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Amin SN, Thompson T, Wang X, Goldklang S, Martin LD, Low DKW, Parikh SR, Sie KC, Dahl JP. Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative. Otolaryngol Head Neck Surg 2024; 170:610-617. [PMID: 37747042 PMCID: PMC10841103 DOI: 10.1002/ohn.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 08/21/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience. METHODS A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions. RESULTS Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses. DISCUSSION In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates. IMPLICATIONS FOR PRACTICE Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.
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Affiliation(s)
- Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Trey Thompson
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Xing Wang
- Department of Biostatistics, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Samantha Goldklang
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Lynn D Martin
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Daniel K-W Low
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathleen C Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA
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Stepan KO, Lavin JM, Mehta V. Patient Safety/Quality Improvement Primer, Part IV: How to Measure and Track Improvements. Otolaryngol Head Neck Surg 2023; 169:1683-1690. [PMID: 37473436 DOI: 10.1002/ohn.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/22/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023]
Abstract
Patient safety and quality improvement (PS/QI) has become an integral part of the health care system, and the ability to effectively use data to track, understand, and communicate performance is essential to designing and implementing quality initiatives, as well as assessing their impact. Though many otolaryngologists are proficient in the methodologies of traditional research pursuits, educational gaps remain in the foundational principles of PS/QI measurement strategies. Part IV of this PS/QI primer discusses the fundamentals of measurement design and data analysis methods specific to PS/QI. Consideration is given to the selection of appropriate measures when designing a PS/QI project, as well as the method and frequency for collecting these measures. In addition, this primer reviews key aspects of tracking and analyzing data, providing an overview of statistical process control methods while highlighting the construction and utility of run and control charts. Lastly, this article discusses strategies to successfully develop and execute PS/QI initiatives in a way that facilitates the ability to appropriately measure their effectiveness and sustainability.
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Affiliation(s)
- Katelyn O Stepan
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer M Lavin
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Vikas Mehta
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
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Lavin JM, Ida JB. Quality Improvement Methodology. Otolaryngol Clin North Am 2022; 55:1301-1310. [DOI: 10.1016/j.otc.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Cordray H, Alfonso K, Brown C, Evans S, Goudy S, Govil N, Landry AM, Raol N, Smith K, Prickett KK. Sustaining standardized opioid prescribing practices after pediatric tonsillectomy. Int J Pediatr Otorhinolaryngol 2022; 159:111209. [PMID: 35749955 DOI: 10.1016/j.ijporl.2022.111209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 04/19/2022] [Accepted: 06/09/2022] [Indexed: 01/01/2023]
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.
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Affiliation(s)
- Holly Cordray
- 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
| | - Kristan Alfonso
- 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
| | - Clarice Brown
- 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
| | - Sean Evans
- 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
| | - Steven Goudy
- 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
| | - Nandini Govil
- 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
| | - April M Landry
- 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
| | - Nikhila Raol
- 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
| | - Kathleen Smith
- Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Kara K Prickett
- 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.
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Hodgson T, Burton-Jones A, Donovan R, Sullivan C. The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review. JMIR Med Inform 2021; 9:e30432. [PMID: 34787585 PMCID: PMC8663492 DOI: 10.2196/30432] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/22/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The use of electronic medical records (EMRs)/electronic health records (EHRs) provides potential to reduce unwarranted clinical variation and thereby improve patient health care outcomes. Minimization of unwarranted clinical variation may raise and refine the standard of patient care provided and satisfy the quadruple aim of health care. OBJECTIVE A systematic review of the impact of EMRs and specific subcomponents (PowerPlans/SmartSets) on variation in clinical care processes in hospital settings was undertaken to summarize the existing literature on the effects of EMRs on clinical variation and patient outcomes. METHODS Articles from January 2000 to November 2020 were identified through a comprehensive search that examined EMRs/EHRs and clinical variation or PowerPlans/SmartSets. Thirty-six articles met the inclusion criteria. Articles were examined for evidence for EMR-induced changes in variation and effects on health care outcomes and mapped to the quadruple aim of health care. RESULTS Most of the studies reported positive effects of EMR-related interventions (30/36, 83%). All of the 36 included studies discussed clinical variation, but only half measured it (18/36, 50%). Those studies that measured variation generally examined how changes to variation affected individual patient care (11/36, 31%) or costs (9/36, 25%), while other outcomes (population health and clinician experience) were seldom studied. High-quality study designs were rare. CONCLUSIONS The literature provides some evidence that EMRs can help reduce unwarranted clinical variation and thereby improve health care outcomes. However, the evidence is surprisingly thin because of insufficient attention to the measurement of clinical variation, and to the chain of evidence from EMRs to variation in clinical practices to health care outcomes.
