Reducing Opioid Exposure in a Level IV Neonatal Intensive Care Unit

Stetson, Raymond C.; Smith, Brandi N.; Sanders, Nicole; Misgen, Megan A.; Ferrie, LaRae J.; Schuning, Virginia S.; Schuh, Allison R.; Fang, Jennifer L.; Brumbaugh, Jane E.

doi:10.1097/pq9.0000000000000312

Cited by 8 publications

(10 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…10,11 Examples of similar quality improvement projects organized in other subspecialty fields have had similar aims and efficacy of decreased opioid medication consumption. [12][13][14][15] Utilizing these principles after deciding to proceed with the AAP's challenge statement, we reviewed our department's baseline dose administration for common urologic outpatient procedures (circumcision, orchiopexy, and IHR) before the initiation of our project. We also reviewed our state's prescribing laws to inform all levels of prescribing providers (surgeon, resident physician, and advanced practice provider) and any changes that may affect our prescribing patterns.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment

Stout

Alpert

Kersey³

et al. 2023

Pediatric Quality &Amp; Safety

View full text Add to dashboard Cite

Introduction: Pediatric patients undergoing outpatient surgeries often receive prescriptions for postoperative pain, including opioid medications. As a result, the American Academy of Pediatrics formally challenged all pediatric surgeons to decrease opioid prescribing for common specialty-specific outpatient procedures at discharge. To meet this challenge, we designed a quality improvement project to decrease the average number of opioid doses administered to pediatric patients undergoing 3 common outpatient urologic surgeries: circumcision, orchiopexy, and inguinal hernia repair (IHR). Methods: We formally challenged providers at our institution to reduce opioid doses per prescription and administration to patients overall. We performed a retrospective chart review at our single pediatric institution to establish baseline opioid prescribing values from July 2017 to March 2018. We aimed to reduce this value by 50% in 6 months and sustain this decrease throughout the project duration. Results: We performed 1,518 orchiopexies, 1,505 circumcisions, and 531 IHRs. The percent change in the average number of opioid doses prescribed per patient from baseline values assessed to 2021 was statistically significant for orchiopexies (P < 0.0001), IHRs (P < 0.0001), and circumcisions (P < 0.0001). In addition, the change in the percentage of patients prescribed opioids from baseline was statistically significant for all 3 procedures (P < 0.001). Conclusions: This project demonstrated that through an organized quality improvement initiative, the average number of opioid medications prescribed and the total percentage of patients prescribed opioids following common outpatient pediatric urologic procedures can be decreased by at least 50% and sustained through project duration.

show abstract

Section: Discussionmentioning

confidence: 99%

“…10,11 Examples of similar quality improvement projects organized in other subspecialty fields have had similar aims and efficacy of decreased opioid medication consumption. 12–15…”

Section: Discussionmentioning

confidence: 99%

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment

Stout

Alpert

Kersey³

et al. 2023

Pediatric Quality &Amp; Safety

View full text Add to dashboard Cite

show abstract

“…Although some neonatal studies reduced opioid prescription, most interventions developed guidelines for initiating pain medications or standardizing formal assessment tools for pain and sedation. 17 , 18 , 28 , 29 Published neonatal studies have not focused on the weaning phase of opioids in the critically ill neonatal population. Given this gap in the literature, we accounted for the duration of opioid exposure and opted to standardize the weaning phase of these medications accordingly.…”

Section: Discussionmentioning

confidence: 99%

“…Some units rely on protocols to prevent opioid initiation. 17 , 18 Others emphasize the importance of treating pain and use management guidelines that center around measures of infant discomfort. Prior quality improvement studies in a non-Neonatal Intensive Care Unit (NICU) population achieved a 20% reduction in opioid use through standardized withdrawal assessment and weaning of opioids.…”

