Achieving Spread and Breaking Down Silos: From Managing Tonsillectomy Pain to Reducing Pediatric Narcotic Usage


Anna H Grosz, MD; Greg Berman, MD

Introduction: In August 2012, the US Food and Drug Administration recommended against codeine use after tonsillectomy in children. The Head and Neck Surgery (HNS) Department at Kaiser Permanente (KP) Northwest (KPNW) implemented this recommendation, then helped other KP Regions and other groups within KPNW do the same.
Methods: Electronic medical records (EMR) tools and opioid reduction protocols were shared with HNS leaders in other Regions and with KPNW surgical services, pediatrics, and pharmacy committees. EMR tools included order sets, smart groups, restriction locators, alternative alerts, and patient instructions.
Results: From 2012 to 2016, KP HNS reduced opioid prescriptions after tonsillectomy in children younger than age 7 years from 79% to 8% in KPNW, 88% to 11% in KP Colorado, 83% to 9% in KP Hawaii, 81% to 52% in KP Northern California, and 62% to 22% in KP Southern California with no increased complications. KPNW surgical services reduced codeine prescriptions per surgical case in children younger than age 7 years from 14% to 0% and in children age 8 to 14 from 19% to 3%. Overall opioid use in KPNW pediatric surgeries went from 17% to 8% per surgical case in children younger than age 7 years and stayed around 40% to 50% for children age 8 to 14 years. Total KPNW pediatric codeine prescriptions in children younger than age 7 years decreased from 924 to 56 and in children age 8 to 14 from 1712 to 288. KPNW pediatric opioid prescriptions in children younger than age 7 years decreased from 1212 to 378 and in children age 8 to 14 years from 2703 to 1173.
Discussion: The US has an opioid epidemic. Children and teens may be exposed to opioids after a surgery or injury and are overlooked in opioid work. We have demonstrated effective tools to reduce codeine and other opioid use in children. EMR tools and methods can be used broadly to fight opioid overuse in children and adults.
Conclusion: KP is uniquely positioned to test and to implement successful opioid reduction protocols such as this. This project highlights the benefits of using EMR tools, breaking down silos, and sharing best practices within a large health care organization across multiple specialties and geographic locations.

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