Journal of Pediatric Surgery 54 (2019) 1866–1871

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Practice Management/Education

Variation in postoperative narcotic prescribing after

pediatric appendectomy☆,☆☆
Sarah B. Cairo a,⁎, Kristen A. Calabro a, Elizabeth Bowdish a,b, Cara Reilly c, Stacey Watt d, David H. Rothstein a,b
a
Department of Pediatric Surgery, John R Oishei Children's Hospital, Buffalo, NY
b
Department of Surgery, State University of New York at Buffalo
c
Department of Perioperative Nursing, John R Oishei Children's Hospital, Buffalo, NY
d
Department of Anesthesiology, John R Oishei Children's Hospital, Buffalo, NY

a r t i c l e i n f o a b s t r a c t

Article history: Background: Overuse of prescription opioids by both pediatric and adult patients has garnered significant atten-
Received 25 June 2018 tion in recent years. Educational interventions have been shown to decrease prescription opioids post-
Received in revised form 27 November 2018 operatively in the adult population; similar data have not previously been reported in pediatrics.
Accepted 29 November 2018 Methods: Educational interventions included staff education, institution of opioid standardization protocol, and
distribution of educational materials to families. Chart review was performed pre- and post-intervention to com-
Key words:
pare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls
Opioid epidemic
Opioid use
were used to assess patient satisfaction and pain control.
Pediatric surgery Results: Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postin-
Adolescent surgery tervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort
Postoperative pain control compared to 6.7% (p b 0.001) POST. There was a significant increase in non-opioid analgesia (p b 0.001) POST.
There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients'
gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of
patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% re-
ported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in
emergency department visits or phone calls for poorly controlled pain following the intervention.
Conclusion: Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to
reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or
presentation for pain.
Level of Evidence: III
© 2019 Elsevier Inc. All rights reserved.

By including pain as “The 5th Vital Sign” in 1995, the Joint Commission
joined forces with quality improvement and patient advocacy groups to
improve patient satisfaction through the use of pain control metrics to
guide medication delivery [1,2]. Despite early reports that addiction
following inpatient use of opioids was nearly impossible, the decades
that followed this well-meaning initiative have been characterized by a
substantial rise in opioid prescribing and overdose in the United States
[3–5]. Though previous estimates for opioid specific deaths have been
revised to account for those attributable to poly-substance abuse, opioid
overdose remains a major contributor to injury related death in the
☆ Disclosures: None of the involved authors has any conflicts of interest or disclosures
to report.
☆☆ Presentations: Poster presentation at American Academy of Pediatrics Annual Meeting;
October 2018, Orlando, FL.
⁎ Corresponding author at: Department of Pediatric Surgery, John R Oishei Children's
Hospital, 1001 Main Street, Buffalo, NY 14203. Tel.: +1 708 917 9359.
E-mail address: scairo2@gmail.com (S.B. Cairo).
United States [6–9]. Though only speculative to link the rising prevalence
of opioid use disorders to the inclusion of pain as “the 5th vital sign,” the
liberalization of prescribing practices for opioids in the mid-90s and
increased emphasis on relieving chronic pain cannot be ignored [2,10].
Though it is difficult to discern how the prescription opioids being
misused by adolescent populations are attained, over-prescribing, espe-
cially in pediatric patients, likely contributes through ease of access [11].
In both adult and pediatric practices, the association between medical
use and prescriptions and long-term opioid abuse has raised concerns
for health care providers across all specialties [12]. Using hospital and
state level data, significant variability was identified in prescribing
patterns following common general surgery procedures. This variability
raises further concerns as to how physicians may be contributing to the
epidemic and whether or not we adequately prepare patients for post-
operative pain expectations and treatment goals [7,13]. In pediatric
and adolescent patients undergoing surgical procedures, studies have
identified substantial variability in quantity of opioid doses prescribed

https://doi.org/10.1016/j.jpedsurg.2018.11.015
0022-3468/© 2019 Elsevier Inc. All rights reserved.
 S.B. Cairo et al. / Journal of Pediatric Surgery 54 (2019) 1866–1871 1867

