OBJECTIVES

Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures.

METHODS

Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills.

RESULTS

Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%).

CONCLUSIONS

The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

From 2001 to 2016, the number of opioid-related deaths in the United States has increased nearly 350%.1  Although the source of this national epidemic is multifactorial, the inordinate number of opioid prescriptions written is thought to be one of the main contributing factors.2  In 2012 alone, 259 million opioid prescriptions were written.2  With 38.2% of nonmedical opioid users reporting that they received their opioids from a family member or friend for free, reducing the amount of unnecessary opioid medication prescriptions is a necessary step in addressing this crisis.35  Although the number of opioids prescribed to patients has been trending downward since 2012, this amount is still 3 times higher today than in 1999.6 

Analyses of pain medication prescribing patterns consistently reveal a large variation among institutions as well as among individual providers in the same institution.79  Orthopedic surgeons account for one of the highest rates of opioid prescriptions across all age groups.10,11  There is strong evidence that the duration of opioid use is the most predictive factor for future opioid misuse.12,13  With the number of opioids prescribed being positively correlated with an elevated consumption rate, the need to minimize the number of opioids provided to patients while still maintaining adequate pain control is evident.14  The possibility exists to decrease or completely eliminate any opioid pain prescriptions at discharge after a surgical procedure. Instead, alternating doses of ibuprofen and acetaminophen have been shown to be an effective method of pain management in some instances.15 

There have been few studies performed focusing specifically on pediatric patients and opioid prescribing patterns although several concerns have been noted in pediatrics. The age of initial medical use of opioids can be linked to future misuse and abuse.16,17  Additionally, estimates of pediatric opioid misuse are likely underestimates because many high schoolers failed to classify the nonmedical use of hydrocodone or oxycodone as an opioid misuse.18  With 11.7% of all opioid prescriptions being written for patients aged 10 to 29 years old, the potential impact of this overprescribing to a vulnerable age group must be aknowledged.10 

Various solutions are being explored to address the opioid epidemic. One approach is the development of pain medication prescribing guidelines.19,20  To address the local deficit in appropriate guidelines for postoperative pediatric opioid prescriptions, we sought to standardize a comprehensive pain management guideline. Our primary aim with this project was to develop the first standardized home-going, postoperative pain management guideline for pediatric orthopedic surgical patients. As part of this standardization process, we aimed to decrease the total number of opioids prescribed without compromising pain management adequacy.

The quality improvement project was deemed exempt from institutional review board oversight. The improvement project was conducted at a large 400+-bed freestanding academic children’s hospital with ∼3000 annual orthopedic surgeries across 10 surgeons in 3 operating locations. The improvement project spanned from August 2017 through December 2019, with subsequent sustainability monitoring ongoing.

The orthopedic care model includes orthopedic surgery patients undergoing both ambulatory and inpatient procedures. Those children admitted to the hospital primarily are admitted to the orthopedic surgery service, although pediatric hospital medicine consultation is available. Both inpatient and home-going pain management is prescribed by the orthopedic resident under the supervision of the orthopedic surgery attending. Before this project, no specific guidance on pain medicine prescribing was given to residents other than education on the nuance of pediatric weight-based dosage. Attending physician pain medicine prescribing was based on their own training and experience and was not standardized before this project.

The improvement project was guided by the Model for Improvement methodology.21  The Model for Improvement was chosen for its ease of use and proven success in accelerating improvement. A multidisciplinary improvement team was formed and included 2 attending physicians (an orthopedic surgeon [the department chair] and an anesthesia and pain management physician [the department chair]), a quality improvement specialist, an electronic medical record (EMR) builder, a clinical pharmacist, and a data analyst. Ad hoc input was solicited early in the project from residents and postanesthesia care unit staff. Key improvement tools included a key driver diagram, process mapping, Pareto charts, simplified failure modes and effects analysis, and plan-do-study-act (PDSA) cycle testing.

The global and specific, measurable, applicable, realistic, and timely aims, combined with key drivers and potential interventions, are guided by the key driver diagram (Fig 1). Among the list key drivers and interventions necessary to successfully implement and sustain a comprehensive postsurgical pain guideline, the improvement team identified and prioritized several key interventions for testing.

FIGURE 1

Pediatric orthopedic postoperative pain management key driver diagram. The project leaders were K.J. and L.E and the revision date was April 4, 2018. ACH, Akron Children's Hospital; COSA, Children's Orthopedic Surgical Associates; KSU, Kent State University; LOR, level of reliability; SMART, specific, measurable, applicable, realistic, and timely.

