IN BRIEF

Using Quality Improvement to Customize Opioid Reduction Strategies

October 30, 2018
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Different specialties across pediatrics have different uses, indications and practices when it comes to opioids. Many primary care pediatricians do not routinely prescribe them. Pediatric surgical specialties, however, may use opioid medications more frequently depending on the patient and procedure performed.

While broad restrictions, such as those enacted on the federal and state levels, aimed to reduce opioid prescribing are helpful, specialty-specific changes from within a department or service line are necessary to make the greatest impact on the appropriate use of opioid medication for pain.

At Nationwide Children’s Hospital, pediatric otolaryngologists (ENT) have been leading the way by collaborating with the hospital’s Opioid Taskforce and Quality Improvement Programs to dramatically decrease the number of opioids prescribed at discharge for tonsillectomy with adenoidectomy – one of the most common pediatric surgical procedures.

At Nationwide Children’s, ENT accounts for 35 percent of all surgical procedures done in the operating room. “Of the approximately 9,000 procedures ENT surgeons perform annually, about 3,000 are tonsillectomies,” says Kris Jatana, MD, pediatric otolaryngologist and director of Pediatric Otolaryngology Quality Improvement at Nationwide Children’s.

“Our patient population, with obstruction in the upper airway, is already more sensitive to opioids and considered higher risk,” says Dr. Jatana.

Using a broad approach with many multifaceted interventions, the ENT team set out to decrease that opioid burden by 50 percent by the end of 2018.

The team uses alternating doses of acetaminophen and ibuprofen as the first line of pain management. Opioid medication is treated as a rescue medication – only for severe pain that is not controlled with non-opioid treatments.

In fact, using these alternative pain control strategies, an increasing number of patients are not discharged with opioid prescriptions at all. In 2016, almost 90 percent of patients received a home-going prescription for opioid medication. In 2018, it has dropped to about 40 percent.  Over the same time period, not only is the number of overall prescriptions reduced by 50 percent but also the number of doses reduced by 50 percent.

“We have essentially reduced the opioids prescribed after tonsillectomy by approximately 75 percent,” says Dr. Jatana. “This equates to about 1,500 fewer prescriptions and 5,000 fewer doses of opioids prescribed per year.”

According to Dr. Jatana, one of the factors that supported the team’s success is the use of e-prescriptions, as they have been able to lower gradually the number of doses prescribed.

“If the patient needs an opioid prescription – either new or as a refill – we can do that electronically, with no inconvenience to families to drive to our clinic to get a paper prescription, many of whom live hours away,” he says.

The e-prescription process involves having parents or caregivers call and discuss the situation with the ENT team to ensure that the non-opioid pain medications are used optimally prior to prescribing additional opioid medication.

The team also utilizes detailed opioid informed consent forms to educate all parents and caregivers, which are documented in the electronic medical record. The comprehensive process exceeds that required by Ohio state laws, says Dr. Jatana.

Other service lines are following suit.

The medical team in the Department of Orthopedics is learning from the ENT example and developing their own approach.

“We know that there’s room for improvement,” says Leanne Winslow, MS, APRN, CPNP and leader of the opioid quality initiative in the Department of Orthopedics at Nationwide Children’s. “We’ve seen declines in prescribing patterns since the state laws changed in 2017, but we know that applying some quality improvement strategies will help us to be better stewards of opioid medications.”

The procedure in the spotlight for the Orthopedics team’s initial efforts is supracondylar humerus fractures. These are common injuries treated by pediatric orthopedic surgeons and often involve using pins to stabilize the elbow joint.

“These procedures are often done on an outpatient basis or inpatient with an early discharge,” says Winslow. “The amount of home-going doses of opioid medication varies from 5 doses to as many as 20.”

By standardizing prescribing practices, utilizing e-prescribing and increasing patient and provider education, Winslow hopes to see results similar to those obtained in ENT.

“With orthopedics, or any surgery really, there’s the misconception that opioid medication is necessary to manage the pain,” she says. “But in many cases, acetaminophen and ibuprofen are sufficient to manage pain when used appropriately.”

Looking to the future, medical teams in these subspecialties and others are planning to expand best practices to other procedure types, further reducing opioid use.

 

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