with more than half of all doses dispensed left unconsumed [14,15].
With only 4% of interviewed families safely disposing of leftover opioids,
one can speculate that increased ease of access to previously prescribed
medication may place communities and individuals at risk of misuse
and diversion [14,16].
In this context, the primary objectives of this study are to describe
practice pattern variation in opioid administration following pediatric
appendectomy, evaluate the efficacy of a low-fidelity educational inter-
vention to reduce opioid administration, and assess patient and family
satisfaction following a change in prescribing practice.
1. Methods
The study protocol, telephone interview script, and use of electronic
medical records were reviewed by the Institutional Review Board of the
State University of New York, University at Buffalo and informed consent
was obtained prior to telephone interview (UB IRB: STUDY00001311).
1.1. Data source and patient selection
equivalents (MME) for standardized evaluation using the Prescription
Drug Monitoring Program (PDMP) Training and Technical Assistance
Center (TTAC) conversion data set [17].
1.2. Educational intervention
A low fidelity intervention in the form of provider education was
conducted over a 2-month period at the Children's Hospital. Education
was provided to all members of the surgical care teams including pre-
and post-operative care area nursing staff, anesthesia providers, surgical
residents, advanced practice providers, and attending surgeons. Educa-
tion included a brief presentation discussing the current state of the
opioid epidemic and literature relevant to chronic opioid use in pediatric
patients with or without a history of surgery. Findings from the retro-
spective review were also included in the education intervention. Mate-
rials for ongoing education were made available in high traffic patient
care areas and handouts were developed with the assistance of the
Patient and Family Advisory Council for distribution to patients and
families at time of operation (Appendix 2).

We performed a retrospective review of patients under age 19 who
underwent appendectomy at a freestanding children's hospital in
Western New York between January 1, 2015 and January 1, 2017. The
Women and Children's Hospital of Buffalo (now the John R. Oishei
Children's Hospital) is the region's largest children's hospital. Patients
were initially identified for inclusion based on a diagnostic code for
acute appendicitis and/or procedural code for laparoscopic appendec-
tomy. Electronic medical records (EMR) were reviewed for all patients
meeting inclusion criteria. Patients with evidence of perforation or
patients presenting for interval appendectomy were excluded from the
retrospective portion of this study. Following intervention, all patients
undergoing appendectomy were identified for inclusion. Chart review
was performed to evaluate inpatient and outpatient prescribing patterns,
pain scores, and patient clinical characteristics associated with different
analgesia requirements. Telephone follow-up was performed for all
patients identified in the second stage of the study with a brief interview
focusing on pain control following discharge (Appendix 1). Survey was
conducted by a member of the clinical research team. Quantity of opioids
prescribed at discharge was converted to morphine milligram
1.3. Statistical analysis
Univariate and descriptive analysis were performed on both pre and
post-intervention data. Categorical variables were compared using
the Pearson's Chi-squared and Fisher's exact test, with 2-tailed Student's
t test for normally distributed continuous variables. All statistical analyses
were performed using Excel and IBM SPSS Statistics Software 24. A
p-value of b 0.05 was used for statistical significance where appropriate.
2. Results
2.1. Pre-intervention retrospective review
A total of 313 cases of acute appendicitis were identified for inclu-
sion in the first phase of the study. Overall, 61.5% were male and the
average age was 13.1 +/− 3.4 years (Table 1). The average BMI was
22.2 +/− 5.6 kg/m 2. The majority of patients were non-Hispanic
(93.0%), White (83.1%) and had commercial insurance (92.0%). 84.3%
of patients were given a prescription for opioids at the time of discharge.

Table 1
Demographics of patients receiving prescription for opioids after pediatric appendectomy (PRE), n (%).

