Background:
Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.
Methods:
After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.
Results:
The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).
Conclusions:
Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors’ quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.
CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, III.
BACKGROUND: Endoprosthetic reconstruction for bone tumor surgery was introduced in the 1970s. It has since evolved to be a successful and acceptable method of reconstruction and has become the gold standard of treatment. At present, 85% of patients will undergo limb salvage surgery with survival ranging from 60% to 90%.
PURPOSE:The complexity of bone sarcomas and limb-sparing surgery is discussed beginning with the initial presentation of the sarcoma patient. Limb-sparing surgery is depicted from initial exposure and removal of the diseased bone, placement of endoprosthetic, and presentation of patient postoperatively. A graphical portrayal is given to outline a stepwise and multidisciplinary approach when treating bone tumor patients. The discussion also includes postoperative care following surgery. Key aspects of nursing care are outlined. Management of patients with bone tumors involves a multidisciplinary team experienced in diagnostics, chemotherapy, and surgery. The priorities for patient and family education are highlighted.
The creation of professional advancement programs is an important goal to support development of nurses and other team members. Maintaining consistency among programs within one institution poses a challenge. The development of an overarching framework has provided this structure. Our framework is composed of core components, key elements, and best practices that can be applied to ensure consistency among all programs. This framework can be applied to existing programs or guide new eight programs.
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