Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

BACKGROUND

Unplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year.

METHODS/INTERVENTION

A multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods.

RESULTS

Unplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019-June 2022, n = 145) compared to the pre-intervention group (January 2016-August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001].

CONCLUSIONS

Postoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness.

TYPE OF STUDY

Prospective Quality Improvement.

LEVEL OF EVIDENCE

Level III.

A Brief Measure Assessing Adolescents' Daily In-Hospital Function Predicts Pain and Health Outcomes at Home After Major Surgery

OBJECTIVE

Pain-related function, an important component of pain assessment, is not systematically assessed in the hospital in part because of a lack of clinically meaningful measures of pain-related function. This prospective cohort study examined whether adolescents' pain-related function during hospitalization, measured daily with the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) is associated with pain and health-related quality of life (HRQOL) 2 weeks following surgery.

DESIGN

Adolescents undergoing major musculoskeletal surgery (N = 93) completed YAPFAQ (11 items) daily for up to three days in-hospital following surgery. Adolescents self-reported health-related quality of life on the pediatric quality of life inventory and pain intensity on a NRS at baseline (pre-surgery) and two-weeks following surgery. Regression models examined mean YAPFAQ and YAPFAQ rate of change as predictors of two-week outcomes, adjusting for sex, surgery type, and baseline pain/HRQOL.

RESULTS

Higher mean YAPFAQ scores (poorer function) were associated with higher pain intensity (β  =  0.2, p = 0.04) and poorer HRQOL (β = -0.3, p = 0.01) at home 2 weeks following surgery. YAPFAQ rate of change was not associated with 2-week outcomes.

CONCLUSIONS

Implementation of the YAPFAQ with in-hospital assessments to measure pain-related function will allow more comprehensive pain assessment. In-hospital YAPFAQ scores can predict important postsurgical outcomes at home and inform post-hospital care.

PERSPECTIVE

This article provides validation of a measure of pediatric pain-related function, the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) to predict important post-hospital outcomes after surgery.