Opioids at discharge, 264 (84.3) No opioids at discharge, 49 (15.7) Total, 313 p-Valuea

Gender 0.79
Male 161 (61.2) 31 (63.3) 192 (61.5)
Female 102 (38.8) 18 (36.7) 120 (38.5)
Age Category b0.001
b 5 years 0 (0) 3 (6.1) 3 (1.0)
5–10 years 48 (18.2) 15 (30.6) 63 (20.1)
11–15 years 114 (43.2) 18 (36.7) 132 (42.2)
N 15 years 102 (38.6) 13 (26.5) 115 (36.7)
Average Age (SD) years 13.5 (3.2) 11.5 (4.0) 13.1 (3.4) b0.001
Average BMI (SD) kg/m2 22.2 (5.7) 21.9 (4.9) 22.2 (5.6) 0.75
Ethnicity 0.05
Hispanic 19 (7.2) 2 (4.1) 21 (6.7)
Not Hispanic 245 (92.8) 46 (93.9) 291 (93.0)
Other 0 (0) 1 (2.0) 1 (0.3)
Race 0.15
White 218 (82.6) 42 (85.7) 260 (83.1)
Black 20 (7.6) 2 (4.1) 22 (7.0)
Asian 5 (1.9) 0 (0) 5 (1.6)
Native American/Alaskan Native 3 (1.1) 0 (0) 3 (1.0)
Unspecified 18 (6.8) 5 (10.2) 23 (7.4)
Insurance provider 0.12
Government 15 (5.7) 0 (0) 15 (4.8)
Self-pay 5 (1.9) 2 (4.1) 7 (2.2)
Commercial 243 (92.0) 45 (91.8) 288 (92.0)
Unknown 1 (0.4) 2 (4.1) 3 (1.0)
a
t-Test for continuous variables; chi-squared for categorical.
1868 S.B. Cairo et al. / Journal of Pediatric Surgery 54 (2019) 1866–1871

Table 2
Operative details for patients receiving prescription for opioids after pediatric appendectomy (PRE), n (%).

Opioids at discharge, 264 (84.3) No opioids at discharge, 49 (15.7) Total, 313 p-Valuea

Type of operation 0.006

SILS 61 (23.1) 6 (12.2) 67 (21.4)
TULA 25 (9.5) 13 (26.5) 38 (12.1)
Two port 5 (1.9) 1 (2.0) 6 (1.9)
Three port 173 (65.5) 29 (59.2) 202 (64.5)
Duration of procedure, avg. (SD) 55.6 (54.8) min 45.6 (15.3) min 54.1 (50.9) min 0.21
Post-operative length of stay, avg. (SD) 21.3 (11.8) hrs 18.6 (10.1) hrs 20.9 (11.6) hrs 0.14
Volume local anesthetic, avg. (SD) 9.1 (7.5) mL 9.5 (7.8) mL 9.2 (7.6) mL 0.76
Opioids post-op (ordered)
Yes 263 (99.6) 48 (98.0) 311 (99.4) 0.18
No 1 (0.4) 1 (2.0) 2 (0.6)
Opioids post-op (given)
Yes 248 (93.9) 36 (73.5) 284 (90.7) b0.001
No 16 (6.1) 13 (26.5) 29 (9.3)
Prescriptions ordered at discharge
APAP 62 (23.5) 38 (77.6) 100 (31.9) b0.001
Ibuprofen 148 (56.1) 35 (71.4) 183 (58.5) 0.05

Abbreviations: Single Incision Laparoscopic Appendectomy (SILS), Transumbilical Laparoscopic-Assisted Appendectomy (TULA), Acetaminophen (APAP), standard deviation (SD).

