Opioid stewardship in pediatric urology following outpatient hypospadias surgery - A quality improvement initiative
Fardod O'Kelly, MD MB MA FRCS(Urol), Martha Pokarowski, BSc MPH, Martin A. Koyle, MD MSc FRCSC FACS FAAP.
The Hospital for Sick Children, Toronto, ON, Canada.
Over-prescription of paediatric opiate medications, particularly in the acute pain and post-surgical settings plays a significant role in opioid exposure trends and the development of opioid-related complications such as over-sedation in hospitalised patients. Prior reports illustrate wide opiate prescribing variability among paediatric surgical patients as well as gross post-operative medication surplus, with an incidence of persistent use 90-days post-surgery between 2.7-15.2%. There currently exists in our institution, significantly heterogenous postoperative opioid prescribing practices. The aim of this prospective quality improvement and patient safety study was to reduce post-operative opioid prescription in a day case hypospadias cohort by 30% over a 4 month period. The hypothesis was that a decrease in post-operative opioid prescription would not lead to an increase in adverse clinical outcomes following hypospadias surgery
Institutional quality improvement committee approval was obtained. Interventions included a mixture of qualitative and quantitative research through PDSA cycles and outcome measurements. These interventions were people-focused through education/training and reminders, and system-focused through simplification and forcing functions. There were no changes to intra-operative management by anesthesiology. Change management achieved through the alignment of stakeholder, education of parents (handouts/online atlas) and a core change team. ER visits, phone and email logs were recorded. Parents were also contacted within a fortnight post-operatively to assess for pain, satisfaction and analgesic requirements. This cohort was then compared to a similar group who had received opioids post-operatively.
There were 54 patients in the intervention arm of this study (22 opioid; 32 non-opioid). The rate of opioid prescriptions decreased from an average of 74% (0-20 doses) to 42% representing an absolute reduction of 32% (relative reduction 44%) over a period of 3 months. This was not associated with any increase in adverse outcomes or unintended consequences as captured through balancing measures. There was a significant reduction in the rate of constipation post-operatively in the non-opioid (9.4% vs. 36.4%; p=0.035)
The implementation of a post-operative opioid-sparing approach to hypospadias is safe with no increase in clinical adverse outcomes for children. The relative reduction of 44% is modest but sustainable, and in line with several campaigns calling for a rationalisation in narcotic usage including Choosing Wisely. Challenges continue to exist in stakeholder engagement and leading practice change in order to ensure sustainability
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