Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

Cordray, Holly; Alfonso, Kristan; Brown, Clarice; Evans, Sean; Goudy, Steven L.; Govil, Nandini; Smith, Kathleen J.; Prickett, Kara K.

doi:10.1016/j.ijporl.2022.111209

Cited by 2 publications

(9 citation statements)

References 53 publications

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“…After provider education and implementing our standardized dosing protocol at BCSC, the average number of oxycodone doses per patient decreased significantly and there were no significant differences in rates of refill requests, 7‐day ED visits, or readmissions. The effects of reducing and eliminating opiates in posttonsillectomy patients have been studied, and our results are consistent with previous reports 4,18‐26 . Cordray et al implemented a similar opiate‐sparing protocol and studied its effects on both prescribing habits and outcomes in 1817 tonsillectomy patients.…”

Section: Discussionsupporting

confidence: 91%

“…A recent study from Emory University explored the elimination of opioid prescribing in patients younger than 6 years of age while prescribing opioids on a select basis for older children and noted a reduction in average opioid counts by 16.3 doses without increasing return visits for uncontrolled pain or reduced oral intake. 18 This study has several limitations which may affect its internal and external validity. First, objective pain measurement is challenging, especially in young children who may have difficulty verbalizing pain.…”

Section: Discussionmentioning

confidence: 94%

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Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

Amin,

Thompson,

Wang

et al. 2023

Otolaryngol.--head neck surg.

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ObjectivePostoperative 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.MethodsA 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.ResultsEach 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.DiscussionIn 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 PracticeDirected 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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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 94%

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

Amin,

Thompson,

Wang

et al. 2023

Otolaryngol.--head neck surg.

View full text Add to dashboard Cite

show abstract

“…Our institution implemented a standardized prescribing protocol for pain management after tonsillectomy in July 2019, which dramatically reduced opioid prescribing and may have influenced providers' prescribing decisions for other types of surgeries. 27 The protocol included age-based guidelines that aimed to minimize opioid prescriptions for patients ages 0-6 years, as well as limitations on total doses and a 0.10 MME/kg dose cap. 27 Our current study reflected similar changes following major ear surgeries.…”

Section: Discussionmentioning

confidence: 99%

“…27 The protocol included age-based guidelines that aimed to minimize opioid prescriptions for patients ages 0-6 years, as well as limitations on total doses and a 0.10 MME/kg dose cap. 27 Our current study reflected similar changes following major ear surgeries. The most dramatic drop in the rate of opioid prescriptions after major ear surgery occurred during the second half of 2019 when the tonsillectomy protocol was implemented; opioid prescriptions for ages 0-6 decreased to 0% in the last year of our analysis, and the average opioid dose fell below 0.10 MME/kg.…”

Section: Discussionmentioning

confidence: 99%

“…In tandem with growing attention to opioid stewardship, our study suggests that protocol development surrounding other surgeries has had carry‐over effects on broader prescribing practices. Our institution implemented a standardized prescribing protocol for pain management after tonsillectomy in July 2019, which dramatically reduced opioid prescribing and may have influenced providers' prescribing decisions for other types of surgeries 27 . The protocol included age‐based guidelines that aimed to minimize opioid prescriptions for patients ages 0–6 years, as well as limitations on total doses and a 0.10 MME/kg dose cap 27 .…”

Section: Discussionmentioning

confidence: 99%

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Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12‐Year Analysis

et al. 2022

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Objective Postoperative opioid prescriptions tend to exceed children's analgesic needs, but awareness of the opioid epidemic may have driven changes in prescribing behaviors. This study evaluated opioid prescribing patterns after major pediatric ear surgery. Methods This study reviewed all cases of tympanoplasty, tympanomastoidectomy, mastoidectomy, cochlear implantation, otoplasty, and aural atresia repair at a pediatric hospital during 2010–2021. Regressions were conducted to identify opioid prescribing trends over time. Potential covariates were assessed. Returns to the system were reviewed as a balancing measure. Results Even without a targeted protocol, opioid prescribing declined significantly. After prescribing peaked in 2012–2013, significant negative trends yielded lower rates of opioid prescriptions, fewer doses per prescription, smaller patient‐weight‐standardized dose sizes, and less variability (all p < 0.001). In 2012, 96.1% of patients received opioid prescriptions; the rate fell to 13.5% by 2021. For patients ages, 0–6, the annual rate of opioid prescriptions dropped from a maximum of 96.3% in 2012 to 0.0% in 2021. The annual average supply of doses per prescription decreased by 68% between 2013 and 2021, reducing the total days' supply to an evidence‐based 3.1 ± 1.6 days. Regressions did not detect changes in returns to the system. Pain‐related returns were rare (0.9%) and did not vary by opioid prescriptions (p = 0.37). Prescribing trends were closely correlated with a tonsillectomy‐focused protocol that our institution implemented in 2019. Conclusion Surgeon‐driven opioid stewardship has improved with no resultant change in revisit rates. Procedure‐specific quality improvement interventions may have broader off‐target effects on prescribing behaviors. Level of Evidence IV Laryngoscope, 133:1987–1992, 2023

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Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

Cited by 2 publications

References 53 publications

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

Opioid Prescribing Trends After Major Pediatric Ear Surgery: A 12‐Year Analysis

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