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Abstract
Background Wide variability exists in opioid doses prescribed after pediatric orthopaedic surgery. Increasing opioid prescriptions by a single day increases the risk of aberrant opioid behavior by almost 10% in the pediatric population.
Objectives The goal of this study is to increase the percentage of patients prescribed opioids based on a standard dosing protocol after pediatric orthopaedic surgery from 0 to 90%.
Methods A multidisciplinary team developed a key driver diagram (figure 1). A prescribing protocol was developed based on the surgery severity. Baseline data began in October 2017 with initial protocol testing starting in November 2017. The primary measure was the weekly percent of patients correctly dosed by the protocol. The secondary measure was the average number of opioids prescribed at discharge each week for all children undergoing orthopaedic surgery between October 2017 and September 2018. Statistical process control charts were used for data analysis with Nelson rules used to determine special cause.
Key driver diagram developed by multidisciplinary team Key driver diagram developed by multidisciplinary team
Results 1645 patient records were prospectively reviewed during the study time period. Adherence to the dosing protocol increased from 0% at baseline to 97% for all categories of surgery (figure 2). Mean prescribed opioid doses following surgical procedures were reduced from 21.9 to 17.8 doses (figure 3), achieving special cause variation.
P-chart showing compliance with the opioid prescribing protocol for the one month prior to protocol being implemented and 11 months following protocol implementation. Compliance with the protocol at end of the study period was 97% P-chart showing compliance with the opioid prescribing protocol for the one month prior to protocol being implemented and 11 months following protocol implementation. Compliance with the protocol at end of the study period was 97%
X-bar chart showing the average number of opioid doses prescribed for the one month prior to protocol being implemented and 11 months following protocol implementation. The average number of doses decreased from 21.9 to 17.8 (4.1 doses) over the study period X-bar chart showing the average number of opioid doses prescribed for the one month prior to protocol being implemented and 11 months following protocol implementation. The average number of doses decreased from 21.9 to 17.8 (4.1 doses) over the study period
Conclusions Implementation of a standardized opioid dosing protocol for pediatric patients undergoing orthopaedic surgery improved protocol-based adherence to over 90% and was associated with reduced opioid doses prescribed at discharge. Future work will investigate whether this may lead to a decrease in aberrant opioid behaviors in pediatric patients.