Postoperative opioid protocol: A 5-year resident-led effort to standardize prescribing patterns.

OBJECTIVES: The combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns. We report an update on the expanded scope of this now 5-year, resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology. METHODS: With Institutional Review Board approval, performed a retrospective review of 12 months before (July 2016 - June 2017) and 48 months after (July 2019-June 2021) implementation of the Expanded Postoperative Analgesia Protocol. The Pre-Protocol and Expanded Protocol cohorts were compared using ANOVA, chi-squared and Fisher Exact tests, with ANCOVA and binary logistic regression for covariate analysis. Cost impact was calculated using average medication spending data for 2018-2019. RESULTS: 470 patients were included in the Pre-Protocol cohort (54 % male, mean age 35 years) and 679 in the Expanded Protocol cohort (63 % male, mean age 36 years). The protocol was effectively implemented as reflected in the reduction of combination opioid medications from 429 (91.3 %) to 26 (3.8 %) (87 % reduction, 95 % CI 86 % to 89 %, p < .001). The protocol resulted in a 66 % reduction in average morphine milligram equivalents per patient (333 mg to 114 mg, mean reduction 219 mg, 95 % CI 206 mg to 232 mg, p < .001), a 68 % reduction in medication refills (refill rate 20 % to 6 %; 14 % reduction, 95 % CI 12 % to 16 %, p < .001) and a 74 % reduction in cost of postoperative medications ($93.82 to $24.64 per patient). CONCLUSION: Through purposeful standardization, this 5-year resident led effort resulted in sustained changes to departmental wide prescribing practices yielding reduced variability, reduced cost, improved opioid management and superior pain control for postoperative patients.

Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review.

In the field of otolaryngology-head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient's real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.

Investigation of Adult Post-Tonsillectomy Hemorrhage Rates and the Impact of NSAID Use.

OBJECTIVES/HYPOTHESIS: Tonsillectomy is one of the most common ambulatory surgeries performed in the United States, yet the incidence of post-tonsillectomy hemorrhage (PTH) in adults remains unclear. In addition, any association between non-steroidal anti-inflammatory drugs (NSAIDs) and PTH in adults is currently unknown. The aim of this study is to examine the incidence and management of adult PTH at a single academic center and to assess for any association between NSAID use and PTH in adults. STUDY DESIGN: Retrospective chart review. METHODS: We conducted a retrospective chart review of adult tonsillectomies performed at our institution between January 1, 2012, and December 30, 2019. Demographics, past medical history, medications, NSAID use, surgical indication, bleeding events, and interventions were documented. The rate of PTH was calculated, logistic regression was performed to assess for any predictive factors, and odds ratios were calculated for NSAID use and PTH. RESULTS: A total of 1,057 adult tonsillectomies were performed within the aforementioned time period. A total of 126 patients experienced 163 bleeding events for a postoperative hemorrhage rate of 11.9%. Most were controlled with bedside interventions, while 29 (23%) bled more than once. The hemorrhage rate for those who were not prescribed NSAIDs postoperatively (n = 625) was 11.7%, compared to 12.6% for those who did receive NSAIDs postoperatively (n = 432), which was not significantly different (adjusted odds ratio 1.01, 95% confidence interval 0.69-1.49; P = .95). CONCLUSIONS: This retrospective cohort study of 1,057 adult patients found the incidence of PTH to be 11.9%. This study found no association between the use of NSAIDs and the rate of PTH, although a higher-powered study is needed. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:949-953, 2022.

Postoperative Analgesia Protocol: A Resident-Led Effort to Standardize Opioid Prescribing Patterns.

OBJECTIVES: The combined impact of variable surgeon prescribing preferences and low resident prescribing comfort level can lead to significant disparity in opioid prescribing patterns for the same surgery in the same academic surgical practice. We report the results of a resident led initiative to standardize postoperative prescription practices within the Department of Otolaryngology at a single tertiary-care academic hospital in order to reduce overall opioid distribution. STUDY DESIGN: Retrospective cohort study. METHODS: Following approval by the Institutional Review Board, performed a retrospective review of 12 months before (July 2016-June 2017) and after (July 2017-June 2018) implementation of the Postoperative Analgesia Protocol, which included all adults undergoing tonsillectomy, septoplasty, thyroidectomy, parathyroidectomy, tympanoplasty, middle ear exploration, stapedectomy, and ossicular chain reconstruction. RESULTS: Seven hundred and thirty eight procedures met inclusion criteria. Following implementation, total morphine milligram equivalents decreased by 26% (P < .0001). The number of patients requiring opioid refills decreased by 49%, and morphine milligram equivalents received as refills decreased by 16% (P < .001). Thyroid and parathyroid surgery had the greatest reduction in morphine milligram equivalents prescribed (84%, P < .001), followed by septoplasty (30%, P = .001) and tonsillectomy (18%, P < .001). The number of patients receiving refills of opioid medications decreased for all procedures (tonsillectomy 54%; septoplasty 67%; thyroid/parathyroid surgery 80%, middle ear surgery 100%). CONCLUSIONS: While every patient and surgery must be treated individually, this study demonstrates that a resident led standardization of pain control regimes can result in significant reductions in total quantity of opioids prescribed. LEVEL OF EVIDENCE: IV Laryngoscope, 131:982-988, 2021.

Hybrid Surgical Simulator: A Temporal Bone Simulator Validation Study of the Stryker Surgical Simulator (S3).

