Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative. Issue 5 (October 2020)

• Record Type: Journal Article
• Authors: O'Kelly, F.; Pokarowski, M.; DeCotiis, K.N.; McDonnell, C.; Milford, K.; Koyle, M.A.
• Is Part Of: Journal of pediatric urology. Volume 16:Issue 5(2020)
• Page Start: 647.e1
• Page End: 647.e9
• Publication Date: 2020-10
• Subjects: Opioid -- Stewardship -- Quality improvement -- Hypospadias -- Ishikawa -- Run chart; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2020.06.012
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Background: Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission. Objective: The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education. Study design: This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study–Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019. Results: Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention. Discussion: We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9. Conclusion: Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children. Summary Figure Trends in opioid prescription and balancing measures pre- and post-implementation of a quality improvement program for opioids reduction with outpatient hypospadias repairs (ER: Emergency room). Summary Figure