FIGURE 1

Pediatric orthopedic postoperative pain management key driver diagram. The project leaders were K.J. and L.E and the revision date was April 4, 2018. ACH, Akron Children's Hospital; COSA, Children's Orthopedic Surgical Associates; KSU, Kent State University; LOR, level of reliability; SMART, specific, measurable, applicable, realistic, and timely.

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First, the team identified the need to match appropriate and evidence-based pain management guidelines with the appropriate surgery. To accomplish this, a 4-tier pain severity guideline was established in concert with the team’s anesthesia and pain management and clinical pharmacist. Informed by initial data of overall opioid usage after various orthopedic surgical procedures, the 4 tiers were defined as follows: minor, moderate, major, and spinal fusion. Minor procedures were those procedures in which patients used little or no narcotics to manage postoperative pain. Major procedures were procedures in which oxycodone was used, in addition to ibuprofen and acetaminophen, for management of postoperative pain. Moderate procedures were procedures in which patients used oxycodone but at lower total amounts than the major category. The patients undergoing spinal procedures had the highest historical overall opioid use and thus were designated as a separate category with respect to maximal pain control dosing requirements. All guideline tiers incorporated ibuprofen and acetaminophen as the primary analgesics for postoperative pain management. In addition, tiered guidelines were further cohorted on the basis of patient weight to ensure weight-based ease in dosing. From these data, the guidelines recommended the specific opioid medication, dosage, strength, duration, and secondary prescriptions if indicated. These initial guidelines were successfully tested as our first PDSA by the senior author in a clinical setting. Initially, a small pilot with a single provider was performed as a test of the appropriateness of tiers and recommended prescriptions to enable changes to guidelines before further spread. After this testing, the guidelines were disseminated to the remainder of the orthopedic staff surgeons for their feedback and use. The guideline PDSA was then tested with the entire team of orthopedic surgeons in the practice. The rotating orthopedic residents and fellows from the numerous rotating training programs were educated on the proper application of the guidelines during their orientation before the start of their patient care. The final pediatric orthopedic pain management guidelines (Fig 2) designate the responsibility to the orthopedic residents and fellows for writing discharge prescriptions under the supervision of the attending orthopedic surgeon.

FIGURE 2

Pediatric orthopedic postoperative home-going pain management guidelines: July 2018 acetaminophen derivatives. Home-going pain management guidelines provide specific recommendations on narcotic to use as well as the recommendation to alternate ibuprofen with the narcotic prescribed. The guidelines also give recommendations for secondary prescriptions when indicated. ACL, anterior cruciate ligament reconstruction; AIS, Adolescent Idiopathic Scoliosis fusion; CRPP, Closed Reduction Percutaneous Pin fixation; I&D, Incision and Debridement; N/A, not applicable; NM, Neuromuscular Spinal Fusion; ORIF, Open Reduction Internal Fixation; PO, Postoperative; q, every.

FIGURE 2

Pediatric orthopedic postoperative home-going pain management guidelines: July 2018 acetaminophen derivatives. Home-going pain management guidelines provide specific recommendations on narcotic to use as well as the recommendation to alternate ibuprofen with the narcotic prescribed. The guidelines also give recommendations for secondary prescriptions when indicated. ACL, anterior cruciate ligament reconstruction; AIS, Adolescent Idiopathic Scoliosis fusion; CRPP, Closed Reduction Percutaneous Pin fixation; I&D, Incision and Debridement; N/A, not applicable; NM, Neuromuscular Spinal Fusion; ORIF, Open Reduction Internal Fixation; PO, Postoperative; q, every.

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Second, the improvement team recognized the risk of incomplete information and communication breakdowns among attending surgeons, residents, and operating room staff. To enhance communication, 2 following key pieces of information necessary to place home-going pain management orders were obtained and recorded in the EMR by the preoperative nursing staff on the day of surgery: the patient’s body weight and the ability to swallow pills. Additionally, the next piece of information necessary to place home-going pain management orders is the pain classification of the procedure as mild, moderate, major, or spinal fusion. This information is obtained intraoperatively during a timeout performed by the orthopedic attending and orthopedic resident placing the orders at or near the end of the procedure. This is often done as the team is closing the surgical incision. Applying PDSA methods, a single surgeon drafted and tested timeout content and iteratively improved the content before spread.

