Decreasing Opioid Usage in Pediatric Cholecystectomy Through Care Standardization: A Quality Improvement Project...

While enhanced recovery after surgery protocols have been successful in adults, their impact in pediatric surgery is less documented.

Reduce opioid use in morphine milligram equivalents by 25% over 32 months through an enhanced recovery after surgery protocol. This period included 5 months dedicated to testing and implementing the protocol, followed by 27 months of full implementation. Process measures ensured adherence, with 30-day readmission rates, pain scores, postoperative nausea and vomiting, pruritus, and hospital length of stay as balancing measures.

Inconsistent perioperative management led to variable opioid use in pediatric laparoscopic cholecystectomy patients at our hospital. A quality improvement project using the Model for Improvement was implemented at a 443-bed pediatric academic hospital. A multidisciplinary enhanced recovery after surgery team implemented perioperative standardizations supported by electronic medical record best practice advisories, monthly educational sessions, and stakeholder engagement.

After full enhanced recovery after surgery protocol implementation, morphine milligram equivalents decreased by 27% over 32 months. Mean pain scores decreased from 4.69 (95% CI: 4.32-5.06) pre-enhanced recovery after surgery to 4.10 (95% CI: 3.84-4.36) post-enhanced recovery after surgery. Postoperative nausea and vomiting incidence decreased from 18% (95% CI: 11.7-26.7) to 15% (95% CI: 9.3-23.3), and pruritus incidence declined from 6% (95% CI: 2.8-12.5) to 5% (95% CI: 2.2-11.2). Mean hospital length of stay was 1.37 days (95% CI: 1.33-1.41) pre-enhanced recovery after surgery and 1.34 days (95% CI: 1.30-1.38) post-enhanced recovery after surgery. The 30-day readmission rate remained unchanged, with the sole readmission attributed to constipation.

Standardizing care through enhanced recovery after surgery protocols effectively reduces opioid use in pediatric laparoscopic cholecystectomy without increasing mean postoperative pain scores, postoperative nausea and vomiting, pruritus, or hospital length of stay.