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Implementation of a Pediatric Posttonsillectomy Pain Protocol in a Large Group Practice
Lauren J Luk1, David Mosen2, Carol J MacArthur1
1Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA.
Insights
Kaiser Permanente Northwest restricted opioid prescriptions for children under 7 after tonsillectomy. This electronic health record (EHR) protocol significantly reduced physician prescribing, proving effective and safe for pediatric pain management.
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.
Objective:
In response to the increased risk of respiratory failure and death after tonsillectomy related to codeine use, Kaiser Permanente Northwest restricted use of opioids in patients <7 years old via electronic health record (EHR). However, opioids could be prescribed at physician discretion by overriding the EHR. This study aims to examine protocol compliance in a large group practice using EHR order sets and complication rates as compared with historical data.
Study Design:
Case series with chart review.
Setting:
Ambulatory care within a health maintenance organization.
Subjects And Methods:
Procedural codes were used to identify children <7 years old who underwent tonsillectomy or adenotonsillectomy approximately 1.5 years before and after implementation of EHR protocol (n = 437). Primary outcome was opioid pain prescriptions received by patients. Secondary outcomes were emergency or urgent care utilization, postoperative bleeding, nausea, vomiting, dehydration, death, and reasons for prescribing opioid pain medication after EHR protocol implementation. Chi-square analysis and Fischer's exact testing were used to compare differences in event rates.
Results:
Implementation of an age-based narcotic protocol significantly decreased physician narcotic prescribing from 82.2% to 15.4% (P < .0001). The most common reason for narcotic prescription after the intervention was the report of inadequate pain control by phone call (35%). There was no significant difference in rate of emergency or urgent care utilization between pre- and postimplementation groups (4% vs 6%, P = .29).
Conclusions:
Implementation of an age-based narcotic restriction for posttonsillectomy patients using an EHR order set is an effective and safe way to influence physician prescription practices.
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