3 Q's for QI | Q&A with Dr. Norman FriedmanJun 6, 2023
One of the most common surgical procedures in otolaryngology is an adenotonsillectomy (T&A). The current overnight monitoring criteria is consensus driven. A IHQSE team, including Dr. Norman Friedman, engaged clinicians and staff across multiple services to revise the perioperative pathway for children having a T&A. Published in The Laryngoscope, the team found that 75% of children who qualified as “high risk” patients by the American Academy of Otolaryngology’s clinical practice T&A overnight monitoring guideline were off oxygen within 3 hours of surgery. Of those, only 3 children went back on oxygen and none of these children had passed an asleep room challenge. From a respiratory standpoint, “high risk” children did not require overnight monitoring if they passed an asleep room air challenge regardless of age, obesity status, asthma diagnosis, and number of obstructive events (OAHI) found on a sleep study.
Q1: Tell us about your approach to this project?
Prior to investigating the best practice patterns for same day surgery for children with obstructive sleep disordered breathing, there was a need for standardization of all the perioperative pain management and patient education. Following adoption of a uniform family education plan and a single T&A postoperative order set, the stage was set to investigate our clinical outcomes.
Q2: Why is this work important?
In an era that values the right patient, right place and right time, a reassessment of the overnight monitoring criteria was appropriate. From a resource utilization standpoint, a decrease in hospital admissions by 75% would decrease the use of contract labor. It would also dramatically improve patient access while simultaneously improving the family experience. It would also free up hospital capacity for more acutely ill patients.
Q3: How do you think this will impact healthcare systems going forward?
Our findings have already influenced healthcare systems on a national level. Nemours Children’s Health has adopted our revised overnight monitoring criteria. Children with non-severe obesity, an OAHI less than 20 and no hypoxemia preoperatively are candidates for same day surgery. Other institutions not aligned with the current T&A clinical practice guidelines have the evidence to support their current clinical practice. We are continuing to monitor our outcomes and will revise our criteria as necessary. Recently, we presented our revised overnight monitoring criteria data at the American Society of Pediatric Otolaryngology. These children who had passed an asleep room air challenge and had same day surgery did not demonstrate an increase in the likelihood of an emergency department or admissions within 48 hours of T&A compared to the baseline group prior to modifying our criteria.