When comparing patients who did and did not receive a prescription providers in the POST group (32.5 ± 38.9 MME or 5.3 ± 3.4 doses vs.
for opioids, there was no difference in patient gender, BMI, ethnicity, 26.7 ± 17.2 MME or 6.5 ± 7.8 doses, respectively, p = 0.76).
race, or insurance provider. Patients who received opioids, however, When comparing patients in the POST cohort with and without evi-
were nearly two years older with an average age of 13.5 +/− dence of perforation, there was no difference in gender, age, BMI, race,
3.2 years compared to 11.5 +/− 4.0 years in patients who did not or ethnicity. Patients with perforation had slightly longer procedures
(p b 0.001). and less local anesthetic used on average. While there were differences
The majority of procedures were performed through a traditional in post-op medication orders between patients with and without perfo-
3-port approach (64.5%) followed by single incision laparoscopic appen- ration, administration of ordered medications and prescribing of
dectomy (SILS) (21.4%) and transumbilical laparoscopic assisted appen- narcotics was comparable (Supplemental Table 2).
dectomy (TULA) (12.1) (Table 2). There was no significant difference
in duration of procedure between patients who did and did not receive
Table 3
opioids (55.6 +/− 54.8 min versus 45.6 +/− 15.3 min, p = 0.21).
Characteristics of patients pre- and post-intervention (non-perforated appendicitis only),
There was also no difference in post-operative length of stay or volume n (%).
of local anesthetic used. Patients who did not receive a prescription
PRE (313) POST (76) p-Valuea
for opioids were significantly more likely to receive a prescription for
acetaminophen with no difference in ibuprofen. Resident physicians Gender
prescribed an average of 18.7 +/− 8.3 doses (92.2 ± 43.5 MME) com- Male 192 (61.3) 39 (51.3) 0.18
Female 120 (38.3) 37 (48.7)
pared to 14.1 +/− 6.0 doses (73.6 ± 32.6 MME) by advanced practice Age Category
providers (p b 0.001). b5 years 3 (1.0) 1 (1.3) 0.63
In comparing characteristics of patients by type of procedure, there 5–10 years 63 (20.1) 18 (23.7)
was no significant difference in gender, age, BMI, duration of procedure, 11–15 years 132 (42.2) 35 (46.1)
N15 years 115 (36.7) 22 (28.9)
volume of local anesthetic and ordering of opioids post-operatively
Average age (SD) years 13.1 (3.4) 12.5 (3.7) 0.18
(Supplemental Table 1). Average BMI (SD) kg/m2 22.2 (5.6) 27.4 (55.4) 0.10
Ethnicity
Hispanic 21 (6.7) 10 (13.2) 0.09
2.2. Post-Intervention Review Not Hispanic 291 (93.0) 65 (85.5)
Other 1 (0.3) 1 (1.3)
Race
A total of 119 patients were identified for inclusion during the White 260 (83.1) 61 (80.3) 0.23
5 months following intervention. 52.9% of these patients were diagnosed Black 22 (7.0) 3 (3.9)
with acute appendicitis, 16.8% underwent interval appendectomies, Asian 5 (1.6) 0 (0)
Native American/Alaskan Native 3 (1.0) 2 (2.6)
10 (8.4%) had gangrenous or suppurative appendicitis, and 16 (13.4%)
Unspecified 23 (7.3) 1 (1.3)
were described as having contained versus diffuse 16 (13.4%) signs of Insurance provider
perforation. Excluding patients with perforated or complex appendicitis, Government 15 (4.8) 16 (21.1) b0.001
patients in the POST cohort did not differ from PRE in gender, age, Self-pay 7 (2.2) 1 (1.3)
average BMI at time of operation, ethnicity, race, or average duration of Commercial 288 (92.0) 59 (77.6)
Unknown 3 (1.0) 0 (0)
surgery (Table 3). There was variability in distribution by procedure
Procedure type
type with more single port operations in the PRE cohort (65.2% com- Single port 202 (65.2) 21 (27.6) b0.001
pared to 27.6% POST). Primary insurance provider also varied between Two ports 5 (1.6) 2 (2.6)
the cohorts. There were significant differences in ordering of opioid Three ports 102 (32.9) 52 (68.4)
Avg Duration of Surgery (SD) 56.6 (22.7) min 51.5 (24.8) min 0.09
and non-opioid analgesia post-operatively (Table 4). Additionally, there
Avg volume local anesthesia (SD) 9.3 (7.6) mL 13.2 (8.6) mL b0.001
were differences in medication administration with significant increases Bupivicaine 0.25% plain, n (%) 277 (88.2) 60 (78.9) 0.09
in administration of acetaminophen, ibuprofen, and ketorolac amongst Bupivicaine 0.25% w epinephrine, n (%) 31 (1.6) 14 (18.4)
patients in the POST group, with concomitant decreases in morphine None documented, n (%) 5 (1.6) 2 (2.6)
and acetaminophen-hydrocodone administration. There was no signifi- Abbreviations: standard deviation (SD).
cant difference in doses prescribed by residents and advanced practice a
t-Test for continuous variables; chi-squared for categorical.
 S.B. Cairo et al. / Journal of Pediatric Surgery 54 (2019) 1866–1871 1869