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Affiliation(s)
- Tobias Hodgson
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Andrew Burton-Jones
- The University of Queensland Business School, The University of Queensland, St Lucia, Australia
| | - Raelene Donovan
- Princess Alexandra Hospital, Metro South Health, Woolloongabba, Australia
| | - Clair Sullivan
- The University of Queensland Centre for Health Services Research, The University of Queensland, Herston, Australia
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Billings KR, Stake C, Arzu J, Lavin J. Outcomes of a Postoperative Data-Extraction Questionnaire After Adenotonsillectomy in Children. Laryngoscope 2021; 131:E2821-E2826. [PMID: 34014559 DOI: 10.1002/lary.29626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/03/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate outcomes of a postoperative telephone questionnaire for children who underwent adenotonsillectomy (T&A). To determine whether episodes of postoperative hemorrhage were not captured until the call, and whether this impacted knowledge of physician rates of hemorrhage. STUDY DESIGN Retrospective database analysis. METHODS Retrospective analysis of outcomes of an 11-question data extraction tool utilized at a tertiary care children's hospital for follow-up in T&A patients <18 years of age over a 2-year period. Sub-analysis of positive responses to the question asking about incidence of postoperative hemorrhage. RESULTS During the study period, 1,068/3,142 (34.0%) parents responded to the phone call. Median age was 6.0 years (interquartile range [IQR] 4.0-8.2), and 566 (53.0%) were male. Ninety (8.4%) noted that the child was still snoring, but only 9 (0.84%) reported signs of obstructed breathing. A total of 402 (37.6%) reported a voice change after surgery. Most children (n = 885, 82.9%) did not receive opioid analgesics, and 252 (23.6%) received acetaminophen/ibuprofen 7 days postoperatively. Return visits to the emergency department were reported in 149 patients; primarily for hemorrhage in 46 (30.8%). In 7 (15.2%) patients, the hemorrhage event was not recorded until the call. The majority-of respondents (n = 1,031, 96.5%) were satisfied with the outcome of the procedure. CONCLUSIONS The postoperative T&A tool provided a means of gathering information on success and satisfaction with surgical outcomes. Children were able to be managed primarily with acetaminophen and ibuprofen. Most complications were captured in the electronic record, although some episodes of hemorrhage were not noted until the call, emphasizing the importance of follow-up. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Kathleen R Billings
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Christine Stake
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Jennifer Arzu
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jennifer Lavin
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Lavin J, Studer A, Thompson D, Ida J, Rastatter J, Manisha P, Huetteman P, Hoeman E, Duggan S, Birmingham P, King MR, Billings K. Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines. Laryngoscope 2021; 131:2610-2615. [PMID: 33979452 DOI: 10.1002/lary.29577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2 = 0.38 P = .003). CONCLUSIONS Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
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Affiliation(s)
- Jennifer Lavin
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Abbey Studer
- Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Dana Thompson
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jonathan Ida
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Jeff Rastatter
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Patel Manisha
- Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patricia Huetteman
- Department of Data Analytics and Reporting, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Erin Hoeman
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Sarah Duggan
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
| | - Patrick Birmingham
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Michael R King
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
| | - Kathleen Billings
- Division of Pediatric Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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