IMPLEMENTATION OF AN INTEGRATED PAEDIATRIC PERIOPERATIVE PAIN PATHWAY FOR PATIENTS UNDERGOING ADOLESCENT IDIOPATHIC SCOLIOSIS SURGERY

Chronic postsurgical pain (CPSP) is known to occur in 20% of children after major surgery1. This is known to be associated with prolonged recovery, increased postsurgical infection risk and psychological distress for the child and parents2. Development of pre- and postoperative interventions aimed to mitigate risk factors may 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 improve perioperative pain management in children undergoing major orthopaedic surgical procedure. An interdisciplinary working group was formed. A perioperative pain pathway was developed, adhering to a 3Ps approach to pain management. Novel areas of focus included pre-operative psychological intervention, parent education, standardized medication order sets, and early identification of increased pain. Various metrics, including length of stay, opioid consumption, and achievement of physiotherapy goals were compared prior to and following the implementation of the pathway. Although children undergoing a wide array of major orthopaedic surgical procedures were enrolled, for the purposes of this analysis children undergoing posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS) were the focus. In the first two years following pathway implementation, 35 children undergoing PSIF for AIS were enrolled. Comparison of metrics were made following chart review of 34 children similarly undergoing PSIF for AIS in the 2 years before pathway rollout. The two groups were well matched for age (pre 14.1 years & post 14.7 years, p=0.10) and weight (pre 55.0 kg & post 57.0 kg, p=0.28). Length of stay in the Intensive Care Unit (pre 1.06 days & post 0.73 days, p < 0.01) and length of hospital stay (pre 6.23 days & post 5.01 days, p < 0.01) significantly decreased. The maximum pain score reported on postoperative day 1 was reduced (pre 6.9/10 & post 5.0/10, p < 0.01). Patients achieved nearly all the standardized physiotherapy goals at earlier times following pathway implementation. Postoperative opioid consumption on the days after surgery were reduced following pathway implementation. Patient and caregiver interviews demonstrated high levels of satisfaction with the integrated pain pathway. A novel Integrated Paediatric Perioperative Pain Pathway, grounded 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 study demonstrated shortened hospital stay, earlier achievement of physiotherapy goals, and reduced initial opioid consumption for children undergoing PSIF for AIS following pathway implementation. Data collection for major paediatric surgeries beyond PSIF is ongoing. Further improvement efforts are required to refine patient selection and organize operative bookings to maximize time for pre-operative interventions.