is all patients discharged having had a major surgery for bowel cancer:

The frequency of any opioids prescribed on hospital discharge

The frequency of slow-release opioid prescription on discharge

The frequency of immediate-release opioid prescription on discharge

The frequency of non-opioid adjuvant analgesia prescription on discharge

The presence of a protocol to guide de-escalation plan for opioids prescribed on discharge

Protocolized use of the ‘reverse pain ladder’ to guide de-escalation

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

The presence of a process to assess opioids prescribed versus opioids actually used following surgical procedures to allow tailoring of opioid prescriptions to need for a patient group/specific procedure

The presence of patient screening for risk of PPOU at discharge

Follow up for patients at greatest risk of persistent postoperative opioid use

The presence of a system to detect new or repeat opioid prescriptions given within 30 days of discharge

The presence of a protocol or clear plan to follow if opioid abuse or misuse is detected

Opioid-related adverse drug events (ORADEs)

The site uses a preoperative screening tool to identify patients at greatest risk of postoperative opioid-related adverse drug events (ORADEs). Documented risk factors are those who are male, obese, over 65, with comorbidities, a history of preoperative opioid use and those concurrently using sedative medication.

The site has a system in place to detect ORADEs among postoperative inpatients

There is a system in place to detect ORADEs in the community setting following discharge