• Alfred Lee, Brian L Chang, Chen Yan, Justin P Fox, Leanne Magee, Michelle Scott, Meg Ann Maguire, Karen Ross, Cara Rakow, Francesca Drake, Andrea McGinnis, Adam Watson, Caroline Burlingame, F Wickham Kraemer, Wallis T Muhly, Jordan Ruby, and Oksana A Jackson.
• From the Division of Plastic and Reconstructive Surgery, the Center for Healthcare Quality & Analytics, Department of Anesthesiology and Critical Care, the Department of Child & Adolescent Psychiatry & Behavioral Sciences, Children's Hospital of Philadelphia; Perelman School of Medicine at the University of Pennsylvania; and the 88th Surgical Operations Squadron, Plastic Surgery Element.
• Plast. Reconstr. Surg. 2020 Feb 1; 145 (2): 507-516.

BackgroundCleft repair requires multiple operations from infancy through adolescence, with repeated exposure to opioids and their associated risks. The authors implemented a quality improvement project to reduce perioperative opioid exposure in their cleft lip/palate population.MethodsAfter identifying key drivers of perioperative opioid administration, quality improvement interventions were developed to address these key drivers and reduce postoperative opioid administration from 0.30 mg/kg of morphine equivalents to 0.20 mg/kg of morphine equivalents. Data were retrospectively collected from January 1, 2015, until initiation of the quality improvement project (May 1, 2017), tracked over the 6-month quality improvement study period, and the subsequent 14 months. Metrics included morphine equivalents of opioids received during admission, administration of intraoperative nerve blocks, adherence to revised electronic medical record order sets, length of stay, and pain scores.ResultsThe final sample included 624 patients. Before implementation (n =354), children received an average of 0.30 mg/kg of morphine equivalents postoperatively. After implementation (n = 270), children received an average of 0.14 mg/kg of morphine equivalents postoperatively (p < 0.001) without increased length of stay (28.3 versus 28.7 hours; p = 0.719) or pain at less than 6 hours (1.78 versus 1.74; p = 0.626) or more than 6 hours postoperatively (1.50 versus 1.49; p = 0.924).ConclusionsPerioperative opioid administration after cleft repair can be reduced in a relatively short period by identifying key drivers and addressing perioperative education, standardization of intraoperative pain control, and postoperative prioritization of nonopioid medications and nonpharmacologic pain control. The authors' quality improvement framework has promise for adaptation in future efforts to reduce opioid use in other surgical patient populations.Clinical Question/Level Of EvidenceTherapeutic, III.

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