A third key driver and intervention was focused on availability of the guideline and ease of use. Once the guidelines were refined, the usability was first tested by the clinical team using laminated pocket cards for easy reference. Without instruction to do so, many of the orthopedic residents produced photograph versions of the pocket card to be used as a visual tool on their smartphones. This was a good example of frontline users adapting a test for improved usability. Ultimately, the EMR build team incorporated the tiered pain management guidelines into the postsurgical order sets (Fig 3 A and B). The user of the home-going pain management order set could opt to not use the order set if necessary to accommodate use of other medications for patients who had drug allergies or other conditions that would restrict the use of the medications in the guidelines. The order set was also developed in a manner that simplified order entry and was consistent with pain category, weight-based ranges, and the need for liquid medications versus tablets.

FIGURE 3

A, EMR order set screenshot revealing the option to choose the pain category. A reminder is placed on this screen to encourage the prescriber to document the reason for prescribing more than a 5-day supply or >30 MME of narcotic. B, EMR order set screenshot revealing the options for moderate procedure based on weight and ability to take tablets. It also includes an educational link for the patient’s family that goes directly into the after-visit summary. Post-OP, postoperative.

FIGURE 3

A, EMR order set screenshot revealing the option to choose the pain category. A reminder is placed on this screen to encourage the prescriber to document the reason for prescribing more than a 5-day supply or >30 MME of narcotic. B, EMR order set screenshot revealing the options for moderate procedure based on weight and ability to take tablets. It also includes an educational link for the patient’s family that goes directly into the after-visit summary. Post-OP, postoperative.

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Fourth, a key driver of improving and standardizing pediatric orthopedic surgery pain management was identified as cultural engagement for attending physicians, residents, and nursing staff. Interventions included socialization and open discussion of the opioid epidemic, including a story of a former patient who suffered opioid addiction and ultimately opioid overdose and death. The nursing staff and advanced practice providers were also included as a part of the team for their role in patient education regarding appropriate narcotic usage, alternative pain medication usage, and appropriate disposal of unused narcotics. Additionally, ongoing engagement was maintained by using high-frequency data sharing of group compliance control charts and Pareto charts for provider-specific data.

Demographics and Guideline Compliance

All demographic data, including surgery type, patient type, and patient characteristics were abstracted from the EMR and calculated by using simple statistics. Our primary outcome measure was provider compliance with the guidelines and was assessed by using a control chart. Compliance was defined with the numerator being the number of patients undergoing orthopedic surgery with the appropriate order set used and the denominator being the total number of orthopedic surgeries. More specifically, prescriptions were evaluated on the basis of the procedure performed and the designated pain category in the guidelines. On the basis of the category, the prescription ordered was classified as greater than, less than, or equal to the guideline’s recommendation. Any prescription following the guidelines (equal) or less than the guideline for the patient’s procedure was designated compliant. Any prescriptions that were greater than the recommended guidelines were designated as noncompliant. Data regarding compliance with the guidelines were initially collected via manual chart audit and ultimately extracted from the EMR by using reporting functions. Data were tracked on a weekly basis beginning in September 2017 after the guidelines were produced. Data were tracked for all orthopedic surgeries in aggregate, as well as compliance for each individual attending orthopedic surgeon. From these data, control charts revealing the surgeons’ compliance guidelines were generated monthly. Our data reflect a percentage of compliance; therefore, a p-chart was used. Shifts in the p-chart centerline were made when ≥8 points were on 1 side of the centerline. Pareto charts depicted failures and difficulties within our tier guidelines and individual provider use of the guidelines.

Opioid Prescribing

The secondary outcome measure was the reduction in opioid prescribed for pediatric orthopedic surgical patients. This was calculated by using the number of morphine milligram Eq (MME) doses prescribed and assessed per surgical patient count. These data were displayed by using an XMR chart and begin with preintervention data beginning in January 2017. The opioid prescribing data were abstracted from the EMR for each of those patients.

Secondary Prescriptions

The balancing measure to assure that we were not underprescribing or inadequately treating our patients’ pain was measuring the number of secondary prescriptions within 14 days of the initial discharge prescription. The date of discharge prescription for patients undergoing outpatient surgery was defined as the date of surgery. The date of discharge prescription for the inpatient surgery was defined as the date of discharge from the hospital.

