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Amin SN, Thompson T, Wang X, Goldklang S, Martin LD, Low DKW, Parikh SR, Sie KC, Dahl JP. Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024; 170:610-617. [PMID: 37747042 PMCID: PMC10841103 DOI: 10.1002/ohn.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/21/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience. METHODS A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions. RESULTS Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses. DISCUSSION In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates. IMPLICATIONS FOR PRACTICE Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.
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Affiliation(s)
- Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Trey Thompson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Xing Wang
- Department of Biostatistics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samantha Goldklang
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Loy KA, Lam AS, Franz AM, Martin LD, Manning SC, Ou HC, Perkins JA, Parikh SR, Low DKW, Dahl JP. Impact of Eliminating Local Anesthesia on Immediate Postoperative Analgesia in Pediatric Ambulatory Adenotonsillectomy. Pediatr Qual Saf 2021; 6:e405. [PMID: 33977193 PMCID: PMC8104218 DOI: 10.1097/pq9.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/31/2020] [Indexed: 11/26/2022] Open
Abstract
Our goal was to standardize intraoperative analgesic regimens for pediatric ambulatory tonsillectomy by eliminating local anesthetic use and to determine its impact on postoperative pain measures, while controlling for other factors. METHODS We assembled a quality improvement team at an ambulatory surgery center. They introduced a standardized anesthetic protocol, involving American Society of Anesthesiologists Classification 1 and 2 patients undergoing adenotonsillectomy. Local anesthesia elimination was the project's single intervention. We collected pre-intervention data (79 cases) from July 5 to September 17, 2019 and post-intervention data (59 cases) from September 25 to December 17, 2019. The intervention requested that surgeons eliminate the use of local anesthetics. The following outcomes measures were evaluated using statistical process control charts and Shewhart's theory of variation: (1) maximum pain score in the post-anesthesia care unit, (2) total post-anesthesia care unit minutes, and (3) postoperative opioid rescue rate. RESULTS No special cause variation signal was detected in any of the measures following the intervention. CONCLUSIONS Our data suggest that eliminating intraoperative local anesthetic use does not worsen postoperative pain control at our facility. The intervention eliminated the added expenses and possible risks associated with local anesthetic use. This series is unique in its standardization of anesthetic regimen in a high-volume ambulatory surgery center with the exception of local anesthesia practices. The study results may impact the standardized clinical protocol for pediatric ambulatory adenotonsillectomy at our institution and may hold relevance for other centers.
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Affiliation(s)
- Kelsey A Loy
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Austin S Lam
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Amber M Franz
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - Scott C Manning
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Henry C Ou
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Jonathan A Perkins
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Sanjay R Parikh
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Wash
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Wash
| | - John P Dahl
- Department of Otolaryngology - Head and Neck Surgery, University of Washington School of Medicine, Seattle, Wash
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Seattle Children's Hospital, Seattle, Wash
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Poulin-Harnois CMS, Low DKW. How to Macguyver an epidural dressing for patients with spica casts. Paediatr Anaesth 2014; 24:1188-9. [PMID: 25279675 DOI: 10.1111/pan.12515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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