O1008: Stopping It Before It Starts: The Effects of a Multimodal Quality Improvement Project on Pediatric Opioid Stewardship

Purpose/Objectives: Opioid misuse, in addition to being a national epidemic and public health crisis, is not unique to adults. A striking 1 in 5 high school students reported lifetime misuse of prescription opioids. Contrary to common belief, 70% of those who abuse prescription painkillers get them from a friend, family member, or from their own prescriptions. Additionally, internal review found that children often use less than half of opioids prescribed for acute pain. Within the field of pediatrics, this created a moral imperative for change. Our objectives were to decrease the amount of opioids prescribed within our institution, and to improve education and safety when they are prescribed.

Design/Methods: In 2016, our hospital assembled a multidisciplinary Opioid Safety Task force. The goal was to approach opioid stewardship using a multi-modal approach: enhance understanding of opioid prescribing, improve prescriber and patient/family education regarding opioid use, and ultimately promote a multidimensional approach to pain, minimizing opioid prescriptions and risk for later abuse and addiction.

Initial work began evaluating prescribing patterns amongst subspecialties prescribing opioids for acute post-operative care and an internal survey to better understand current prescriber practice discussing the risks, benefits, and safety surrounding storing and disposal of opioids with patients and families. Subspecialty champions were identified to lead internal education and culture change.

In response to CDC recommendations and increasing legislation, custom electronic health record tools were developed to promote best-practice prescribing, institution-wide communication regarding patient opioid use, compliance with regulatory requirements, and improved patient education.

Results: Multiple outcome metrics were pursued from focused aims with specific subspecialty units to reduce the rate of prescribing to increased compliance with legislation requirements. More focused efforts were implemented on improving state required opioid education documentation which improved from 13% to 100% by utilization of EHR tools. Perhaps most dramatically, by leveraging decision support within the EHR and subspecialty led culture change, we were able to decrease the number of opioids prescriptions per month from 1100 in 2017 to 600 in 2021. A previous patient and family education handout was revised in 2019 after feedback and automatically added to homegoing instructions if an opioid was prescribed.

Improvements were tracked over time using control charts.  An I-chart was used to display the overall number of hospital wide opioid prescriptions from February 2017 through October 2021 and a p-chart was used to display the percentage of prescriptions for which education was provided from July 2017 through November 2019.

Conclusion/Discussion: The momentum of these initiatives hinged on prescriber/subspecialty engagement. Leveraging EHR tools for real-time decision support was critical for guiding prescribing behaviors and providing knowledge of complex legislation surrounding opioid prescribing. Engaging patients/families to assess understanding was also key to improving the opioid education provided. All of these efforts combined enabled a 79% reduction in opioid doses prescribed from 2015 to 2020 while still adequately addressing acute pediatric pain.