During the improvement period, there were ∼2000 surgeries performed annually (2017: n = 1958 surgeries; 2018: n = 1790; 2019: n = 2028) by 9 pediatric orthopedic surgeons. The frequencies of the different surgery pain tiers in 2017 (October–December) were 44% minor, 48% moderate, 5% severe, and 3% spinal fusion. In 2018, the frequencies were 41% minor, 50% moderate, 6% severe, and 1% spinal fusion. Finally, in 2019, the frequencies of pain tiers were 45% minor, 48% moderate, 3% severe, and 4% spinal fusion. Ambulatory surgeries were 63%, and 37% were inpatient surgeries. Additional demographics of the patient population from 2018 to 2019 are provided in the patient demographics table (Table 1).

TABLE 1

Patient Demographics

DemographicPercentage of Population
Sex, %  
 Female 47 
 Male 53 
Age, median (IQR), y 13 (9–16) 
Wt, median (IQR), kg 55 (29.8–72) 
Surgical procedure, percentage of total  
 Fracture care 41 
 Reconstructive knee procedures 19 
 Feet 11 
 Hand 
 Shoulder 
 Hip 
 Spine 
 Miscellaneous 
DemographicPercentage of Population
Sex, %  
 Female 47 
 Male 53 
Age, median (IQR), y 13 (9–16) 
Wt, median (IQR), kg 55 (29.8–72) 
Surgical procedure, percentage of total  
 Fracture care 41 
 Reconstructive knee procedures 19 
 Feet 11 
 Hand 
 Shoulder 
 Hip 
 Spine 
 Miscellaneous 

A table describing the patient demographics over the course of 2018 and 2019. These demographics include age, weight, sex, and surgical procedure.

The annotated control chart (Fig 4) reveals aggregate guideline compliance over time as well as annotations of key interventions. Initial results after introduction of the guidelines in September 2017 revealed ∼55% compliance. After the introduction of the pocket cards in October 2017, there was a near immediate upward shift in compliance to 77.5%. A second shift was recognized after the sharing of data through personalized run charts, an aggregate control chart, and a provider-level Pareto chart to all orthopedic residents and attending physicians. This upward shift led to an average of 86.6% compliance. A final and sustained shift (20 months) was recognized after the institution of the EMR order set, increasing compliance to 90%.

FIGURE 4

P control chart revealing the orthopedic providers’ combined percentage of compliance with the appropriate guidelines on a weekly basis. Institution of the EMR order set enabled consistently high (>90%) compliance over a long-term.

FIGURE 4

P control chart revealing the orthopedic providers’ combined percentage of compliance with the appropriate guidelines on a weekly basis. Institution of the EMR order set enabled consistently high (>90%) compliance over a long-term.

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Provider-level compliance data with the EMR order sets improved in each individual provider and are depicted in small multiples shown in Supplemental Fig 6.

The aggregate reduction in prescribed MME rates (MME per patient) is shown over time in Fig 5. The improvement initiative initially resulted in a 34% reduction in MME per patient but ultimately resulted in a 54% reduction in opioids prescribed during the study period, which has been sustained for 12 months.

FIGURE 5

Opioids prescribed in MME per patient from 2017 to 2019. The XMR control chart reveals MME per patient calculated monthly over the course of improvement study and annotated for key interventions.

FIGURE 5

Opioids prescribed in MME per patient from 2017 to 2019. The XMR control chart reveals MME per patient calculated monthly over the course of improvement study and annotated for key interventions.

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The balancing measure of opioid represcription was tracked during the course of the study, and while a variation occurred in 2018, the number of represcriptions returned to the original value in 2019 despite lower MME opioid prescription rates. The represcription rates are as follows: 2017: n = 53 represcriptions, 3% of total patients; 2018: n = 92 represcriptions, 5% of total patients; 2019: n = 69 represcriptions, 3% of total patients.

With this quality improvement initiative, we sought to address and favorably impacted 2 key aims: optimize postoperative pain management and reduce opioid prescriptions. The primary aim of care standardization around postoperative pain was accomplished with >90% of patients undergoing orthopedic surgical interventions receiving guideline-based care. Guideline-based care is a proven strategy to successfully standardize and improve both pediatric medical and surgical care.22,23  Additionally, guideline-based care leveraging the EMR to standardize perioperative care and improve outcomes are similarly achievable.23  Even opioid reduction can be achieved intraoperatively by using guideline-based care standardization by anesthesia while simultaneously reducing postoperative nausea.24  Postoperative pain management guidelines are gaining attention in many surgical disciplines, although pediatric-specific and orthopedic-specific guidelines have not appeared in published literature in a meaningful way.

