Implementing Guidelines for Pediatric Tonsillectomies

Trillium Health Partners, encompassing three sites- Credit Valley Hospital, Mississauga Hospital, and Queensway Health Centre, claims their hospitals are leading with outstanding performance, fiscal responsibility, and quality patient care (Trillium Health Partners, n.d.).

With the emergence of the Health System Funding Reform in 2012, drastic changes were made to hospital funding. In particular, to promote innovative and evidenced-based practice, thirty percent of hospitals’ overall funding was allocated towards Quality Based Procedures (QBP) (Provincial Council for Maternal and Child Heath & Ministry of Health and Long Term Care, 2013). QBPs are specific clusters of patient services that offer opportunities for healthcare providers to perform services based on best practice. It is suggested that when organizations adopt clinical evidenced-informed practices, quality patient care will flourish, while also increasing system efficiencies and decreasing costs (Ontario Health Association, 2013).

One of the procedures covered under QBPs is Pediatric Tonsillectomy, with or without Adenoidectomy. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) articulates the specific evidence-based components of care that should be provided for these patients from pre- to post-operation. The Director of Women and Children’s Health indicates that practice variation, lack of standardization, lack of evidenced-based practices, and physician resistance all contribute to the organization’s inability to enact QBP standards for this procedure since it was issued in 2014. Specifically, no standardized pre-screening tool exists to assess for complications prior to surgery. In particular, children are neither assessed nor properly diagnosed with obstructive sleep apnea syndrome (OSAS) using a sleep study, the gold standard. This assessment, however, is vital since OSAS patients have a high risk of postoperative respiratory complications (Leong & Davis, 2007).

On the day of surgery, it is not standard that patients receive a pre-operative acetaminophen loading dose for prophylactic pain management. Some anesthesiologists vocalize their discomfort with administering acetaminophen rectally, while others are not aware of the significant impact of this administration on post-operative pain management. The American Academy of Otolaryngology Clinical Practice Guideline for Tonsillectomy in Children states that rectal administration is better tolerated than oral administration and is the most effective in reducing pain and opioid requirements following surgery (Baugh et al, 2011). In addition, children with adequate acetaminophen analgesia have less post-operative nausea and vomiting.

Both the Director and Educator of Pediatrics argue that physician resistance has been a significant barrier to implement QBP standards (Cathie Boudeau, personal communication, April 27, 2015). Nonetheless, both the surgical and pediatric nurses have disclosed that they look forward to changes that encourage standardization and quality patient care. The Educator has explained that she has already began drafting a post-operative standardized PPO form, which has, surprisingly, gained significant approval by physicians. Therefore, the Educator has requested the writer focus on standardizing the pre-operative experience.

Currently, patients and families receive a Pre-Operative Information Sheet. The Educator has noted, however, that this form does not align with QBP advisement. In addition, families have vocalized that the sheet should be more comprehensive and visually appealing. In addition, a standardized pre-assessment form to screen for complications needs to drafted. Changing behaviour in regards to administration of pre-operative acetaminophen will also be considered in this project. The Quality-Based Procedures Clinical Handbook for Paediatric Tonsillectomy with and without Adenoidectomy (2013) will be used as the reference to create a Pre-Operative Information Sheet for families and patients, as well as a pre-assessment checklist to screen for complications.

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