Implementation of a Pediatric Posttonsillectomy Pain Protocol in a Large Group Practice.

Area of Science:

• Pediatric Surgery
• Pharmacology
• Health Informatics

Background:

• Codeine use in children under 7 after tonsillectomy poses risks of respiratory failure and death.
• Kaiser Permanente Northwest implemented an electronic health record (EHR) restriction on opioid prescriptions for this age group.
• Physician overrides of the EHR system were possible, necessitating an evaluation of protocol compliance.

Purpose of the Study:

• To assess the compliance with an age-based opioid restriction protocol for post-tonsillectomy patients.
• To compare complication rates before and after the EHR-based protocol implementation.
• To evaluate the impact of the protocol on physician prescribing practices.

Main Methods:

• A case series with chart review was conducted.
• Children under 7 undergoing tonsillectomy or adenotonsillectomy before and after protocol implementation (n=437) were identified using procedural codes.
• Opioid prescriptions, emergency care utilization, and postoperative complications were analyzed using chi-square and Fischer's exact tests.

Main Results:

• Physician opioid prescribing decreased significantly from 82.2% to 15.4% post-protocol (P < .0001).
• The primary reason for prescribing opioids post-intervention was patient-reported inadequate pain control via phone (35%).
• No significant difference was observed in emergency or urgent care utilization rates between the pre- and post-implementation groups (4% vs 6%, P = .29).

Conclusions:

• An age-based narcotic restriction protocol integrated into EHR order sets effectively reduces physician opioid prescribing for post-tonsillectomy patients.
• The protocol demonstrates safety, with no increase in emergency care utilization.
• This strategy successfully influences physician prescribing behavior in pediatric pain management.