AN INTEGRATED PAEDIATRIC PERIOPERATIVE PAIN PATHWAY TO REDUCE CHRONIC PAIN AFTER MAJOR PAEDIATRIC ORTHOPAEDIC SURGERY

Chronic postsurgical pain (CPSP) is known to occur in 20% of children after major surgery. This is known to be associated with prolongation of recovery, higher risk of postsurgical infection and psychological distress for the child and parents leading to missed school days and higher economic costs. Early identification and pre-operative intervention for children who are at a higher risk of development of CPSP prior to surgery may help reduce rates of CPSP. The purpose of this quality improvement initiative is to develop, implement and evaluate a novel Integrated Paediatric Perioperative Pain Pathway to reduce chronic pain in children undergoing major orthopaedic surgical procedures. An interdisciplinary working group was formed, with representatives from anaesthesia, orthopaedic surgery, physiotherapy, psychology, child life, social work, pharmacy and nursing. Current peri-operative pain management strategies at our institution were analyzed, and opportunities for improvement were identified. A perioperative pain pathway was developed, adhering to a 3Ps (pharmacologic, physical and psychosocial) approach to pain management. Novel areas of focus included pre-operative psychological intervention (e.g., education and coping tools), parental education and coaching, improved transition of pain management throughout phases of care, and early identification and management of patients experiencing increased pain. Data collected included rate of pre-operative intervention, rate of psychosocial intervention, pain management modalities used, opioid consumption, and rate of conversion to chronic pain. Due to challenges related to the COVID-19 pandemic, the pathway was rolled out in stages between April 2021-April 2022. In the first six months following full pathway implementation, 34 orthopaedic surgical patients were enrolled. All patients were assessed by the multidisciplinary team pre-operatively, and 29/34 (85.3%) underwent pre-operative psychosocial interventions. Electronic Medical Record order sets were developed to standardize non-opioid medication administration for all patients. 20/34 (58.8%) were discharged from the pathway two weeks postoperatively, and 14/34 (41.2%) required ongoing management from anaesthesia, psychology, social work or child life. At two weeks post-operatively, 8/34 patients (23.5% were still using opioid medications, and no patients were still using opioid medications at 3 months post-operatively). One patient (2.9%) was diagnosed with chronic pain at three months post-operatively and was referred to the chronic pain clinic. One additional patient had pre-operative chronic pain which failed to resolve post-surgically, and was also redirected to the chronic pain clinic. Patient and caregiver interviews demonstrated high levels of satisfaction with the Integrated Paediatric Perioperative Pain Pathway. A novel Integrated Paediatric Perioperative Pain Pathway, based on a 3Ps model for pain management and with a focus on perioperative pain education, can significantly improve pain management for children undergoing major orthopaedic surgery. This can reduce opioid dependence and conversion to CPSP. Ongoing improvement efforts are required refine patient selection and referrals to the pathway, and to organize operative bookings to maximize time for pre-operative interventions.