Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative

• Published in: Journal of pediatric urology 2020-10, Vol.16 (5), p.647.e1-647.e9
• Main Authors: O'Kelly, F., Pokarowski, M., DeCotiis, K.N., McDonnell, C., Milford, K., Koyle, M.A.
• Format: Article
• Language: English
• Subjects: Hypospadias; Ishikawa; Opioid; Quality improvement; Run chart; Stewardship
• ISSN: 1477-5131; 1873-4898
• DOI: 10.1016/j.jpurol.2020.06.012

Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission. The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education. This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study–Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019. Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention. We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9. Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any a