Effect of a Standardized Electronic Medical Record Order Set on Opioid Prescribing after Tonsillectomy

Abstract

Objective Approximately 5% of children develop new persistent opioid use after tonsillectomy. Critical review of our prescribing practices revealed inconsistent and excessive opioid prescribing after this procedure in children. We sought to improve our practice by using a standardized electronic medical record (EMR)–based order set. Methods Retrospective chart review of outpatient tonsillectomy performed before and after institution of an EMR intervention with comparison of opioid and nonopioid analgesic (NOA) prescription characteristics as well as outcomes including hemorrhage and readmission. Results Analysis of 276 preorder set and 128 post–order set tonsillectomies revealed a significant increase in NOA utilization following initiation of the order set and a significant reduction in doses of opioid prescribed. Due to a change to a stronger opioid in the order set, morphine dose equivalents (MDEs) prescribed were not decreased in the post–order set cohort. Variability between prescriptions and providers was significantly decreased in the post–order set group in terms of doses and MDEs, and dangerously high outlier prescriptions were eliminated. No differences in pain control, postoperative hemorrhage, presentation to the emergency department, or readmission were identified. Discussion An EMR-based intervention improved the quality and safety of posttonsillectomy opioid prescribing at our institution. Moving forward, this order set provides a platform with which to titrate opioid prescriptions and NOA to optimal pain control and safety levels. Implications for Practice A standardized EMR-based order set can improve the quality of opioid prescribing after tonsillectomy.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy

“…In a recent retrospective analysis, use of a standardized EHR order set was associated with a reduction in opioid prescriptions after T&A. 18 Our initiative supports this work through prospective methods, demonstrating an effect that was both large scale and sustained. Furthermore, through tracking opioid prescriptions generated by calls to the office and returns to the ED after discharge, we demonstrated a reduction in the proportion of patients receiving an opioid prescription throughout the recovery period.…”

The Role of Electronic Medical Records in Reducing Unwarranted Clinical Variation in Acute Health Care: Systematic Review

“…Almost all the studies were based on the implementation of an intervention (new or refined) into a clinical setting (35/36, 97%) with 1 qualitative analysis of EMRs by clinicians [36]. Most studies were quality or process improvement based (28/36, 78%) [33][34][35]37,[39][40][41][42][43][44][45][47][48][49]51,52,54,55,58,59,[61][62][63][64][65][66][67] [33][34][35][36][39][40][41][42][43][46][47][48]50,52,54,58,60,62,63,65,66,70]. Many papers addressed the minimization or elim...…”

“…Most studies were quality or process improvement based (28/36, 78%) [33][34][35]37,[39][40][41][42][43][44][45][47][48][49]51,52,54,55,58,59,[61][62][63][64][65][66][67] [33][34][35][36][39][40][41][42][43][46][47][48]50,52,54,58,60,62,63,65,66,70]. Many papers addressed the minimization or elimination of a particular drug prescription/use (17/36, 47%) [39,40,…”

“…Regarding overall disposition, most studies reported positive results (30/36, 83%) [33][34][35][37][38][39][40][41][42][43][45][46][47][48][49][50][51][52][53][54][58][59][60][62][63][64][65][66][67]70], while a minority reported mixed [44,55,56] or negative results [36,57,61] (3/36, 8% each). That is, the authors concluded in most studies that the EMR was used successfully as part of an initiative to address clinical variation.…”

“…1. Publication bias: most papers (30/36, 83%) reported positive results [33][34][35][37][38][39][40][41][42][43][45][46][47][48][49][50][51][52][53][54][58][59][60][62][63][64][65][66]70], with a minority reporting mixed [44,55,56] or negative results [36,57,61] (3/36, 8% for both). The completeness of results including nonsignificant effects was not always assured.…”