Table 4 educational intervention, we identified significant variability in pre-

Post-operative narcotic utilization pre- and post-intervention (acute appendicitis only), n (%). scribing practices between resident physicians and advanced practice
PRE (313) POST (76) p-Valuea providers such as nurse practitioners and physician assistants. Following
Post-op medications ordered
the intervention, however, there was a reduction in the variability and
Acetaminophen 186 (60.0) 75 (98.7) b 0.001 overall reduction in both in hospital and out of hospital opioid utilization
Ibuprofen 136 (43.9) 61 (80.3) b 0.001 with increased use of non-opioid analgesia. Through follow-up phone
Ketorolac 37 (11.9) 14 (18.4) 0.13 calls, this study found high levels of patient or parent satisfaction follow-
Morphine 270 (87.1) 70 (92.1) 0.17
ing the change in practice and education intervention. Additionally, very
Acetaminophen-hydrocodone 258 (83.2) 11 (14.5) b 0.001
Medications Administeredb few parents reported inadequate pain control and the vast majority
Acetaminophen 77 (41.4) 60 (80.0) b 0.001 preferred to minimize opioids usage, in the future. There were some
Ibuprofen 81 (59.6) 52 (85.2) b 0.001 differences in the characteristics of patients in the PRE and POST cohorts
Ketorolac 31 (83.8) 12 (85.7) 0.87 which are attributed to the inclusion of patients with complicated or
Morphine 197 (73.0) 32 (45.7) b 0.001
perforated appendicitis POST and limiting evaluation to simple, acute
Acetaminophen-hydrocodone 216 (83.7) 8 (72.7) 0.34
Prescriptions at discharge appendicitis PRE. Though we included potentially sicker patients under-
Acetaminophen 60 (19.4) 74 (97.4) b 0.001 going more difficult operations POST, there was still a significant reduc-
Ibuprofen 145 (46.8) 72 (94.7) b 0.001 tion in post-operative opioid utilization regardless of perforation status.
Acetaminophen-hydrocodone 244 (78.7) 6 (7.9) b 0.001
In the first phase of this study we sought to identify factors associated
Miralax 171 (55.2) 37 (48.7) 0.35
with increased opioid utilization in pediatric patients following appen-
a
chi-Squared for categorical variables. dectomy. In the retrospective portion of the study there was no signifi-
b
Proportion of patients with medication ordered who received it.
cant difference in patients receiving opioids based on gender, ethnicity,
or BMI. Patients were more likely to receive a prescription for opioids
the older they were despite no change in opioid utilization during hospi-
2.3. Telephone follow-up talization based on patient age. Higher prescription distribution in older
patients is particularly relevant given recent studies reporting nonmedi-
Of the 119 patients who underwent laparoscopic appendectomy in cal use of a prescription opioid by nearly 13% of high school seniors
the POST cohort, 72 (60.5%) were available for follow-up phone survey. obtained through diversion or left over prescriptions [18]. Furthermore,
One survey was conducted with the patient who had turned 18 since up to 40% of high school students report that opioids are relatively easy
time of surgery and the remainder were conducted with a parent or to obtain, due in large part to increasing frequency of opioid prescrip-
guardian. Multiple attempts were made to contact all patients/parents; tions in adults and children [19,20]. In addition to the factors of increas-
none of those who were successfully contacted refused participation in ing age and use of cigarettes, a single prescription for barbiturates or
the follow-up interview. Seven patients/parents could not be reached sedatives are associated with significantly increased risk of opioid misuse
due to incorrect contact information. The remainder either did not an- in pediatric and adolescent patients and, not surprisingly, persistent
swer their telephone, did not respond to voice mails, or did not have ac- misuse of opioids in adulthood [12,21]. Though this cannot be tied
tive voice mail. There was no statistically significant difference in age, directly to inappropriate prescribing patterns, there are concerns that
gender, or race of patients who were and were not available for increased access to opioids is unlikely to deter substance abuse, even
follow-up. The mean time from discharge to follow-up was 37.5 days amongst pediatric and adolescent patients [20].
(IQR 29.0–50.8 days) and the median post-operative length of stay With increasing concern for nonmedical opioid utilization and rising
was 18.8 h (IQR 8.1–30.2 h) (Table 5). Pain within the first 24 h of dis- rates of prescription opioid use in pediatric emergency departments
