Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

Holly Cordray; Kristan Alfonso; Clarice Brown; Sean Evans; Steven Goudy; Nandini Govil; April M Landry; Nikhila Raol; Kathleen Smith; Kara K Prickett

doi:10.1016/j.ijporl.2022.111209

Sustaining standardized opioid prescribing practices after pediatric tonsillectomy

Int J Pediatr Otorhinolaryngol. 2022 Aug:159:111209. doi: 10.1016/j.ijporl.2022.111209. Epub 2022 Jun 12.

Authors

Affiliations

¹ Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA.
² Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
³ Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA.
⁴ Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA. Electronic address: kara.prickett@emory.edu.

PMID: 35749955
DOI: 10.1016/j.ijporl.2022.111209

Abstract

Introduction: Opioid prescribing patterns after pediatric tonsillectomy are highly variable, and opioids may not improve pain control compared to over-the-counter pain relievers. We evaluated whether a standardized, opioid-sparing analgesic protocol effectively reduced opioid prescriptions without compromising patient outcomes.

Methods: A quality improvement project was initiated in July 2019 to standardize analgesic prescribing after hospital-based tonsillectomy with/without adenoidectomy. An electronic order set provided weight-based dosing and defaulted to non-opioid prescriptions (acetaminophen and ibuprofen). Patients ages 0-6 received non-opioid analgesics alone. Patients ages 7-18 received non-opioid analgesics as first-line pain control, and providers could manually add hydrocodone-acetaminophen for breakthrough pain. Opioid prescriptions and quantities were compared for 18 months of cases pre- versus post-standardization. Postoperative returns to the system were reviewed as a balancing measure.

Results: From 2018 through 2020, 1817 cases were reviewed. The frequency of opioid prescriptions decreased significantly post-standardization, from 64.9% to 33.5% of cases (P < .001). Opioid prescribing for young children steadily decreased from over 50% to 2.4%. Protocol adherence improved over time; outlier prescriptions were eliminated. Opioid quantities per prescription decreased by 16.3 doses on average (P < .001), and variance decreased significantly post-standardization (P < .001). The incidence of returns to the system did not change (P = .33), including returns for pain or decreased intake (P = .28).

Conclusion: An age-based and weight-based analgesic protocol reduced post-tonsillectomy opioid prescriptions without a commensurate increase in returns for postoperative complaints. Standardized protocols can facilitate sustained changes in prescribing patterns and limit potentially unnecessary pediatric opioid exposure.

Keywords: Non-narcotic analgesics; Opioid analgesics; Pain management; Pediatrics; Quality improvement; Tonsillectomy.

MeSH terms

Acetaminophen
Adolescent
Analgesics
Analgesics, Non-Narcotic*
Analgesics, Opioid / therapeutic use
Child
Child, Preschool
Humans
Infant
Infant, Newborn
Pain, Postoperative / drug therapy
Practice Patterns, Physicians'
Tonsillectomy* / adverse effects

Substances

Analgesics
Analgesics, Non-Narcotic
Analgesics, Opioid
Acetaminophen