Section: Introductionmentioning

confidence: 99%

Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates

Vyas

Cardona

Carroll

et al. 2022

Pediatric Quality &Amp; Safety

View full text Add to dashboard Cite

Introduction: Pain impacts brain development for neonates, causing deleterious neurodevelopmental outcomes. Prescription opioids for analgesia or sedation are common; however, prolonged opioid exposure in neonates is associated with neurodevelopmental impairment. Balancing the impact of inadequate pain control against prolonged opioid exposure in neonates is a clinical paradox. Therefore, we sought to decrease the average days of opioids used for analgesia or sedation in critically ill neonates at a level IV Neonatal Intensive Care Unit by 10% within 1 year. Methods: A multidisciplinary quality improvement team used the model for improvement, beginning with a Pareto analysis, and identified a lack of consistent approach to weaning opioids as a primary driver for prolonged exposure. The team utilized 2 main interventions: (1) a standardized withdrawal assessment tool-1 and (2) a risk-stratified opioid weaning guideline. Results: We demonstrated a reduction in mean opioid duration from 34.3 to 14.1 days, an increase in nursing withdrawal assessment tool-1 documentation from 20% to 90%, and an increase in the documented rationale for daily opioid dose in provider notes from 20% to 70%. Benzodiazepine use did not change. Conclusion: Standardized withdrawal assessments combined with risk-stratified weaning guidelines can decrease opioid use in critically ill neonates.

show abstract

“…Of the remaining 19 algorithms (68%), all but one (88) combined sedation with at least one other condition, which were distributed as follows: 12 "pain-sedation" algorithms (61, 63, 64, 73, 75-77, 84-86, 93-95), four "pain-sedation-IWS" algorithms (62, 74, 78-80, 83), one "pain-sedation-delirium-IWS" algorithm (66), and one "sedation-IWS" algorithm (82). The other combination was "pain-IWS" (88).…”

Section: Algorithm Characteristicsmentioning

confidence: 99%

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

et al. 2023

View full text Add to dashboard Cite

BackgroundPain, sedation, delirium, and iatrogenic withdrawal syndrome are conditions that often coexist, algorithms can be used to assist healthcare professionals in decision making. However, a comprehensive review is lacking. This systematic review aimed to assess the effectiveness, quality, and implementation of algorithms for the management of pain, sedation, delirium, and iatrogenic withdrawal syndrome in all pediatric intensive care settings.MethodsA literature search was conducted on November 29, 2022, in PubMed, Embase, CINAHL and Cochrane Library, ProQuest Dissertations & Theses, and Google Scholar to identify algorithms implemented in pediatric intensive care and published since 2005. Three reviewers independently screened the records for inclusion, verified and extracted data. Included studies were assessed for risk of bias using the JBI checklists, and algorithm quality was assessed using the PROFILE tool (higher % = higher quality). Meta-analyses were performed to compare algorithms to usual care on various outcomes (length of stay, duration and cumulative dose of analgesics and sedatives, length of mechanical ventilation, and incidence of withdrawal).ResultsFrom 6,779 records, 32 studies, including 28 algorithms, were included. The majority of algorithms (68%) focused on sedation in combination with other conditions. Risk of bias was low in 28 studies. The average overall quality score of the algorithm was 54%, with 11 (39%) scoring as high quality. Four algorithms used clinical practice guidelines during development. The use of algorithms was found to be effective in reducing length of stay (intensive care and hospital), length of mechanical ventilation, duration of analgesic and sedative medications, cumulative dose of analgesics and sedatives, and incidence of withdrawal. Implementation strategies included education and distribution of materials (95%). Supportive determinants of algorithm implementation included leadership support and buy-in, staff training, and integration into electronic health records. The fidelity to algorithm varied from 8.2% to 100%.ConclusionsThe review suggests that algorithm-based management of pain, sedation and withdrawal is more effective than usual care in pediatric intensive care settings. There is a need for more rigorous use of evidence in the development of algorithms and the provision of details on the implementation process.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021276053, PROSPERO [CRD42021276053].

show abstract

Reducing Opioid Exposure in a Level IV Neonatal Intensive Care Unit

Abstract: Supplemental Digital Content is available in the text.

Cited by 8 publications

References 22 publications

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment

Reducing Opioid Prescriptions after Common Outpatient Pediatric Urologic Surgeries: A Quality Improvement Assessment

Standardized Scoring Tool and Weaning Guideline to Reduce Opioids in Critically Ill Neonates

Effectiveness, quality and implementation of pain, sedation, delirium, and iatrogenic withdrawal syndrome algorithms in pediatric intensive care: a systematic review and meta-analysis

Contact Info

Product

Resources

About