A Quality Improvement Initiative to Improve Early Postoperative Pain Outcomes After Tonsillectomy in Children.

Background: Intraoperative opioid use during pediatric tonsillectomy is commonly avoided to reduce the risk of postoperative respiratory adverse events (PRAEs). Avoidance of perioperative opioids may contribute to increased early postoperative pain, which can result in patients receiving rescue doses of opioids in the postanesthesia care unit (PACU).

Aims: The aim of this project was to reduce moderate to severe pain in PACU for pediatric tonsillectomy/adenotonsillectomy patients by 50% within 12 months.

Methods: Pilot data was collected on the intraoperative care and PACU pain outcomes of patients between June 2018 and June 2020. A six-item toolkit was designed, then implemented from April 2021, with identical data points collected for comparison. Postintervention patients were categorized into toolkit compliance groups: (1) Standard of care (< 5 of 6 items delivered), (2) Partial Toolkit (5 of 6 items delivered), and (3) Toolkit (100% adherence). Statistical process control charts were used for data analysis.

Results: Data was collected for 420 patients. Baseline data reported 65.8% of patients experienced moderate-severe pain in PACU. In the first 12 months of toolkit implementation (2021-2022), the incidence of moderate to severe pain decreased to 47.1% in the 100% adherence group (28% reduction). In subsequent years (2022-2024), this measure decreased further to 31% (53% reduction overall). Pretoolkit, 69% of patients received rescue opioids in PACU. In the first 12 months of toolkit implementation (2021-2022), the incidence of rescue opioids in PACU decreased to 35% in the 100% toolkit adherence group (49% reduction). From 2022 to 2024, this decreased to 45% (35% reduction).

Conclusion: Through the implementation of the tonsillectomy toolkit, we helped reduce early postoperative pain by 28% in the first year. Continued data collection showed the intervention to be sustainable and delivered subsequent decreases in moderate to severe pain by a factor of 53%. These improvements were achieved without increasing PRAEs, postoperative nausea/vomiting incidence, or PACU length of stay.