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Standardizing Opioid Prescribing in a Pediatric Hospital: A Quality Improvement Effort
Carolina Donado1,2, Jean C Solodiuk1,2, Susan T Mahan3,4
1Departments of Anesthesiology, Critical Care and Pain Medicine and.
Insights
A new opioid prescribing algorithm significantly reduced opioid prescriptions and dose variability in pediatric patients. The algorithm achieved high compliance, improving pain management and reducing overall opioid use.
Area of Science:
- Pediatric Anesthesiology
- Pain Management
- Quality Improvement in Healthcare
Background:
- Opioid analgesics are crucial for moderate-to-severe pain from various conditions, including trauma, surgery, and sickle cell disease with vaso-occlusive episodes (SCD-VOC).
- Limited evidence exists on appropriate opioid dosing for specific indications, leading to variability in prescribing practices.
Purpose of the Study:
- To develop and implement a standardized opioid prescribing algorithm with dosing guidelines for specific pediatric procedures and conditions.
- To achieve and sustain 90% compliance with the developed guidelines within one year of implementation.
Main Methods:
- A multidisciplinary team developed an algorithm guiding prescribers through patient evaluation, including medical history, physical examination, and identification of red flags.
- The algorithm incorporates opioid-sparing interventions prior to prescribing opioids.
- Data from opioid prescriptions between January 2015 and September 2020 at a pediatric academic quaternary care institution were analyzed.
Main Results:
- Over five years, 83,037 opioid prescriptions were analyzed across 53,804 patients.
- The proportion of encounters with at least one opioid prescription decreased from 48% to 25% between 2015 and 2019.
- Compliance with specific guidelines reached approximately 85% for periacetabular osteotomies and SCD-VOC, and nearly 100% for anterior-cruciate ligament surgery, with significant reductions in dose variability.
Conclusions:
- The developed algorithm, guidelines, and improvement process effectively reduced both the number of opioid prescriptions and prescribing variability.
- Further evaluation of specific departmental initiatives is warranted to sustain and optimize opioid stewardship.
Background:
Opioids are indicated for moderate-to-severe pain caused by trauma, ischemia, surgery, cancer and sickle cell disease, and vaso-occlusive episodes (SCD-VOC). There is only limited evidence regarding the appropriate number of doses to prescribe for specific indications. Therefore, we developed and implemented an opioid prescribing algorithm with dosing guidelines for specific procedures and conditions. We aimed to reach and sustain 90% compliance within 1 year of implementation.
Methods:
We conducted this quality improvement effort at a pediatric academic quaternary care institution. In 2018, a multidisciplinary team identified the need for a standard approach to opioid prescribing. The algorithm guides prescribers to evaluate the medical history, physical examination, red flags, pain type, and to initiate opioid-sparing interventions before prescribing opioids. Opioid prescriptions written between January 2015 and September 2020 were included. Examples from 2 hospital departments will be highlighted. Control charts for compliance with guidelines and variability in the doses prescribed are presented for selected procedures and conditions.
Results:
Over 5 years, 83 037 opioid prescriptions in 53 804 unique patients were entered electronically. The encounters with ≥1 opioid prescription decreased from 48% to 25% between 2015 and 2019. Compliance with the specific guidelines increased to ∼85% for periacetabular osteotomies and SCD-VOC and close to 100% for anterior-cruciate ligament surgery. In all 3 procedures and conditions, variability in the number of doses prescribed decreased significantly.
Conclusion:
We developed an algorithm, guidelines, and a process for improvement. The number of opioid prescriptions and variability in opioid prescribing decreased. Future evaluation of specific initiatives within departments is needed.
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