Perhaps because they can have ice cream or popsicles afterward. Or perhaps because children have had their tonsils removed for decades without much incident. Whatever the reason, for patients and families, having a tonsillectomy is sometimes approached casually.
But none of these treats or historical notions should belie the fact that surgery is surgery. In fact, providing clear guidance from the get-go regarding what to expect post-operatively, may be able to help families better cope with the recovery and better manage related pain.
This is what Kathleen Billings, MD, and Jennifer Lavin, MD, pediatric otolaryngologists at Lurie Children’s Hospital and their research team have started to examine. They noticed a pattern of Emergency Department (ED) visits from children who had their tonsils removed, which posed some questions. Why are so many children presenting in the ER after being discharged from having had tonsillectomies and how can we reduce this?
“In many cases, tonsillectomies can be done in one day, with the patient going home afterward without a hospital stay,” said Dr. Lavin. “However, the healing still has to happen, which is tricky as tonsils are located in a highly used part of the body. We need to use the surgical site to swallow; it does not have a chance to rest. Children who visit the ER within days of having this surgery most commonly show signs of dehydration from not swallowing, as it has been too painful.”
Other research by Renee Manworren, PhD, APN and team at Lurie Children’s discovered that Lurie Children’s Hospital was not alone in identifying this as an issue. In fact, according to administrative data from the Pediatric Health Information System (PHIS), 38% of the ER revisits for post-operative pain are due to tonsillectomies, despite the fact that they comprise only 19% of all surgeries.
The research team looked at this to see what could be done better to reduce these return visits. Specifically, they focused initially on postoperative pain regimens and pain discharge instructions.
Pain regimens historically have included acetaminophen and perhaps the prescription opioid codeine. However, an FDA black box warning issued in August 2012 has curtailed codeine prescribing use, challenging medical professionals to identify other methods to manage severe pain experienced after tonsillectomies. Furthermore, safety concerns about codeine have led to uncertainty of whether any narcotics should be used as first line in tonsillectomy, leading to many philosophies on post-operative pain control. These vary within a practice and by provider, based on what has been most effective for their patients in the past. While this variation can sometimes work on a case by case basis, complications can arise.
For instance, with multiple different pain regimens there runs the risk that an inconsistent message can be conveyed about an individual patient’s postoperative pain plan. This can lead to parental confusion about how to manage their child’s postoperative pain. From a health quality perspective, it became clear that a greater standardization in the designation and communication of pain regimen is needed when patients are discharged.
As a result, the Lurie Children’s team aligned on just three fixed options which are now available for use when developing the discharge papers. And when a pain regimen is selected, it is hard coded and automatically populated into the patient’s discharge instructions.
“This helps eliminate previous variability and uncertainty that in turn helps reduce possible human error. It is a step forward in increasing safety and enhancing patient care,” said Dr. Lavin.
Streamlining the post-operative pain regimen and pain discharge instructions are important starting points. Also, the team is also looking at other possible interventions such as additional pre-operative counseling and post-operative patient/family support.
Part of this next phase will include looking at characteristics associated with the patients who had return ED visits to see if there are other trends that can be addressed.
“Sometimes parents call frustrated because day one after surgery everything was fine, but by day three their child is in intense pain,” said Dr. Lavin. “As physicians, we know that pain spikes at three-to-seven days post-surgery. Parent comments such as these, however, suggest that this knowledge may not be universally communicated in a way that is effective.”
Through focus groups, the team will be engaging parents and children who have had tonsillectomy experiences to see what their concerns are, what they wish they would have known, and how we can best address those concerns to further enhance the patient experience.
“We may look at other communications vehicles, such as a video or an app, to ensure the families know what to expect and how they can best support their child through the recovery phase,” said Dr. Lavin. “We want to ensure that the at-home recovery is as smooth, and pain-free, as possible.”