Ten hospitals are reducing opioid prescriptions for

image: Opioid prescription decreases for children undergoing appendectomy infographic
see Following

Credit: American College of Surgeons

Key points to remember

  • A quality improvement initiative implemented in 10 children’s hospitals reduced opioid prescriptions by nearly 80% in pediatric appendectomy patients using a standardized prescription protocol.
  • Emergency department visits remained unchanged after implementation, and family satisfaction with pain management was high.
  • Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Pediatrics played a central role in enabling participating hospitals to more easily identify variations in prescribing practices.

CHICAGO: As public awareness of opioid abuse in the United States has grown, so have efforts to reduce, if not eliminate, opioid use after various types of surgeries. . A regional quality improvement (QI) effort to reduce opioid prescriptions among children who had appendectomy resulted in an almost 80% reduction in prescriptions. The study consisted of setting up a standardized prescription protocol aimed at significantly reducing opioid prescriptions for these young patients.

“We were able to demonstrate that we could minimize the prescription of opioids and at the same time show that there was no increase in emergency room visits after surgery or that families were not satisfied with the management of pain,” said study senior author Lorraine Kelley-Quon, MD, MSHS, FACS, a pediatric surgeon at Children’s Hospital Los Angeles and assistant professor of clinical surgery and public health sciences. and populations at the Keck School of Medicine at the University of Southern California.

The results of studies of this quality improvement initiative in 10 children’s hospitals in the western United States have been published online in the Journal of the American College of Surgeons (JACS). The study included 1,524 children who had appendectomies at the 10 hospitals; all are members of the Western Pediatric Surgery Research Consortium.

Study context
Appendectomy is the most common operation in hospitalized children. “We wanted to do a project to minimize variation in prescribing opioids for children undergoing appendectomy. To do this, we wanted to use an already existing data infrastructure, the American College of Surgeons National Surgical Quality Improvement Program.® Pediatric platform, to streamline this process,” Dr. Kelley-Quon said. Developed in conjunction with the American Pediatric Surgical Association, ACS developed the pediatric version of the NSQIP specifically for pediatric surgical specialties. Similar to the ACS NSQIP, the pediatric program allows participating hospitals to collect highly reliable clinical data and compare their surgical results with the results of other program participants.

Previous studies have shown that typically half or more of the opioid prescriptions families receive after surgery are not used.1.2 “There has been a large amount of data over the past few years that has shown that most children undergoing surgery who are prescribed opioids are receiving more opioids than are actually needed,” said the Dr. Kelley-Quon. She noted that half of the hospitals in the study already had a protocol in place to minimize opioid prescribing to children after appendectomy, but the rest did not have a standardized protocol for opioid prescribing and practice. varied between surgeons.

Study details
The protocol used recently published guidelines, co-authored by Dr. Kelley-Quon, for prescribing opioids in pediatric surgical patients.3 The implementation focused on three pillars, Dr. Kelley-Quon explained:

  • educate health care providers about the risks of misuse and abuse associated with unused prescription opioids
  • emphasizing the use of non-opioid over-the-counter pain relievers, such as acetaminophen and ibuprofen
  • involve families in the management of the child’s postoperative pain

Results and conclusions of the study
After implementing the QI program, researchers reported that:

  • 4% of children went home with opioid prescriptions compared to 18.2% previously (p
  • In hospitals that did not have a prescription protocol, the reduction was just as significant: from 37.9% before implementation to 8.8% after (p
  • The reduction was even significant in hospitals that had a protocol: from 2.7% before to 0.8% after (p=0.003), a change of 70%.

The researchers note that some providers send children home after appendectomy with opioid prescriptions to avoid emergency room visits for pain flare-ups, even though another study reported that children who received opioids had higher levels. higher number of emergency room visits one month after surgery.4 In the study conducted by Dr. Kelley-Quon and colleagues, emergency department visits remained essentially unchanged after the quality improvement program:

  • 8.9% before versus 9.9% after (p=0.54).
  • In addition, average pain management satisfaction scores were high after the intervention: 4.7 on a scale of 0 to 5.

