Title: Laxative prescribing for post operative head and neck cancer patients at Derriford Hospital
Abstract:
Introduction: Patients are at increased risk of constipation following major head and neck surgery. They are often prescribed strong analgesics post-operatively and opioid-induced constipation is a common adverse effect. Constipation can also be affected by other contributing factors including anaesthetic medications, limited physical activity and changes in fluid and diet intake. It is recommended that a prophylactic laxative is co-prescribed when commencing strong opioid therapy during admission. This is supported by guidelines from the Association of Anaesthetists and British Pain Society. Recommendations for the choice of laxatives are published by the National Institute for Health and Care Excellence (NICE) and the local hospital trust.
Aim: The aims were to increase the co-prescription rate of laxatives for post-operative head and neck cancer patients on opioids, to reduce the incidence of opioid-induced constipation and to improve post-operative recovery. This would be achieved through the evaluation of current prescribing practices, sharing of recommendations with the surgical team and introduction of reminders in the prescribing workflow.
Method: A two-cycle audit was undertaken on patients who have undergone major head and neck surgery under the Oral and Maxillofacial Surgery team at Derriford Hospital. The inclusion criteria were surgical treatment of head and neck cancer with free flap or regional flap reconstruction. The standard was 100% compliance in all patients reviewed. A total of 20 patient records were reviewed. The results were evaluated based on compliance with the following criteria: whether laxative(s) was prescribed during post-operative hospital stay; whether the laxative(s) was prescribed immediately post-op; and the appropriateness of laxative chosen.
Results: Excellent compliance has been maintained in regards to laxatives being prescribed during the patients’ hospital stay. From cycle 1 to cycle 2 of the audit, the mean timing of laxative prescription was reduced by 26.7% (0.73 days post-operation) and the maximum timing was reduced by 62.5% (5 days post-operation). The choice of laxative regimen was also more appropriately aligned with local guidelines (compliance increased from 18% to 100%).
Conclusion: Changes have been implemented within the Oral and Maxillofacial Surgery department. This included visual reminders and staff education, which have led to a significant improvement in the appropriate prescription of laxatives for post-operative head and neck patients. This is important as constipation could lead to increased risks of post-operative complications and prolonged hospital stay. Chronic constipation is also associated with a negative impact on quality of life. A departmental re-audit is planned in 12 months.
