• Article
  • January 19, 2017

How National Guidelines Impact Tonsillectomy Perioperative Care and Outcomes

Two hospitals share their strategies for care.

Tonsillitis, one of the top 10 pediatric conditions with significant, cumulative health care costs, affects almost half a million children each year. To help standardize and improve care, in 2011, the American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) published evidence-based care guidelines recommending the following practices for tonsillectomies: perioperative use of dexamethasone, elimination of routine antibiotic use, discharge education for families, and monitoring of bleeding complication rates.

To assess the effectiveness of these guidelines, a 2015 study published in Pediatrics measured the use of evidence-based processes among otherwise healthy children undergoing tonsillectomy from 2009 and to 2013. Data from 29 children's hospitals participating in the Pediatric Health Information System (PHIS) were included.

This study found that the AAOHNS guidelines were associated with improvement in perioperative care processes, but they were not associated with improved or worse outcomes. Among the children's hospitals included in the study, perioperative dexamethasone use increased slightly, and antibiotic use decreased substantially. Bleeding rates were stable, but revisit rates for complications increased slightly because of revisits for pain.

Two participating children's hospitals shared their experience adopting the AAOHNS guidelines.

Use evidence-based practice

Brendan Campbell, M.D., M.P.H., physician quality safety officer for Surgical Services at Connecticut Children's Medical Center, says it was easy for the five ear, nose and throat (ENT) surgeons at the hospital to decide to modify tonsillectomy practices to support improved outcomes for the patients. "They made the decision to universally adopt the evidence-based guidelines recommending the use of dexamethasone and avoidance of antibiotics in tonsillectomy/adenoidectomy (TA) patients because it was the right thing to do," Campbell says.

The hospital ranked second out of 40 PHIS hospitals in 2015, which indicates good performance when using dexamethasone and avoiding antibiotic use when performing TA procedures. Campbell says having a small group of hospital-employed surgeons practicing together at a freestanding children's hospital made it easier to initiate and maintain engagement for quality initiatives.

Campbell says the hospital has not seen an increase in return visits to the emergency department or an increase in re-admissions for postoperative bleeding, nausea or vomiting after adopting the national guidelines for dexamethasone and antibiotic use. "Decreasing variation in practice lowers costs and reduces opportunities for error," he says. "Similar initiatives with pediatric spine surgery and laparoscopic appendectomy have led to better outcomes for patients and lower costs for the hospital."

Standardize for successful improvement

In 2015, Cincinnati Children's Hospital Medical Center ranked fourth out of 40 PHIS hospitals for using dexamethasone and avoiding antibiotic use with tonsillectomies. Stacey Ishman, M.D., surgical director, credits a standardized process with supporting improvement activities.

Standardized TA order sets within the electronic medical record have dexamethasone pre-checked. If the surgeon determines it's not appropriate for the child, he or she will not order the drug. Antibiotics are not pre-checked, again requiring the surgeon to decide if the child requires the use of an antibiotic.

Acetaminophen and ibuprofen orders are pre-checked for discharge, and pain management issues are managed by phone to decrease the need for a return visit. "Surgeons at Cincinnati Children's review recommendations from professional associations and receive education on potential changes," Ishman says. "Agreement with the recommendations usually results in the development or modification of existing order sets to reinforce new practice."

A team reviews the order sets every six to 12 months, and as recommendations change or internal review reveals additional opportunities, the sets are changed. "Strong support for quality improvement has grown as more leaders and staff members are trained in the Rapid Cycle Improvement Collaborative approach," Ishman says. A nurse practitioner, trained in RCIC, manages the order sets.

Currently, the hospital's focus is on compliance with order sets and following postoperative bleeding rates for TA. Ishman says the benefits of using standardized order sets include: fewer staff hours pulling and charging for items that are not specifically ordered; avoiding possible side effects of medications with no evidence-based value; decreased time in recovery; and decreased need for return visits and readmissions.

Participating PHIS hospitals interested in identifying their ranking can contact Carla Hronek for an unblinded version of the data. Send questions or comments to magazine@childrenshospitals.org.