What Was Done?
Global Problem Addressed
Opioid abuse and overdose in adults is a well-known public health crisis. It has been reported that more than 5 million people in the United States alone abuse opioids and more than 30,000 deaths annually are attributed directly to opioid overdose.
Only recently has the focus shifted to include the pediatric population. Often the first exposure can be directly attributed to receiving a prescription after surgery. Several studies have shown that opioid prescribing practices show variability between procedures, institutions, and surgeons and often result in excessive prescriptions.
Low-fidelity educational interventions often resulted in practice changes and can overall decrease the number of opioids prescribed.
Identification of Local Problem
Increased awareness of variability of opioid prescriptions at our own institution was brought about by participation in a study for the pediatric surgery research collaborative assessing opioid prescriptions after umbilical hernia repairs.
Participation in this study led us to add a question about opioid usage into our telephone prompt after our outpatient surgeries. We commonly use a surgical specialty nurse driven telephone follow-up in two weeks after outpatient surgeries to assess for general recovery, pain control, incision issues, or any need for clinic visits. Assessing the patients’ responses revealed that most patients after common outpatient surgeries were prescribed an excessive dose of opioids. The patients stated that on average they took 50 percent or less doses. In order to decrease excess pain medications available that could possibly contribute to addiction or abuse, we created a guideline for average doses to prescribe after common outpatient surgeries. We hypothesized that this change in protocol would decrease the number of opioids prescribed without an adverse effect on postoperative pain or complications in our patient population.
How Was the Quality Improvement (QI) Activity Put in Place?
Context of the QI Activity
- Arkansas Children’s Hospital is a 336-bed, free-standing academic and teaching children’s hospital.
- The surgical team consists of six general surgeons, two surgical fellows, three nurse practitioners, a research resident, and several rotating surgical and anesthesia residents.
- The quality improvement project was largely physician and fellow driven to standardize and improve opioid prescription patterns after outpatient surgeries.
Planning and Development Process
Prior to implementation of the prescription guideline, opioid prescriptions were at the discretion of the operating residents, fellows, or attending surgeons. We retrospectively reviewed all of our outpatient cases utilizing telephone follow-up for a total of six months from August 1, 2018, to January 31, 2019. Parents were asked specifically how many doses of opioids the patient used. The average doses used were then analyzed and information was relayed to the staff surgeons and fellows. All practitioners agreed to make an effort to decrease the opioid prescriptions since most doses were not being utilized. A guideline was created with all attending surgeons agreeing to adhere to the guideline (Table 1).
