• Phase 1: Education
• Grand rounds on pharmacology, risks/benefits, and clinical considerations of ITOs
• Summary of literature prepared and distributed to department
• Phase 2: Workflow standardization
• Order set created with institutional electronic medical record committees
• Ensured evidenced-based monitoring and rescue medications available
• Acute pain service workflow drafted
• Feedback solicited from acute pain service anesthesiologists
• Minimizes variability in practice
• Streamlined acute pain service documentation
• Basic chart review done of those receiving ITOs vs controls, including pain scores for first 6 hours post-operatively and rescue pain medications given

Figure 1: Educational material prepared for institution of ITOs protocol. A grand rounds presentation (A) was prepared and given to the department. Then, a workflow was drafted (B), which describes the process of placing ITOs at our institution and how to monitor and follow the patients postoperatively. Finally, a document containing background information on ITOs (C) was prepared and distributed to the department via our department’s file sharing system for those who wanted additional information on ITOs.

Figure 2: ITO order set created with postoperative monitoring and rescue medications. Order set was created using evidence-based monitoring that follows current guidelines. Additional rescue medications for pain, pruritus, and nausea were included for ease and patient comfort. The order set was then added to the electronic medical record ordering system with the help of institutional electronic medical record subcommittees.

Figure 3: Pain scores obtained from patients receiving ITO vs those receiving TAP blocks. Pain scores were measured on an hourly basis for the first 6 hours upon arrival to the PACU. This pilot study included 6 ITOs patients and 12 control patients. Controls were selected to match for procedure, surgeon, gender, and age.