“The study provides important information for pediatric and general surgeons, as both specialists perform appendectomies and other surgeries in children,” said faculty professor Mary E. Fallat, MD, FACS, FAAP. of Medicine from the University of Louisville and Medical Director. , surgical grade, at Norton Children’s Hospital in Louisville, Ky., which was not involved in the study.

“General surgeons may not be as aware of advances in postoperative pain control in children’s hospitals. Due to increased awareness of opioid abuse, many pediatric and subspecialty pediatric surgeons have embraced the concept of moving away from narcotic use altogether after outpatient procedures. [hernias] and short stay procedures [appendectomy and cholecystectomy] and recommend alternating acetaminophen with nonsteroidal anti-inflammatory drugs to increase the use of local and regional anesthesia in the operating room,” said Dr. Fallat, who is also program vice president. ACS Children’s Surgery Audit.

Dr. Kelley-Quon noted that the use of the ACS NSQIP Pediatric was critical in implementing the study intervention. “NSQIP has really helped surgeons see how an individual hospital compares to other hospitals across the country,” she said. “What our project has done is go the extra mile to enable a group of hospitals to use the real-time platform to truly change the practice of a specific quality improvement initiative across multiple hospitals in that time.”

Dr. Fallat added, “The study confirms the use of the Pediatric NSQIP as a valuable database for conducting research studies that can lead to improved patient care. The hospital consortium model allows for research studies like this with the accumulation of a much larger patient population. She noted that most of the hospitals involved in the study are either audited or in the process of being audited through the ACS Pediatric Surgery Audit Program. An update to this program, which will come into effect later this year, will include an opioid management model. “This model will identify an approach and its feasibility for hospitals that have not yet adopted it,” she said. The new standards are available online.

A video discussing the results can be found here.

Dr. Kelley-Quon’s co-authors are Shadassa Ourshalimian, MPH; Justin Lee, MD; Katie W. Russell, MD, FACS; Karen Kling, MD, FACS; Stephen B. Shew, MD, FACS; Claudia Mueller, PhD, MD, FACS; Aaron R. Jensen, MD, MEd, MS, FACS; Lan Vu, MD, FACS; Benjamin Padilla, MD, FACS; Daniel Ostlie, MD, FACS; Caitlin Smith, MD, FACS; Thomas Inge, MD, FACS; Jonathan Roach, MD, FACS; Romeo Ignacio, MD, FACS; Katrine Lofberg, MD, FACS; Stephanie Radu, MCR; Autumn Rohan; and Kasper S. Wang, MD, FACS.

Dr. Kelley-Quon and the co-authors have no financial relationships to disclose. Dr. Fallat has no relevant disclosure.

“FACS” means that a surgeon is a member of the American College of Surgeons.

Quote: A multi-institutional quality improvement project to minimize opioid prescribing in children after appendectomy [ACS] NSQIP-Pediatrics. Journal of the American College of Surgeons. DOI: 10.1097/XCS.0000000000000056

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1 Van Cleve WC, Grigg EB. Variability in opioid prescribing for children undergoing day surgery in the United States. J Clin Anesth. 2017;41:16-20.

2 Monitto CL, Hsu A, Gao S, et al. Prescribing opioids for the treatment of acute pain in children on discharge from hospital. Anesthesia Analg. 2017;125(6):2113-2122.

3 Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. Guidelines for prescribing opioids in children and adolescents after surgery: expert panel opinion. JAMA Surgery. 2021;156(1):76-90.

4 Anderson KT, Bartz-Kurycki MA, Ferguson DM, et al. Too much of a bad thing: offloading opioid prescriptions for pediatric appendectomy patients. J Pediatr Surg. 2018;53(12):2374-2377.

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About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. His accomplishments significantly influenced the course of scientific surgery in America and made him an important advocate for all surgical patients. The College has over 84,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.

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