Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative.

BACKGROUND: Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission. OBJECTIVE: The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education. STUDY DESIGN: This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n = 84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study-Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019. RESULTS: Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention. DISCUSSION: We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9. CONCLUSION: Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children.

Stone growth patterns and risk for surgery among children presenting with hypercalciuria, hypocitraturia and cystinuria as underlying metabolic causes of urolithiasis.

INTRODUCTION: Hypercalciuria, hypocitraturia and cystinuria are the most common underlying metabolic stone abnormalities in children. The present study compared stone growth patterns, stone burden, and the risk of stone-related surgery among these underlying metabolic conditions. METHODS: A retrospective cohort of 356 children with renal stones, followed from 2000 to 2015, was studied. Differences among metabolic groups were determined using Kruskal-Wallis test; the Scheffé-test was used for multiple comparisons to determine differences among single groups. Independent sample t-test was used when adequate, given the sample size, and Chi-squared test was used for categorical variables. Stone growth rates were calculated as differences in diameter divided by time elapsed between U/Ss (mm/year). Logistic regression was performed to assess the effect of initial stone size on the likelihood of surgery. RESULTS: Median stone size at presentation was significantly different among groups, with cystinuria being the group with the largest proportion of stones >10 mm, while patients with stones <5 mm were likely to have a normal metabolic workup (P < 0.05). Stones with a higher growth rate were found in the operative group, while slower growing stones were mostly managed conservatively (3.4 mm/year vs 0.8 mm/year, respectively; P = 0.014). However, stone growth rates were not significantly different among metabolic groups. On the other hand, the rate of new stone formation in cystinuric patients at their first follow-up was 30.4%, which was significantly higher than in patients with hypercalciuria (16.3%) or with a normal metabolic workup (17.2%; P < 0.05). Compared with stones <5 mm, stones measuring 5-10 mm were more than four times more likely to result in surgery, whereas the likelihood of surgery for 10-20 mm or >20 mm stones was almost 16 or 34 times, respectively (P < 0.001). CONCLUSIONS: It is believed that this is the first study to evaluate stone growth patterns, stone burden and surgical risk among children with hypercalciuria, hypocitraturia and cystinuria. Cystinuric patients presented with larger stones at the time of diagnosis, higher new stone formation rates, and were at higher risk of surgery. While no significant difference of growth rate was found among metabolic groups, stones with a higher growth rate were significantly more likely to result in surgical treatment than slower growing stones. Initial stone size, location of largest stone, previous urinary tract infection, and patient's metabolic type significantly influenced the likelihood of a surgical intervention. Better understanding of the natural history ultimately helps surgeons and clinicians defining prognosis, treatment, and prevention plans for pediatric urolithiasis.