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The Reducing Opioid Use in Children with Clefts Protocol: A Multidisciplinary Quality Improvement Effort to Reduce
Alfred Lee1, Brian L Chang1, Chen Yan1
1From the Division of Plastic and Reconstructive Surgery, the Center for Healthcare Quality & Analytics, Department of Anesthesiology and Critical Care, the Department of Child & Adolescent Psychiatry & Behavioral Sciences, Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; and the 88th Surgical Operations Squadron, Plastic Surgery Element.
Insights
Reducing opioid exposure in pediatric cleft repair is achievable through quality improvement initiatives. This project successfully lowered postoperative opioid use without impacting patient recovery or pain levels.
Area of Science:
- Pediatric Surgery
- Pain Management
- Quality Improvement
Background:
- Cleft repair necessitates multiple surgeries, leading to repeated opioid exposure and associated risks in children.
- A quality improvement (QI) project was initiated to decrease perioperative opioid use in cleft lip/palate patients.
Purpose of the Study:
- To implement and evaluate a QI project aimed at reducing perioperative opioid administration in pediatric cleft repair patients.
- To decrease postoperative opioid administration from 0.30 mg/kg to 0.20 mg/kg of morphine equivalents.
Main Methods:
- Key drivers of perioperative opioid use were identified to develop targeted QI interventions.
- Data on opioid administration, nerve blocks, order set adherence, length of stay, and pain scores were collected retrospectively and prospectively.
- The study period included baseline data (Jan 2015–May 2017), a 6-month QI intervention period, and a subsequent 14-month follow-up.
Main Results:
- A total of 624 patients were included (354 pre-QI, 270 post-QI).
- Postoperative opioid administration decreased significantly from 0.30 mg/kg to 0.14 mg/kg of morphine equivalents (p < 0.001).
- No significant differences were observed in length of stay or pain scores post-QI implementation.
Conclusions:
- Perioperative opioid use after cleft repair can be effectively reduced through targeted QI strategies focusing on education, standardized pain control, and non-opioid alternatives.
- The QI framework demonstrated success in a short timeframe and holds potential for application in other pediatric surgical populations to mitigate opioid use.
Background:
Cleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.
Methods:
After identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.
Results:
The final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).
Conclusions:
Perioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.
Clinical Question/Level Of Evidence:
Therapeutic, III.
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