Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric

Abstract

BACKGROUND There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology. STUDY DESIGN Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children’s hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis. RESULTS Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high. CONCLUSION Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.

Institutional and Regional Variation in Opioid Prescribing for Hospitalized Infants in the US

“…Expanded efforts to quantify and report opioid prescribing for children have led to the development of evidence-based prescribing guidelines and quality improvement initiatives . However, these efforts largely exclude infants, despite opioid exposure having unique neurodevelopmental risks in this age group.…”

“…Expanded efforts to quantify and report opioid prescribing for children have led to the development of evidence-based prescribing guidelines and quality improvement initiatives. 57 , 58 , 59 , 60 , 61 , 62 , 63 However, these efforts largely exclude infants, despite opioid exposure having unique neurodevelopmental risks in this age group. Future studies are needed to examine the long-term effects of prolonged opioid exposures in high-risk infants and further understand the impact of variations in institutional prescribing.…”

Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000–2020

“…Other notable recommendations in 2012-2013 drew attention to the specific concerns of prescribing codeine after tonsillectomy to children < 2 years old. These entreaties created an environment among pediatric providers that likely led to an extension of provider concern from codeine to all opioids, and from tonsillectomy (with or without adenoidectomy) specifically to other pediatric surgical and non-surgical conditions, further influencing opioid prescription to children [3,5,19,20,40,41]. In 2018, the FDA updated guidance to further limit the prescribing of opioid-containing cough and cold preparations to persons 0-18, likely leading to additional declines beyond the years we evaluated [6].…”