K. K. Somers1, R. Amin2, K. M. Leack1, D. M. Gourlay1, M. J. Arca1 1Medical College Of Wisconsin,Children’s Hospital Of Wisconsin And Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Pediatric Surgery, Department Of Surgery,Milwaukee, WI, USA
Introduction: Postoperative care after appendectomy may be first exposure to opioids for many children. We implemented quality improvement (QI) project to decrease inpatient and outpatient opioid utilization after laparoscopic appendectomy for acute appendicitis, hypothesizing that a significant impact can be achieved with simple, targeted steps.
Methods: We organized our QI project using Excellence in Quality Improvement Principles (EQUIP). We compared the following variables between pre-implementation (2013-2016) to post-implementation (9/2017 through 7/2018) periods: demographic data, pain scores, inpatient post-operative intravenous (IV) and enteral narcotics use, number of opioid doses prescribed at discharge, length of stay (LOS), returns to system for pain or constipation. We queried a state-based enhanced prescription drug monitoring program (ePDMP) to determine if narcotic prescriptions were filled. A multidisciplinary team reviewed current state using driver diagrams, fishbone diagrams, impact assessment models, and rank ordering creating “Plan –Do-Study-Act” (PDSA) program. Interventions to optimize pain management included: 1) ice packs on incisions in the recovery unit; 2) pain scores within thirty minutes of arrival to the ward; 3) standardized order set with scheduled non-opioid analgesics; and 4) instructing surgery team on pre- and post-op communication with parents. Post implementation, data were discussed weekly to enable rapid and contemporaneous cycle changes.
Results: There were 815 patients pre-implementation and 193 post-implementation, with no statistically significant differences in age, gender, and median pain scores. Post-implementation, 73.5% had local ice packs in recovery unit, 98.8% had appropriately documented pain scores on arrival to ward, and the order set was utilized in over 94% of patients. There were statistically significant decreases in the use of IV and enteral opioids while in hospital, and number of opioid doses prescribed at discharge, and mean length of stay (hours). 59.4% of patients filled narcotic prescriptions. Though not statistically significant, we found overall reduction in return to the health care system for pain or constipation.
Conclusion: By using a multidisciplinary assessment of current state, culture and management of parental, patient, and nursing expectations, organizations may be able reduce overall opioid consumption in postoperative patients.
