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Stephenson KJ, Krinock DJ, Vasquez IL, Shewmake CN, Spray BJ, Ketha B, Wolf LL, Dassinger MS. Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital. J Patient Saf 2024; 20:299-305. [PMID: 38240645 DOI: 10.1097/pts.0000000000001209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. METHODS We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. RESULTS A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed ( P < 0.0001), prescriptions filled ( P = 0.009), and opioid doses taken ( P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call ( P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. CONCLUSIONS Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.
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Affiliation(s)
| | - Derek J Krinock
- From the Department of Surgery, University of Arkansas for Medical Sciences
| | - Isabel L Vasquez
- Department of Surgery, Arkansas Children's Hospital Research Institute
| | | | | | - Bavana Ketha
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Lindsey L Wolf
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
| | - Melvin S Dassinger
- Department of Pediatric Surgery, Arkansas Children's Hospital, Little Rock, Arizona
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Rahman R, Patel C, Hathaway C, Patel E, Bouldin E, Tey CS, Raol N, Alfonso K. Opioid stewardship and perioperative management of pediatric tympanoplasty. Int J Pediatr Otorhinolaryngol 2023; 173:111713. [PMID: 37696228 DOI: 10.1016/j.ijporl.2023.111713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/14/2023] [Accepted: 08/27/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To provide insight into the intraoperative management, admission course, pain management, and graft success of microscope- and endoscope-assisted tympanoplasty. STUDY DESIGN Retrospective Chart Review. METHODS This study included children 18 years and younger who underwent ambulatory tympanoplasty at a tertiary pediatric hospital between January 2018 and December 2020. Medical records were reviewed and information about intraoperative factors, surgical approach, laterality, complications, and post-operative perforation closure success rates was collected. Multivariate analysis was performed to compare and contrast the two surgical approaches. RESULTS The review included 321 pediatric patients who underwent a tympanoplasty. Endoscopic tympanoplasty accounted for 17.4%, while microscopic tympanoplasty accounted for 82.6%. In both approaches, the rate of intraoperative complications, postoperative complications, audiological improvements, and perforation closure success rates were statistically similar. However, patients who underwent endoscopic tympanoplasty were 3.96 times less likely to require opioids in the post-anesthesia care unit (PACU) and had a shorter post-operative admission length. This pattern emerged regardless of the type of graft used. Obtaining an autograft was not associated with a higher opioid requirement in the PACU. CONCLUSION While both approaches are viable, our findings demonstrate the reduced need for opioids with similar success rates following an endoscopic tympanoplasty. Ultimately, the trade-off for the minimally invasive endoscopic approach appears to be a less painful experience for the child while promoting clinically appropriate opioid stewardship in the perioperative setting.
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Affiliation(s)
- Rahiq Rahman
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Chhaya Patel
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA; Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Campbell Hathaway
- University of South Carolina School of Medicine, Greenville, SC, USA
| | - Eshan Patel
- Emory University School of Medicine, Atlanta, GA, USA
| | - Emerson Bouldin
- Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Ching Siong Tey
- Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Nikhila Raol
- Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, 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, Atlanta, GA, USA; Emory University School of Medicine, Atlanta, GA, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA, USA.
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Kelley-Quon LI, Cho J, Barrington-Trimis J, Kipke MD, Clapp JD, Krueger EA, Leventhal AM. Longitudinal trajectories of prescription opioid misuse in adolescents. Drug Alcohol Depend 2022; 236:109470. [PMID: 35504242 PMCID: PMC10027390 DOI: 10.1016/j.drugalcdep.2022.109470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Adolescent misuse of prescription opioids is hazardous. This study aimed to generate data on prescription opioid misuse trajectories across adolescence and identify risk factors and mechanisms for more dangerous use trajectories. METHODS Using a prospective longitudinal cohort repeated measures design, baseline (Fall 2013) and seven semiannual assessments were administered through Spring 2017 in 10 public high schools in Los Angeles, CA. Frequency of past 30-day prescription opioid misuse was captured. Trajectory groups were identified using growth mixture modeling and multinomial logistic regression identified associations between baseline risk factors with membership in each trajectory group. RESULTS Overall, 3395 students were evaluated (53.4% female, Mean [SD] age at baseline=14.58[0.40]; range=12.83-16.29). Four discrete misuse trajectories were identified among 1062 students: (1) Minimal/Experimental (infrequent time-limited use; range of estimated mean number of days using prescription opioid across waves=0.0-0.6 days]; N = 705[20.8%]); (2) Low Deescalating (range=2.0-0.7 days; N = 189[5.6%]); (3) Moderate Escalating (range=0.7-3.6 days; N = 108[3.2%]); and (4) Frequent Persistent (range=4.7-9.4 days; N = 60[1.8%]). Students reporting tobacco, cannabis, alcohol use, or impulsivity in 9th grade were more likely to demonstrate membership in the Moderate Escalating trajectory class when compared to 2333 (68.7%) students reporting sustained abstinence. Female sex, peer opioid misuse, alcohol use, other substance use, impulsivity, or delinquent behavior reported in 9th grade was associated with membership in the Frequent Persistent trajectory class. CONCLUSIONS Prescription opioid misuse in adolescence appears to follow 4 discrete trajectories, including the potentially problematic Moderate Escalating and Frequent Persistent trajectories. Female sex, peer influences, substance use, and intrapersonal risk factors were associated with membership in these classes.
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Affiliation(s)
- Lorraine I Kelley-Quon
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA; Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
| | - Junhan Cho
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Jessica Barrington-Trimis
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Michele D Kipke
- Division of Research on Children, Youth and Families, The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John D Clapp
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Evan A Krueger
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Adam M Leventhal
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
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