Introduction

This topic is intended to help anyone who is interested in quality improvement surrounding Opioid Use and Stewardship. While most projects address efforts geared toward decreasing opioid use in the perioperative care of children, other materials are available addressing a variety of topics including opioid disposal and provider/patient education.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

video link discussion of the Outcomes committee’s opioid prescribing guidelines [1]

Opioid Reduction

American College of Surgeons and APSA

(please also see the jointly created pediatric pain control materials on the Patient and Parent education page)

Children’s Healthcare of Atlanta

In light of the the current opioid epidemic, health care providers are focusing on decreasing opioid prescribing. As pediatric surgeons, we serve as a potential gatekeepers of opioids and opioid diversion for our patients, their families and communities. This quality improvement project specifically address the widely documented variation in prescribing practices after common surgical conditions and uses umbilical hernia repair as a launching pad for these efforts.

There are three basic phases of this project.

1. Retrospectively review discharge opioid prescribing practices at your center. We recommend three months of baseline data. These data should include surgeon specific practices and outcomes should include proportion of patients being discharged with opioid prescriptions, number of doses, and strength of doses.
2. Low fidelity educational intervention presented during a division meeting or a grand rounds type of talk where the opioid epidemic is reviewed along with the baseline data collected. Recommendations and guidelines for nonopioid analgesic options are reviewed. An example presentation is in included in this toolkit.
3. Collect three months of postintervention data similar to items noted in number 1. Decreased proportions of patients and fewer doses are the expected outcomes.

Protocol

• CHOA recommendations
• Pediatric Surgery Associates recommendations

Resources

Intervention description

Data collection sheet

Presentation

Stakeholders: surgeons (attendings, fellows, residents, etc), physician extenders (e.g. PAs, NPs), pharmacy, recovery room nursing staff

Challenges and solutions: For surgeons who refuse to stop prescribing consider having them concentrate on decreasing the number of doses prescribed.

Submitted by Mehul Raval

Additional implementers: Erik Pearson

Hasbro Children’s Hospital / Brown University

This was a prospective survey study investigating parents’ and guardians’ thoughts and actions related to narcotic medication prescriptions given to their injured children. Using a two-survey approach at discharge and seven to10 days later, participants were asked questions on whether their children’s narcotic prescriptions were filled, reasons for filling or not filling, duration of pain requiring narcotics and discharge education, storage and disposal of the
medications.

Resources

• IRB approval written consent form
• initial survey at hospital discharge and follow-up email survey and phone script seven to 10 days postdischarge

Stakeholders: pediatric surgery patients, pediatric surgery providers and prescribers, families, parents and guardians of pediatric surgery/injured patients, communities experiencing opioid misuse

Challenges and solutions: One challenge we encountered during the study was following up with parents for the second survey. This survey was administered seven to 10 days after the pediatric patient was discharged from the hospital and given over either phone call or email. There was some challenge with contacting parents (some did not pick up or answer the phone, others did not respond to emails). A way we navigated this issue was ensuring we made contact at least three times within the seven to 10 day window frame and asking parents for both phone number and email so that we had at least two modes of contact. We would also call at various times of the day (morning versus evening) to try to accommodate participants’ schedules.

Submitted by Anna Delamerced, Hale Wills

C.S. Mott Children’s Hospital

Through the work of a multidisciplinary task force, this quality improvement has two objectives

1. To reduce opioid prescribing for pediatric patients where evidence is lacking that the benefit outweighs the risk with attention to postoperative pain management.
2. Where evidence exists to support the benefit of opioid prescribing for postoperative pain management, we aim to improve our practices in order to minimize opioid related risk for the patient, the family and the community.

Protocol

• Best practices for postoperative pain management

Resources

• Data collection packet, including chart review variables, follow-up survey, pain journal
  distributed at discharge, and protocol
• task force guide
• graphic on “go bag" distributed at PACU discharge
• pharmacy education worksheet
• preoperative instructions for pediatric surgery patients incorporated into preop clinic
• discharge order sets on pain management
• clearing house document available after discharge on “Safe Opioid Use in Children”\
• clearing house document available after discharge on “Non-Drug Options for Pain Control in
  Children”

Stakeholders: surgeons (pediatric surgery, otolaryngology, urology, and orthopedic surgery), residents, advanced practice providers, clinic nurses, postanesthesia care unit (PACU) nursing, child life, pharmacy, pediatric trauma injury prevention, anesthesia, acute pain service

Challenges and solutions:

1. Integration of efforts across departments: Several departments are engaging in efforts to reduce opioids and improve disposal. Through this QI work, we have identified several ongoing projects and identified ways in which to collaborate and align efforts. In this way, we are working to identify a common message to communicate to patients and families. Similarly, we are finding ways to integrate our work in the children’s hospital into institutional efforts to promote longevity.
2. Cultural resistance to change: For some procedures, there has been resistance to reduce opioid prescribing in part driven by concerns of access to liquid oxycodone if needed after discharge. To further explore the spectrum of barriers and facilitators to opioid reduction, we have conducted a stakeholder analysis and qualitative exploration of barriers and facilitators to best target future efforts.
3. Breadth of providers coming into contact with the patient: As the message has shifted to use of non-opioids, often without any opioid prescription at all, we have found that a single clinician in the preoperative clinic or PACU who insists that a parent must fill an opioid prescription or that the opioid should be administered around the clock may change the message the family hears and cause parental anxiety. We addressed this through creation of education and materials with ongoing evaluation and engagement of champions within each unit. For example, we are in the process of finalizing our institutional best practices for pediatric opioid prescribing and the PACU nurses on our task force are working with their leadership to identify best modes of dissemination and education throughout the PACU nursing.

