Reducing Pediatric Posttonsillectomy Opioid Prescribing: A Quality Improvement Initiative

Abstract

Objective: Postoperative pain is the most common morbidity associated with tonsillectomy. Opioids are frequently used in multimodal posttonsillectomy analgesia regimens; however, concerns regarding respiratory depression, drug-drug interactions, and medication misuse necessitate responsible opioid stewardship among prescribing surgeons. It is unclear if intentionally reducing opioid prescription doses negatively affects the patient experience.

Methods: A quality improvement team reviewed all posttonsillectomy opioid prescriptions at a pediatric ambulatory surgery center between January and June 2021 (preintervention, 163 patients). Following this review, we performed an opioid education session for surgeons and studied opioid prescribing habits between July and December 2021 (Plan-Do-Study-Act [PDSA] 1, 152 patients). We then implemented a standardized prescription protocol of 7 doses of oxycodone per patient and again reviewed prescriptions between January and June 2022 (PDSA 2, 178 patients). The following measures were evaluated: initial number of opioid doses prescribed, need for refills, 7-day emergency department (ED) visits, and readmissions.

Results: Each intervention reduced the average number of initial oxycodone doses per patient (12.2 vs 9.2 vs 6.9 doses, P < .001). There were no changes in the rate of refill requests, 7-day ED visits, and readmissions, by descriptive or Statistical Process Control analyses.

Discussion: In 2 PDSA cycles, we achieved a 43% reduction in the number of doses of oxycodone prescribed following tonsillectomy. We did not observe any increased rates in balancing measures, which are surrogates for unintentional effects of PDSA changes, including refills, ED presentations, and readmission rates.

Implications for practice: Directed provider education and standardized posttonsillectomy prescription protocols can safely decrease postoperative opioid prescribing. Further PDSA cycles are required to consider even fewer opioid prescription doses.

Keywords: PS/QI; opioids; pediatric otolaryngology; sleep apnea/snoring; tonsillectomy.

Figure 1:

Schematic summarizing interventions, PDSA cycles, and timeline.

Figure 2:

X-bar charts for opioid prescription dose counts immediately following tonsillectomy. Key: Center line (CL)- Mean of each cohort. Dashed lines- Upper and lower confidence limits (3 standard deviations above and below the mean).

Figure 3:

P-charts for balancing measures. (A) Refill requests. (B) ED visits (all-cause) within 7 days of surgery. (C) ED visits (pain-related) within 7 days of surgery. (D) Readmissions within 7 days of surgery.