charge was reported as moderate (5.1 ± 1.2 on a scale from 1 to 10) (EDs) over the past decade, the medical community has begun to
and 8.3% of the follow-up cohort received a prescription for opioids. describe mechanisms for addressing the opioid epidemic [22,23]. In
Most patients in this group were given acetaminophen and/or ibupro- EDs in many states, for example, prescription drug monitoring pro-
fen after discharge. The majority, 95.8%, reported adequate pain control grams have been enacted though the effect of these remain to be seen
with this regimen and 94.4% reported that they would be willing to [24,25]. In EDs and in the primary care setting, the introduction of opioid
avoid opioids again in the future. Of the patients/parents who would prescribing protocols with details step-up approaches have resulted in
prefer opioids in the future, two had specific concerns related to comor- significant reductions in distribution of opioid prescriptions [26,27]. In
bid psychiatric conditions and difficulties with communication. surgical patients where peri-operative opioid administration in opioid
naïve patients is associated with risk of subsequent misuse, efforts are
3. Discussion being made towards more judicious opioid use [5,28]. In adult patients,
for example, guidelines for discharge prescriptions have helped reduce
In this single center case review we evaluated prescribing practices the volume of doses prescribed by evaluating common usage [29,30].
and opioid utilization in pediatric general surgery. Prior to a low fidelity Though not entirely unique to the United States, organizations such
as the European Society for Pediatric Anaesthesiology have developed
more formalized recommendations for perioperative pain management
Table 5
Patient (parent) follow-up interview, n = 72 (60.5% of population).
in children to help curtail inappropriate use of opioids [31–33]. Similar
to the protocol developed during the course of this study, most groups
Time to follow-up call, median (IQR) 37.5 (29.0–50.8) days recommend peri- and post-operative use of non-steroidal analgesia or
Age of patients, avg. (SD) 11.4 (3.7) years
paracetamol with intravenous or oral tramadol in the ward and intrave-
Post-operative LOS, median (IQR) 18.8 (8.1–30.2) hours
Pain score first 24 h after discharge, avg. (SD) 5.1 (1.2) nous opioids while in the recovery room.
Narcotic Rx given, n (%) 6 (8.3) In accordance with fast track pathways, enhanced use of nonopioid
Rx filled, n (%) 5 (83.3) analgesia and alternative methods for pain control have gained popu-
Days received analgesia, avg. (SD) 3.4 (2.1) days
larity in the United States. With evidence of variable prescribing of
APAP administered, n (%) 60 (83.3)
Ibuprofen administered, n (%) 59 (81.9) nonopioid analgesia in adult surgical patients, it stands to reason that
Pain adequately controlled, n (%) 69 (95.8) in both adult and pediatrics, improved utilization of these tools may
Limit narcotics in the future, n (%) 68 (94.4) aide in reducing unnecessary opioid prescribing and administration.
Abbreviations: LOS length of stay, APAP acetaminophen, Rx prescription, avg. (SD) average Our protocol encouraged providers to schedule medications such as
and standard deviation, IQR interquartile range. acetaminophen and ibuprofen or ketorolac post-operatively. Other
1870 S.B. Cairo et al. / Journal of Pediatric Surgery 54 (2019) 1866–1871
recent studies on the effect of an educational program for standardiza-
tion of post-operative pain control have recommended scheduling
these medications for up to 3 days [7,29,34]. Though more difficult
to standardized, the use of local anesthetic has also been promoted
including teaching of techniques to maximize benefit [35].
In the event that opioids are prescribed, we found a significant
difference in average number of doses prescribed by residents com-
pared to advanced practice providers. While we speculate that this is
due in large part to the trainees' experience with adult patients and
rotation through a number of different facilities working with surgeons
with variable practice patterns, our findings mirror those of other single
institution reviews [36–38]. In response to this variability and infre-
quent exposure to opioid prescribing prior to residency, many programs
have developed formal education around this topic [39]. Courses typi-
cally include information on calculating morphine milligram equiva-
lents in mock surgical scenarios, use of non-opioid analgesia, and a
