pediatric orthopedic post-operative pain management · •orthopedic physicians •orthopedic nurse...
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Pediatric Orthopedic
Post-operative Pain
Management
Kerwyn Jones MDLaurie Engler MHA
Local Problem(Circa 2017)
7 rotating orthopedic residents/ 9 orthopedic surgeons
Prescribing postoperative
narcotics
Wide variation in opioid
prescriptions
Local Problem2017
Morphine Milliequivalents (MME)
19,998
Local ProblemLack of Standardization• Over/ under prescribing
• Patient confusion
• Staff confusion
• Resident confusion
• Patient risk
Multi-disciplinary team• Informatics
• Order Set team
• Epic Build team
• Orthopedic Physicians
• Orthopedic nurse
• Pain management team
• Pharmacist
• Quality specialist
Design and Implementation
• All orthopedic surgical patients
• Development of standardized guideline
• Test on small scale design and process• One provider, one nurse
• Expanded to all orthopedic providers
James M. Anderson Center for Health Systems Excellence
SMART Aim
Key Drivers
Interventions (LOR #)
Increase the percentage of
time the post-operative pain
management guidelines are
appropriately followed at
discharge from 56% to 90%
by 6/30/18.
Project Leader(s): Laurie Engler
Provide a comprehensive,
standard approach to patient
perioperative care planning
while reducing the amount of
opioids prescribed.
Global Aim
Pediatric Orthopedic Post-
operative Patients
Population
Revision Date: 4/4/18
Pediatric Orthopedic Post-Operative Pain Management KDD
Culture (Attending /Resident)
Support/Buy In
Adequate, Effective Amount of
Medication Guideline per Category
Guidelines Reference Tools
Available
Provider Knowledge of the Post-
operative Pain Management
Guidelines
Accurate Procedure Category
(Complexity of surgery to category)
Obtain patient medication usage through patient
tracking and interviews
Analyze KSU Research data collection LOR 1
Attend COSA provider and Resident meetings
Share data and reporting
Establish incentive LOR 1
Educate at Resident Orientation of the existing
guidelines
Educate Residents how to use Guidelines
Educate Where to find Guidelines
Assess Resident Procedure and Category
understanding
Attend Resident Conferences LOR 1
Establish clear definition of what procedure fits
into which category
Determine accuracy of procedure to category by
analyzing patient medication usage per
procedure per category LOR 1
Build Epic Order Set
Establish Clinical Decision Support LOR 2
Provide pocket cards
Place guidelines / posters in resident areas
Provide Phone apps
Place guidelines on ACH intranet LOR 1
Predicted Pain (Categories)
11
MinorEx: Closed reduction, Closed reduction percutaneous pinning, superficial debridement, arthroscopy without implants (chondroplasty, meniscectomy) 01
ModerateEx: Open reduction internal fixation, deep debridement, arthroscopy with implants (ACL, labral repair) 02
MajorEx: Hip osteotomies, long bones osteotomies, multiple procedures 03
Spinal Fusion (Idiopathic/ Neuromuscular)04
Guideline Output
12
Minor
Drug: Hydrocodone-Acetaminophen (Norco or Hycet)
Duration: 3 days
Moderate
Drug: Oxycodone-Acetaminophen (Roxicodone or Percocet)
Duration: 5 days
Major
Drug: Oxycodone-Acetaminophen (Roxicodone or Percocet)
Duration: 5 days
Spinal Fusion
Drug: Oxycodone-Acetaminophen (Percocet)
Duration: 10 days
Postoperative Time Out(End of surgical procedure)
1. Weight bearing status
2. Dressing change
3. Follow up date
