Implementation of an Opioid Weaning Protocol at a Tertiary Care Children’s Hospital

Abstract

OBJECTIVES: Evaluate the implementation of a pharmacist-managed opioid weaning regimen and objective opioid withdrawal assessment tool in pediatric patients requiring an opioid wean. We hypothesized that this combination would be associated with a reduction in the wean duration and length of stay and decrease episodes of opioid withdrawal. METHODS: Retrospective cohort study utilizing pediatric inpatients requiring an inpatient opioid medication wean. The study was conducted in 3 phases from chart review of patients admitted from 2012 to 2020: baseline preintervention (phase 1), pharmacist-managed weaning regimen (phase 2), and addition of an objective assessment tool, the Withdrawal Assessment Tool-1 (phase 3). Data collection included the total wean duration, total duration of hospital admission, and number of episodes of opioid withdrawal. RESULTS: The study included 115 patients with 36 patients in phases 1 and 3 and 43 patients in phase 2. Median age ranged from 0.46 to 0.84 years and the majority of children were males. No significant differences in patient characteristics such as age, weight, sex, and previous opioid exposure were found between phases. Length of stay, wean duration, and episodes of withdrawal with need for rescue dose all decreased significantly from phase 1 to phase 3. CONCLUSIONS: Use of a pharmacist-managed weaning regimen combined with the Withdrawal Assessment Tool-1 tool was associated with significantly shorter methadone weans and overall length of stay. This has implications for wide spread dissemination and standardization of this approach in tertiary care children’s hospitals caring for patients after ICU admission.

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

“…The characteristics of the 32 included studies are summarized in Supplementary Table S6, and the details of the algorithms are provided in Supplementary Table S7. Twenty-three studies used a quasi-experimental design (73%) (61, 63, 64, 66, 70-74, 76-83, 85-88, 93, 95), seven were cohort studies (21%) (65,75,84,(90)(91)(92)94) and two were RCTs (6%) (62, 89). The studies were conducted across 11 countries: 15 in the United States (47%) (62, 64, 65, 70-72, 74, 75, 86-88, 90-93), 11 in six European countries (34.3%) (61, 63, 66, 73, 76-80, 94, 95), three in Australia (9.4%) (83-85), and three in three Asian countries (9.4%) (81, 82, 89).…”

“…The distribution of the 28 algorithms by type of condition represented is shown in Figure 2. Nine (32%) of the 28 algorithms focused on one condition alone (65, 70-72, 81, 87, 89-92), one on pain (87), one on sedation (81), and seven on IWS/weaning (65,(70)(71)(72)(89)(90)(91)(92). Of the remaining 19 algorithms (68%), all but one (88) combined sedation with at least one other condition, which were distributed as follows: 12 "pain-sedation" algorithms (61, 63, 64, 73, 75-77, 84-86, 93-95), four "pain-sedation-IWS" algorithms (62, 74, 78-80, 83), one "pain-sedation-delirium-IWS" algorithm (66), and one "sedation-IWS" algorithm (82).…”

“…Nurses were responsible for managing the algorithm (88.9%) (61-66, 70-81, 83-86, 88, 89, 91-93, 95), one algorithm was managed by a pharmacist (3.7%) (82), another by a pharmacist, a critical care physician, and a nurse (3.7%) (90), and one by a pharmacist and nurse (3.7%) (65). One study did not report the HCP responsible for management (87).…”

“…Fifteen studies included information on the process and documentation of algorithms. Of these, ten (67%) integrated the measurement instruments into the electronic health record (61, 65,66,74,81,86,88,[92][93][94][95], two (13%) included a portion as an order set in the electronic health record (70,85), and three were paper-based at the bedside (63,64,71). The measurement instruments used by algorithm, condition, and measurement frequency are summarized in Supplementary Table S8.…”

“…The measurement instruments used by algorithm, condition, and measurement frequency are summarized in Supplementary Table S8. Of the 14 algorithms that included IWS (62, 65, 66, 70-72, 74, 78-80, 82, 83, 88-92), the most commonly used measurement instrument was the WAT-1 (69%) (62, 65, 66, 71, 74, 89-92), and the monitoring frequency varied from 4 to 12 h (62, 65,66,71,[89][90][91][92]. Nineteen algorithms included pain measurement instruments (61-64, 66, 73-80, 83-88, 93-95), of which seven (37%) assessed pain without using a combined pain and sedation measurement instrument (62, 64,74,83,87,88,93), the most commonly used was the FLACC (57%) (62, 64, 74, 93), and was monitored every 4 h (62, 74,83,93).…”