The secondary aim, which we believed was directly dependent on our success in defining a usable standardized pain management guideline, was to decrease opioid prescriptions in the pediatric orthopedic surgical population.25  Although we believe the cause of the opioid epidemic is multifactorial, it is also our belief that health care prescribers of opioids have the opportunity and responsibility to modify opioid prescribing behaviors.

As with many guidelines and protocols, the implementation of standardized guidelines, by themselves, were not enough to create a meaningful change in opioid prescription patterns within our department. This was immediately evident after review of our initial compliance rate of 54.9% shortly after initiation of the guidelines. The keys to our guideline success were systemwide education, transparency of data, provider involvement in developing postoperative timeout, and institution of a user-friendly EMR order set. Each of these small tests of change informed subsequent changes and validated the interventions before they were hardwired in the EMR. Nursing staff support was an important part of our team providing critical patient feedback and education. With each intervention, our compliance rates improved, evident in our control chart data. This is especially true in a system like ours in which there are 5 to 7 orthopedic residents rotating through the system on 1-month, 2-month, and 3-month rotations. A guiding principle of this and other local improvement initiatives is to “make it easy to do the right thing.” It would be difficult to achieve sustainability without standardization of the guidelines and especially without the use of the EMR order set. Furthermore, if iterative improvement continues and the guidelines change, it would be difficult to assure that rotating residents would easily adopt the changes without the timeouts and EMR. The order set gives us a method to ensure that they are all using the same guidelines.

Lastly, considering a quality improvement tactic we employed during this project was the use of individualized data. Although we used deidentified surgeon-specific data, many improvement teams struggled with the decision about individualized and transparent data versus deidentified data.26,27  We chose to initially use deidentified data because we felt the culture of our system was not ready at that time for identified data. However, the surgeon with the lowest compliance recognized himself on the compliance Pareto chart and acknowledged that he was an outlier. He directly pledged future support for the guidelines in a public fashion at that first meeting. This helped us understand how promoting end-user feedback as well as communal data sharing can drive improvement.

The estimated cost to society of opioid misuse was estimated to be $55.7 billion in 2007.28  Any effort to positively impact this crisis would presumably have a positive impact as well on this cost to society. Perhaps most importantly, any effort to decrease even 1 child’s risk of opioid misuse is well worth this effort.

In summary, use of standardized home-going pain management guidelines led to a decrease in opioid prescribing in a pediatric patient population undergoing orthopedic surgical procedures.

There were 2 key limitations to this improvement project. First, we only addressed the amount of opioids prescribed by the providers rather than the actual consumption of narcotics by the patients. As a result, the decrease in opioid consumption could either be over - or underestimated versus the baseline period. Therefore, it is difficult to determine if there is a chance to further reduce opioid prescriptions by means of additional reduction in opioid dose or durations. Secondly, we did not measure the patient-reported adequacy of postoperative pain management. We have standard instructions for patients or parents to call for inadequate pain control, although specific measures were not tracked. It is possible that simply tracking the number of secondary prescriptions as a balancing measure may have been too blunt of a measure to detect inappropriate pain control. However, plans are being developed to address this need.

Postoperative pain management in pediatric orthopedic patients can be standardized and result in a large-scale reduction in opioid prescriptions without compromising pain control. Perhaps more meaningful is the fact that the major elements of this improvement work can be replicated easily beyond our local experience to accelerate improvement and decrease opioid prescriptions in other pediatric surgical subspecialties’ postoperative pain management. The next steps are exciting because we believe this work can be replicated beyond the confines of pediatric orthopedic surgery, resulting in a locally and nationally scalable impact on reducing unnecessary opioid prescriptions. We contend this is both an opportunity and responsibility in a continued effort to improve child health.

We thank Elizabeth Kendrick, CNS, for assistance with development of the guidelines, Samantha Gunkleman, MD, and April Love for their work on the EMR order set, the pharmacy staff and Carl Roose for assistance with guidelines, and Karen Skerlong for her secondary data analysis.

FUNDING: No external funding.

Dr Jones conceptualized and designed the study, operationalized the project within the provider group, and revised the final manuscript; Ms Engler designed the data collection instruments, collected data, conducted the initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Farid developed the guidelines used in the study and reviewed and revised the manuscript; Ms Fonte collected data, conducted initial analysis, and drafted the initial manuscript; Dr Bigham provided conceptual input to the study design and performed significant manuscript revision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

EMR

electronic medical record

MME

morphine milligram Eq

PDSA

plan-do-study-act

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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