Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative

Role of patient and family engagement in quality improvement for pediatric surgery

In recent decades, the role of quality improvement (QI) in pediatric surgery has grown substantially. Patient and family engagement can help to maximize the impact of QI by enhancing safety and patient outcomes. Yet, broader, systematic efforts to actively involve patients and families in QI initiatives remain a persistent gap in pediatric surgery. To address this gap, we propose an agenda centered on three key goals for future quality improvement efforts: (1) building partnerships with patients and their families; (2) expanding the use of patient-reported outcomes (PROs) and novel, cross-disciplinary research methods; and (3) engaging patients and families consistently across all stages of pediatric surgical care. Fulfilling this agenda will be essential in shifting our mindset to view QI as a collective that involves patients, families, clinicians, and payers in continuous, system-wide opportunities to evaluate and improve care. Actively listening to and collaborating with patients and families may also help renew our focus on narrowing the gap between current practice and the best possible practice for children undergoing surgery.

Does ketorolac administration at the time of hypospadias surgery increase unplanned encounters in the immediate postoperative period?

INTRODUCTION & OBJECTIVE

The opioid crisis has raised concerns for long-term sequela of routine administration of opioids to patients, particularly in the pediatric population. Nonsteroidal anti-inflammatory drug use is limited in hypospadias surgery due to concerns for post-operative bleeding, particularly with ketorolac. We hypothesize that ketorolac administration at the time of hypospadias repair is not associated with increased bleeding or immediate adverse events.

METHODS

A retrospective single institution study included all patients undergoing hypospadias surgery from 2018 to 2021. Outcomes measured include peri-operative ketorolac administration, opioid prescriptions, and unplanned encounters (i.e., emergency department or office visits). Comparative statistics using non-parametric and binary/categorical tests and a logistic regression were performed.

RESULTS

1044 patients were included, among whom there were 562 distal, 278 proximal and 204 hypospadias complication repairs. Ketorolac was administered to 396 (37.9%) patients and its utilization increased during the study period [Summary Figure]. Patients receiving ketorolac were older (p = 0.002) and were prescribed opioids less often after surgery (2.0% vs 5.2%, p = 0.009). There was no difference in unplanned encounters across repair types (p = 0.1). Multivariate logistic regression showed ketorolac use was not associated with an increased likelihood of an unplanned encounter.

DISCUSSION

The use of NSAIDs post-operatively has traditionally been limited due to concerns about bleeding risks, however the present study displayed no significant increases in unplanned patient encounters either in the ED or outpatient clinic after ketorolac administration. Our study has several limitations including its retrospective and single-institutional design, difficulties of pain assessment in pediatric population, and possibility of under estimation of unplanned encounters due to limited access to patients' records outside of our institution.

CONCLUSIONS

The use of ketorolac is not associated with an increase in unplanned encounters in children undergoing hypospadias repair. It should be considered a safe agent for perioperative analgesia to decrease opioid utilization. Further studies will evaluate long-term surgical outcomes in children receiving ketorolac after hypospadias repair.

Trends in opioid and nonsteroidal anti-inflammatory (NSAID) usage in children undergoing common urinary tract reconstruction: A large, single-institutional analysis

INTRODUCTION AND OBJECTIVE

Opioid stewardship is recognized as a critical clinical priority. We previously reported marked reductions in narcotic administration after implementation of an opioid reduction protocol for pediatric ambulatory urologic surgery. We hypothesize that a decrease in post-operative and discharge opioid administration will not increase short-term adverse events.

STUDY DESIGN

All pediatric patients undergoing open or robot-assisted laparoscopic pyeloplasty or ureteral reimplantation between 2015 and 2019 were included. Patients' demographics, opioid and NSAID administration, urology or pain-related emergency department (ED) visits, readmissions, and reoperations within 30 days of surgery, were aggregated.

RESULTS

438 patients, with a median age of 3.5 years (IQR 1.5-8.3) at the time of surgery, met the inclusion criteria. Annual rates of inpatient opioid administration and prescriptions decreased significantly over the study period, while rates of intra-operative, inpatient, and prescribed NSAIDs significantly increased. There was no significant difference in the occurrence of ED visits, readmissions, or reoperations within 30 days of surgery between patients who received an opioid prescription and those who did not. Multivariate regression showed that patients who did not receive an opioid prescription at discharge were found to be at a lower risk for unplanned encounters including ED visits, readmissions, or reoperations (OR:0.5, 95%CI: 0.2-0.9, p = 0.04).

DISCUSSION

The present study shows the decreasing trend in inpatient opioid administration and opioid prescription after discharge, when accompanied by an increase NSAID administration, does not result in a significant change in rates of unplanned encounters and complications, similar to results from previous studies on non-urological and ambulatory urological surgeries.

CONCLUSIONS

Non-opioid pain control after major pediatric urologic reconstruction is safe and effective. We found that a reduction in opioid administration can be associated with a reduced risk of unplanned ED visits, readmissions, or reoperations. Further investigations are required to corroborate this finding.

Postoperative pediatric urology opioid prescriptions at a tertiary academic medical center

INTRODUCTION

Opioid abuse is a public health crisis, and often this starts postoperatively. Limited data are available on pediatric urology practitioners. We examined the likelihood of postoperative opioid prescriptions in our practice.

OBJECTIVE

To determine rates of post-operative opioid prescriptions following urologic surgery in a tertiary academic center, and to identify what factors are related to opioid prescriptions.

STUDY DESIGN

We retrospectively reviewed opioid prescriptions for children who underwent a procedure in the operating room between 1/1/17 and 12/31/19. We collected data on gender, age, surgeon, procedure, length of stay, ethnicity, race, and whether opioids had been used pre-operatively. We grouped procedures into five categories: minor penile surgery, cystoscopic procedures, scrotal surgery, hypospadias repair/penoplasty, and pyeloplasty/ureteral reimplant. Multivariable logistic regression was used to determine odds ratios (OR) of opioid prescriptions.

RESULTS

1102 procedures had data available. 14.2% (n = 156) received opioid prescriptions. Using minor penile surgery as a baseline, scrotal surgery increased the odds of an opioid by 1.42; hypospadias, pyeloplasty, and other procedures reduced the odds by 0.53, 0.55, and 0.54, respectively (no patient received opioids for endoscopic procedures). Ambulatory procedures had a lower rate of opioids (0.40), and age was a major factor, with the odds of a prescription increasing by a factor of 1.45 per year of age. Since January of 2017, the opioid prescription rate has decreased from 18% in 2017 to 7.7% in 2019.

DISCUSSION

We found a relatively low rate of opioid prescribing in our pediatric patients, mostly in older children undergoing penile and scrotal procedures. Our rate was comparable to several other institutions that have examined their prescription rates in surgical patients. Heightened awareness has resulted in decreased opioid usage over time (to 6.9%). Limitations included the retrospective nature of our study, which did not allow us to assess whether pain control was adequate or if the opioids prescribed were used by patients. Opioids are rarely needed in pediatric patients.

CONCLUSIONS

85.8% of post-operative pediatric urology patients at our institution were not provided with prescription opioids. Factors associated with a higher likelihood of receiving a prescription were increasing age and scrotal surgery.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.