Submitted by Calista Harbaugh

Additional implementers: Samir Gadepalli

University of Texas Houston / Children’s Memorial Hermann Hospital

This was an attempt to reduce the amount of opioid prescriptions provided after simple appendectomy. In brief, UTH retrospectively reviewed their prescribing patterns for these patients. Essentially, the faculty were very surprised at the amount and variation in prescriptions used. After the single event, the physician assistants essentially stop asking for prescriptions after simple appendicitis.

Resources

• presentation

List tools, ordersets, what steps you did to accomplish this project. (Index of items contained in folder) We provided prior point and the data that we used to the events are surgeons that this practice he did the change.

Stakeholders: nine pediatric surgeons, families, three physician assistants and patient’s/families. We have a resident service with a fellow.

Challenges and solutions: There was minimal resistance to this change. Essentially, the behind the scenes work done by our physician assistants changed our practice. Families needed some education about what to use as nonnarcotic pain control but otherwise the change was fairly simple.

Submitted by KuoJen Tsao

Opioid Use after Appendectomy

Yale University

In order to discover the actual patient use and need of opioid after routine laparoscopic appendectomies - we called parents/patients one ot three weeks after their surgery to discuss analgesia and medication use.

Protocol

• IRB proposal

Resources

• patient assent and welcome letter
• parent welcome letter
• - “Smart phrase” in the electronic medical record to use as an introduction to the study
  and a way to opt-out of receiving a phone call
  - IRB approval for parental contact as well as approval to interview patients <18 years old
  about their level of pain control-- this involved a verbal consent/assent
  - Question set to ask each parent including description of 10-point pain scales

Stakeholders: pediatric surgery patients, pediatric surgery providers and prescribers, appendectomy patients, families of pediatric surgery patients, communities suffering from opioid abuse

Challenges and solutions: After IRB approval, the greatest challenges included insuring all appendectomy patients had the “smart phrase” entered into their discharge instructions and reaching parents by phone . To solve the first problem, help was enlisted from those on the surgical team who do not rotate off of the service - the pediatric surgery fellow, APRNs and attendings. Ultimately, They also often personally checked the pediatric surgery list in the morning and evening to add the welcome letter to each patients’ discharge paperwork. For the second issue of patient contact they found that by leaving a message with a call back number and answering the corresponding unidentified phone numbers, many parents did indeed call back.

Submitted by Mollie Freedman-Weiss

Opioid Reduction in Neonates

University of Virginia

UVA implemented an opioid reduction strategy in the neonatal intensive care unit for children undergoing nonemergent gastrointestinal surgery. The opioid reduction strategy was a subset of a larger multidisciplinary Neonatal Intensive Care Unit (NICU) Early Recovery After Surgery (ERAS) effort at our institution. The opioid reduction strategy specifically was centered on

1. standing intravenous (IV) acetaminophen administration (dosed to weight of child) for 48 hours postoperatively
2. Postoperative pain management education for the neonatal nurse practitioner and neonatal nursing team
3. Directly addressing post operative pain management strategy at the NICU provider sign out following each nonemergent operation. With this intervention we demonstrated a dramatic decrease in postoperative opioid use (treatment group- 0.07 Morphine equivalents (mg/kg) vs. historical control- 9.44 morphine equivalents (mg/kg) p < 0.0001). The neonates had similar pain scores over both periods and our quality improvement was appropriately safe.

Process

1. Started with a stakeholder’s meeting of pediatric surgery, pediatric anesthesiology, and neonatal intensivist teams. Discussed feasibility and potential challenges of a NICU ERAS protocol including directly discussing an opioid reduction strategy in the NICU.
2. Obtained UVA IRB approval for investigation
3. Worked with our inpatient pharmacy group to approve a postoperative order set which included 48 hours of standing IV Acetaminophen (1-year process)
4. Concurrently worked with NICU team to provide postoperative pain management education sessions. We discussed clinical benefits and better safety profile of reduced opioid use. Additionally, we encouraged reduction of continuous opioid infusions.
5. Prioritized postoperative pain management on provider sign out in NICU.

Protocol

• protocol

Resources

• IRB exemption application
• NICU ERAS presentation

Stakeholders: neonates undergoing gastrointestinal surgery as well as their parents, pediatric surgery team, neonatal intensivist team including specifically the nurse practitioners and bedside nurses and pediatric pharmacists.

Challenges and solutions: The biggest challenge was obtaining IV Acetaminophen approval by the pharmacy. Given concern for the price of the medication (approximately $22 per 1000 mg) IV Acetaminophen initially could only be ordered on an individual basis at our institution. We were able to address this by working closely with pharmacists and its pain subcommittee to approve it for 48 hours postoperatively. Price was addressed when it was determined that we could use multiple doses of IV Acetaminophen from the single 1000 mg bottle. This is compared to the typical dosing in an adult that uses the entire bottle.

The education intervention was less of a challenge as we included the neonatal intensive care team from the onset of the quality improvement project. This allowed a natural integration of the education interventions. The NICU nurse practitioners and bedside nurses were eager to receive additional training on postoperative pain management strategies.

Submitted by Jeffery Gander

References