Patient Reported Outcomes (PRO) after Initiation of an Opioid-free Post-operative Pain Management Pathway in Outpatient Pediatric Urologic Surgery
Arun Srinivasan, MD, Seo Young Lee, MSN, CPNP, Erica Gale, MSN, CPNP, Sharmayne Siu, BA, Ravindra Sahadev, MD, Joy Kerr, MSN, CPNP, Natalie Plachter, MSN, CPNP.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
BACKGROUND: Previously presented study that looked at our prescription patterns for outpatient surgical procedures showed an opioid prescription rate of over 50%, which was primarily driven by physician preference. Since then, an opioid-free post-operative care protocol has been implemented. This includes standardized field block and intravenous ketorolac at the end of all procedures, updated prescription order sets, optimized patient family education documents on pain recognition and management, and routine physician and resident education on opioid prescription rates. Our aim for this study is to report patient reported outcomes (PRO) with opioid-free pain management protocols for children undergoing outpatient urologic surgery. METHODS: All outpatient urologic surgeries from the months of October to December of 2018 were included. Parents were informed of the pain management protocol when surgical consent was signed during the outpatient visits and again on the morning of the procedure. All patients in the study followed our opioid-free protocol. Families were given detailed pain care instructions via the patient family education document and were encouraged to contact our office either by phone or email with postoperative questions and concerns. Parents were contacted the day after the procedure and again 3-5 days after surgery with a set of five questions as part of a problem-specific PRO questionnaire. This was to assess pain, recovery time, quality of life, and satisfaction with pain management postoperatively. RESULTS: A total of 128 patients ranging from 6 months to 19 years of age (with median age of 3.4 years) underwent surgery with 95% being male. Urologic surgeries included orchiopexy, urethral meatoplasty, circumcision, circumcision revision, chordee repair, concealed penis repair, hernia/hydrocele repair, hypospadias repair, cystoscopy, suprapubic tube placement, lysis of penile adhesions, ureteral stent removal, vaginoscopy, exam under anesthesia, ureteroscopy and laser lithotripsy with stone extraction, scrotoplasty, urethrostomy, penile skin tag removal, and botox to the bladder neck. After the implementation of the protocol, our opioid prescription rate fell to 4%. By the PRO questionnaire, families reported a low average patient pain score of 3.7 (SD = 2.4) and a high satisfaction with pain management, scoring an average of 9 on a scale of 1-10. There was no increase in the frequency of post-operative phone calls or ER visits related to pain related concerns during this study. Families reported a quick post-operative recovery time of an average of 2.7 days to resume normal activities after surgery. CONCLUSIONS: In outpatient urologic surgeries, opioid prescriptions can be minimized without increasing pain scores or adversely affecting quality of life during the recovery period as measured by a problem-specific PRO questionnaire. 
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