review of rules and regulations around prescribing and discarding con-
trolled substances [34,40,41]. Not only did we seek to educate resident
providers on multimodal pain management strategies in pediatrics
but we incorporated multiple members of the care team to enhance
pathway utilization and acceptance of change, a strategy infrequently
mentioned in the literature.
Though differences in opioid prescribing were evaluated for statistical
significance over the course of this study, the phases described are part of
a traditional Plan-Do-Study-Act (PDSA) quality improvement cycle. By
incorporating patient and parent satisfaction into the model, we studied
the impact of the changes made on patient pain control allowing for
ongoing change and improvements in patient care. Several studies
have begun to address the difficulties in assessing pain, a subjective expe-
rience, in the perioperative period, especially in children. Though still
challenged by the subjective nature of pain, concerns have been raised
that parents and guardians may underestimate their child's pain
[42–44]. In our study, parents and guardians were interviewed to assess
post-operative pain in follow-up. While this method presented a risk of
bias or underreporting, as described above, distribution of handouts
prior to discharge including the standard Wong Baker Faces scale utilized
during the hospitalization, was designed to address this as much as
possible [45–47]. Taking this into account, the next phase of this study
will compare modalities for the assessment of postoperative pain and
continue through the PDSA cycle for further quality improvement.
3.1. Limitations
This study has a few limitations which may influence its general-
izability. While the study was conducted at a regional children's hospi-
tal and includes a large number of patients, it may not be generalizable
to all populations. One factor that may affect the ability to enforce a
opioid reduction program as was done at our institution is distance
traveled by patient/family to reach surgical care. While providers are
engaged and enthusiastic about the initiative, they may be more apt
to give a prescription for opioids to a family that lives farther away
than one that lives nearby. Depending on the community served, this
may exacerbate or highlight socioeconomic variability in prescribing
practices. A larger study with more variability in patient demographics
is needed to address this point.
One area of variability identified in this study which has not been
fully flushed out is the use of local anesthesia. As noted, there was an
increase in the volume of local anesthetic administered with the majority
of providers using bupivacaine without epinephrine. Though the educa-
tion intervention included a description of proposed best practices for
administration to include transverse abdominis block, a formalized
simulation lab with monitoring of individual provider delivery was not
performed. While many institutions have transitioned to regular use of
formal regional nerve blocks or nerve catheters, this is not yet been per-
formed at our institution and would likely further progress in reducing
opioid prescribing in pediatric general surgery [48,49].
Another limitation is the time between the pre-intervention data
collection and post-intervention. Specifically, it would be reasonable
to see a decrease in opioid administration as a reflection of increased
attention to the opioid epidemic over the 12 months preceding the
formal intervention. Because of this and a variety of patient and
provider factors affecting opioid usage and administration, the results
described in this study cannot be solely attributed solely to the educa-
tional intervention. While this study tracked the prescribing patterns
following appendectomy for 6 months after intervention, the rotating
nature of providers in a surgical training program necessitates frequent
re-education and may introduce variability to the findings. Training of
nurses, advanced practice providers, and creation of educational tools
and posters, however, are meant to combat this variability and enhance
programmatic sustainability.
4. Conclusion
There is variability in the opioid prescribing practices following out-
patient surgical procedures in pediatrics. Low-fidelity educational inter-
ventions and creation of a standardized pathway is an effective tool to
reduce opioid prescribing and promote alternative means of analgesia.
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpedsurg.2018.11.015.
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