Using Real-World Data for Improvement—The Seattle Children’s Example

Introduction

Seattle Children's Bellevue Clinic and Surgery Center (Bellevue) is a stand-alone pediatric clinic and ambulatory surgery facility that cares for over 4000 surgical patients annually. Anesthesiologists and nurse anesthetists use standardized anesthesia protocols for the most commonly performed surgical procedures to optimize quality and consistency of patient care. Outcomes are tracked using a software program that can display real-world data from the electronic medical record (EMR) as statistical process control (SPC) charts. These charts are updated daily, allowing for rapid Plan-Do-Study-Act (PDSA) cycles and continuous improvement. One of the outcomes tracked is opioid administration. Data showed that despite using multimodal analgesia, including frequent regional anesthesia, over 70% of surgical patients received intraoperative opioids in 2016 and 2017 ( Fig. 51.1 ).

Starting in July 2018, the Bellevue team began a concerted quality improvement (QI) initiative centered around the removal of intraoperative opioids from standardized anesthesia protocols. The decision to initiate this opioid reduction work was influenced by a series of events that occurred between 2017 and early 2018.

First, a review of 2017 patient outcome data showed that intravenous (IV) acetaminophen was not opioid sparing and was costly. So the team decided to look for a cheaper alternative, identifying dexmedetomidine as a possible replacement. Then in early 2018, the national opioid shortage intensified, leading to a hospital-wide alert to conserve supplies. Finally, opioid use after routine surgery became a recognized gateway to new persistent opioid use. In the setting of the national opioid epidemic, concerns began to arise that opioids administered perioperatively could play a role in postoperative opioid consumption through such mechanisms as opioid tolerance and/or opioid-induced hyperalgesia.

These three events aligned to impel the team to develop a new standardized protocol that eliminated intraoperative opioids for the highest-volume surgery—tonsillectomy and adenoidectomy (T&A)—where opioid-related side effects such as respiratory depression and airway obstruction are not well tolerated. Research into dexmedetomidine as an alternative to IV acetaminophen identified several articles evaluating dexmedetomidine in place of morphine for T&As. After much discussion, intraoperative morphine and acetaminophen were replaced with dexmedetomidine and ibuprofen. When initial results were not favorable, the team replaced ibuprofen with ketorolac based on (1) evidence of ketorolac's safety for pediatric T&As and (2) similar reoperation rate data in Bellevue's T&A patients receiving ketorolac versus no ketorolac. This protocol change yielded better results, with comparable postanesthesia care unit (PACU) times and maximum pain scores for the dexmedetomidine and ketorolac group versus the morphine-acetaminophen cohort, and no increase in 30-day reoperation rate for tonsillar bleed.

Success with reducing opioid administration for T&As without compromising effective analgesia inspired the team to expand the use of dexmedetomidine (see Fig. 51.1 ). After multiple PDSA cycles, dexmedetomidine was incorporated into standardized protocols for the most commonly performed procedures, while exploiting opioid-sparing analgesics already popular at Bellevue, such as regional anesthesia and nonsteroidal anti-inflammatory drugs. The results of these interventions were so promising that by January 2019, the team removed intraoperative opioids from all protocols (see Fig. 51.1 ).

Methods