INTRODUCTION: The Stryker Surgical Simulator is a hybrid, temporal bone simulator that uses both tactile and haptic feedback combined with a computer interface. We sought to validate this simulator as an otolaryngology resident training tool for performing tympanomastoidectomy. MATERIALS AND METHODS: 15 residents and staff performed five basic cortical mastoidectomies. Staff surgeons comprised the "expert" cohort and resident surgeons comprised the "trainee" cohort. Subjective evaluation of the face validity and content validity was assessed via pre- and postquestionnaires. Objective evaluation of content validity was assessed through grading of each temporal bone dissection specimen, comparing time to task completion, and calculating the rate of injury to critical structures. Study approved by the Institutional Review Board (2013.0001). RESULTS: Post hoc questionnaires showed that both staff and residents subjectively rated the simulator favorably on face validity, content validity, and all global assessment categories, though there were no significant distinctions between groups (P > 0.05). The resident group had a significantly longer drilling time compared with the staff group throughout the series of tympanomastoidectomies (P = 0.008), and both groups showed a decrease in time to task completion with repetitive drilling. However, there were no significant differences in surgical performance as evaluated by a blinded senior neurotologist (P = 0.52). There were also no critical injuries recorded by the simulator in any of the 75 trials, preventing any evaluation on this measure. CONCLUSIONS: Despite favorable subjective evaluations by both staff and residents, objective discrimination between experienced and novice participants was not achieved. This was likely in part due to inherent design flaws of the simulator. This emphasizes the potential shortcomings of surgical simulation models for highly technical procedures and points to the importance of intensive study and validation prior to incorporation of commercial training models into surgical training programs.

Impact of resident training on operative time and safety in hemithyroidectomy.

BACKGROUND: The purpose of this study was to present our assessment of the impact of resident participation on operative duration and outcomes after hemithyroidectomy, which may identify opportunities for optimization of educational programs, reduction in cost of healthcare delivery, and maximizing patient safety, while continuing to train a competent physician workforce for the future. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) dataset from 2006 to 2012 identified 13,151 adult patients who underwent hemithyroidectomy. Differences in operative duration, postoperative complications, reoperation, and readmission rates were assessed based on stratification by resident participation in surgery. RESULTS: Compared with operations performed by attending surgeons alone, resident participation with attending supervision prolonged the operative duration by 10.5% (82.5 minutes vs 91.2 minutes; p < .0001). The incidence of readmission and wound complications was higher for patients who underwent surgery with resident participation. CONCLUSION: Resident participation in hemithyroidectomy may be associated with increased operative duration, higher incidence of wound complications, and readmission. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1212-1217, 2017.

A systematic review of the quality of evidence of ablative therapy for small renal masses.

PURPOSE: We critically assessed the methodological and reporting quality of published studies of ablative techniques for small renal masses. MATERIALS AND METHODS: We performed a systematic PubMed® and EMBASE® literature search from January 1966 to March 2010 to identify all full text, original research publications on ablative therapy for renal masses. Six reviewers working independently in 3 teams performed duplicate data abstraction using Strengthening the Reporting of Observational Studies in Epidemiology criteria, which were pilot tested in a separate sample. RESULTS: A total of 117 original research publications published in a 15-year period (1995 to 2009) met eligibility criteria. No randomized, controlled trials were identified. All studies were observational and 88.9% had 1 arm with no comparison group. Median sample size was 18 patients (IQR 5.5, 40.0) and 53.8% of studies included 20 or fewer patients. Median followup was 14.0 months (IQR 8.0, 23.8) and only 19.7% of studies had an average followup of greater than 24 months. Of the studies 20.5% mentioned the number of operators involved and only 6.0% provided information on their experience level. Of the studies 66.7% addressed the recurrence rate. Disease specific and overall survival was reported in only 15.4% and 16.2% of studies, respectively. CONCLUSIONS: The published literature on the therapeutic efficacy of ablative therapy for renal masses is largely limited to uncontrolled, 1-arm observational studies. In the absence of higher quality evidence ablative therapy outside research studies should be limited to select patients who are not candidates for surgical intervention.

Direct-to-consumer advertising for urological pharmaceuticals: a cross-sectional analysis of print media.

OBJECTIVE: To investigate direct-to-consumer advertising (DTCA) of prescription drugs that are relevant to urological conditions. Evidence suggests that DTCA of prescription drugs increase pharmaceutical sales. Concern about such advertising methods has recently increased owing to the market withdrawal of heavily marketed drugs that were found to have serious health risks. METHODS: Three consecutive issues of 26 popular magazines during a 3-month period were screened for urology-related DTCA. Advertisements were abstracted using a standardized evaluation form that was pilot-tested in a separate sample of nonurological advertisements. Variables analyzed included the type of advertisement, claims of effectiveness, references of research studies, inducements, and use of tables, figures, and pictures. RESULTS: We identified 8 unique DTCA in 4 different magazines (Ladies Home Journal, Golf Digest, Sports Illustrated, and Good Housekeeping). All advertisements were disease-specific and targeted patients with benign prostatic hyperplasia-related symptoms (n = 3), incontinence (n = 3), or erectile dysfunction (n = 2). The median number of claims made per DTCA was 3 (range, 2-6). None of the claims made were supported by research data, as presented in tables or figures, or referenced peer-reviewed publications. The most common types of appeals addressed symptom control (8/8), lifestyle improvement (7/8), effectiveness (4/8), and dependability (3/8), while none addressed drug safety. CONCLUSIONS: DTCA of prescription drugs for urological conditions are found in select journals and focus on few highly prevalent conditions. None of the advertisement claims identified in this study were supported by research data. There seems to be significant room for improvement in the quality of information provided by urological advertisements.