4. Pain category• Minor
• Moderate
• Major
• Spinal fusion
Photo of guidelines on smart phones 11-16-17
Epic Order Set 8/1/18
0
10
20
30
40
50
60
70
80
90
1009/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
Resident and Attending Education at Indications Conference 2/19/18
COSA Staff meeting 06/20/18
New Guidelines on Pocket Cards 10/23/17
Photo of guidelines on smart phones 11-16-17
Epic Order Set 8/1/18
0
10
20
30
40
50
60
70
80
90
1009/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
Resident and Attending Education at Indications Conference 2/19/18
COSA Staff meeting 06/20/18
Photo of guidelines on smart phones 11-16-17
Epic Order Set 8/1/18
0
10
20
30
40
50
60
70
80
90
1009/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
Resident and Attending Education at Indications Conference 2/19/18
COSA Staff meeting 06/20/18
0
10
20
30
40
50
60
70
80
90
1009/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
Resident and Attending Education at Indications Conference 2/19/18
COSA Staff meeting 06/20/18
0
10
20
30
40
50
60
70
80
90
100
9/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
Ortho Staff meeting 06/20/18
EMR Order Set
EMR Order Set
EMR Order Set
0
10
20
30
40
50
60
70
80
90
100
9/0
3/1
7 (
n=
35
)
9/2
4/1
7 (
n=
44
)
10
/15
/17 (
n=
38)
11
/05
/17 (
n=
55)
11
/26
/17 (
n=
40)
12
/17
/17 (
n=
57)
1/0
7/1
8 (
n=
57
)
1/2
8/1
8 (
n=
49
)
2/1
8/1
8 (
n=
39
)
3/1
1/1
8 (
n=
38
)
4/0
1/1
8 (
n=
29
)
4/2
2/1
8 (
n=
40
)
5/1
3/1
8 (
n=
47
)
6/0
3/1
8 (
n=
42
)
6/2
4/1
8 (
n=
36
)
7/1
5/1
8 (
n=
38
)
8/0
5/1
8 (
n=
49
)
8/2
6/1
8 (
n=
44
)
9/1
6/1
8 (
n=
41
)
10
/07
/18 (
n=
34)
10
/28
/18 (
n=
33)
11
/18
/18 (
n=
28)
12
/09
/18 (
n=
48)
12
/30
/18 (
n=
30)
1/1
3/1
9 (
n=
39
)
2/0
3/1
9 (
n=
50
)
2/2
4/1
9 (
n=
73
)
3/1
7/1
9 (
n=
40
)
4/0
7/1
9 (
n=
39
)
4/2
8/1
9 (
n=
34
)
5/1
9/1
9 (
n=
43
)
6/0
9/1
9 (
n=
47
)
6/3
0/1
9 (
n=
26
)
7/2
1/1
9 (
n=
31
)
% C
om
pli
an
t
Weeks
Percentage of Compliance with Appropriate Guidelines
Weekly Compliance Data Points Average Proportion of Compliance Control Limits
EMR Order Set
Post- Order Set Implementation
Provide a comprehensive, standard approach to patient perioperative care planning while
reducing the amount of opioids prescribed.
MME
27
44% Reduction
16998
9465
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Before Guidelines After Guidelines
Mo
rph
ine
Equ
ival
ents
MORPHINE EQUIVALENTS
p < 0.051 year random sample
Balancing MetricSecondary prescriptions
EMR opioid medication orders within 14 days of discharge in the ED and Office in the same 100 patient random sample were reviewed to analyze our balancing measure.
Before guidelines:• 5/100 obtained a refill
After guidelines:• 10/100 obtained a refill*
Balancing MetricSecondary prescriptions
Analysis of refills:
• 2/10 Original prescription were prescribed below the recommended guideline
• One by type of medication and one by type of category (amount)
• 8/10 guidelines were followed appropriately
• Including 1 MVA not related to surgery and original prescription
• 3/10 guidelines were appropriately prescribed spine cases
$ Savings to Society $
$242,370
Shared Organizational Order Sets and Clinical Pathways
BURN 336 CARDIOTHORACIC 116
DENTAL, 2473
ENT 4778
EYE 856
GENERAL 2548
ORTHO 2452
PLASTIC 617UROLOGY
985
2018 Akron Children's Hospital Surgical Cases (All Campuses)
Spread within Institution
Home Going Pain Management Guidelines
Spread Nationally
