• Usman Ali, Maisie Tsang, Fiona Campbell, Clyde Matava, Brenda Igbeyi, Sindu Balakrishnan, Kelly Shackell, Gloria Kotzer, and Conor Mc Donnell.
• Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
• Paediatr Anaesth. 2020 Apr 1; 30 (4): 415-423.

BackgroundPostoperative pain is a significant cause of morbidity in pediatric anesthesia, which can result in delayed discharge and unplanned hospital admission. Children undergoing strabismus surgery are known to be a particularly high-risk group for postoperative pain.AimThe aim of this project was to reduce the incidence of moderate to severe postoperative pain by 25% over a period of 12 months in children undergoing strabismus surgery.MethodsThis was a multidisciplinary quality improvement project using the Institute for Healthcare Improvement model for improvement and iterative Plan-Do-Study-Act cycles. Baseline data from one hundred patients were collected retrospectively from patient records. Subsequently, iterative interventions introduced comprised: a perioperative bundle (comprising preoperative acetaminophen, intraoperative dexamethasone and ketorolac, a long-acting opioid, and two anti-emetics), email reminders, dissemination of results at departmental rounds, and an intraoperative clinical decision aide. Postoperative pain data were collected as an outcome measure, and length of stay in PACU was monitored as a balancing measure. Statistical process control charts were constructed to monitor bundle compliance and incidence of postoperative pain in the postanesthesia care unit.ResultsPostoperative pain and bundle compliance data were collected for 1127 children in total. Baseline mean monthly incidence of moderate to severe postoperative pain was 47.3%. By the conclusion of this project, the incidence of postoperative pain decreased to 21%. Concurrently, mean bundle compliance increased to 78.7%. Mean length of PACU stay for baseline audit patients was 72.5 min compared with 70 min for patients after the introduction of the strabismus macro (November 2018-April 2019, n 91) (mean difference, 2.5; 95% CI, -3.86 to 8.86; P = .439).ConclusionThrough the implementation and adoption of an evidence-based bundle of care, we successfully decreased the incidence of moderate to severe postoperative pain for children undergoing strabismus repair. We demonstrated that combining nudge theory with QI methodology can be an effective means of delivering positive results in quality improvement projects.© 2019 John Wiley & Sons Ltd.

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