As the opioid crisis grew into a national epidemic, the nine pediatric orthopedic surgeons at Akron Children’s began analyzing their own pain prescribing practices and how they compared with peers. This led to a standardized protocol that has reduced the amount of narcotics being prescribed by 54 percent.
“The opioid epidemic, a multifactorial issue with many causes, is one of the most alarming public health concerns of our time and it’s imperative that providers recognize prescribing patterns that may be contributing to the problem,” said Kerwyn Jones, MD, pediatric orthopedic surgeon. “While efforts are being undertaken to improve adult pain management worldwide, very little has been done in pediatrics.”
Starting in 2017, Dr. Jones led a study group that included Laurie Engler, a quality initiative specialist; Samantha Gunkelman, MD, a pediatric hospitalist; and April Love, an EMR specialist. In a survey of four other pediatric orthopedic programs along with Akron Children’s own providers, they found wide variability in prescribing patterns.
Prescribing variations are rooted in differences in medical education and practices across different orthopedic surgery residency and fellowship programs.
“Most residencies and fellowships are based in the adult world, not pediatrics,” said Engler. “In the late 1990s, pain was thought of as a fifth vital sign. In the medical world, a great emphasis was placed on doing everything we could to control our patients’ pain levels. Since that time, we continue to learn more about factors contributing to pain and what we can do to mitigate them.”
Working with colleagues in Akron Children’s Pain Center and Pharmacy, the team established a standardized approach to prescribing pain medicine after orthopedic surgery, based on the surgery’s complexity and anticipated pain level. The new prescribing guidelines are based on four surgical categories (a mild, moderate, major procedure or a spinal fusion); the patient’s weight; whether the patient prefers pills or a liquid medicine; and if it’s the first or second prescription.
Guideline education, along with laminated pocket cards for easy reference, was given to all providers, including residents. The team met regularly with providers to obtain feedback regarding the efficiency of these tools. Data was collected on all post-operative prescription orders and analyzed to determine guideline compliance.
Next, the hospital electronic medical records (EMR) team created an order set with the pain prescription guidelines and discharge instructions. Once this was in place, the team reported a 90 percent compliance rate for providers using the pain prescribing guidelines at discharge.
“We have reduced the amount of narcotics prescribed by approximately 54 percent while maintaining good pain control after surgery,” said Dr. Jones.
All surgical teams at Akron Children’s now have standardized post-op pain management guidelines for at least some of their surgical procedures. This includes General Surgery, ENT, the Burn Center, the Heart Center, Dental, Neurosurgery, Plastics and Reconstructive Surgery, Urology, the Vision Center and Maternal Fetal Medicine.
Robert Stewart, MD, chief of Cardiothoracic Surgery, said children and even most teens are rarely prescribed narcotics beyond the first 24 hours following open-heart surgery.
“They do well on a schedule of acetaminophen and ibuprofen, and are in the playroom rather than in bed under the effects of a narcotic,” he said. “The mind is a powerful thing.”
Following the lead of the orthopedics team, the Heart Center team spent the past year formalizing their prescribing guidelines, which are based on weight and age, the location of the incision, and if the patient has experienced any breakthrough pain while taking the acetaminophen/ibuprofen combination.
The process included some good discussions among providers about prior assumptions, including the assumption that all babies’ post-surgical cries are from pain. Frequently, it turns out, the baby is just as likely to be hungry.
“To accomplish change and make it sustainable, you must win ‘hearts and minds,’” said Dr. Jones. “You have to share a compelling story while using the data to educate. And you have to make it easy. We are increasingly seeing the benefits of standardization in medicine. It becomes part of the provider’s routine. It enhances safety for the patient, and there’s a quality/cost value for the health care system.”