title: Impact of a Standardized Treatment Guideline for Pediatric Iatrogenic Opioid Dependence: A Quality Improvement Initiative.
abstract: OBJECTIVE
  To determine whether utilization of a hospital-based clinical practice guideline for the care of pediatric iatrogenic opioid dependence (IOD) would promote a decrease in opioid exposure and improve management of opioid abstinence syndrome (AS).
  
  
  METHODS
  This study is a retrospective chart review of critically ill patients from a tertiary care children's hospital. Inclusion criteria included mechanically ventilated patients up to 18 years of age who received continuous opioid infusions for at least 7 days and any length of methadone administration. Data on IOD patients from January 2005 to June 2010 was divided into 3 periods: baseline, phase 1, and phase 2. Primary outcome was decrease in opioid exposure, measured by methadone duration of use and any additional opioid bolus doses used in AS management. Documentation of additional opioid bolus doses was regarded as a surrogate measure of AS. Secondary outcomes included total cumulative fentanyl dose, continuous fentanyl infusion duration of use, and hospital and pediatric intensive care unit length of stay.
  
  
  RESULTS
  There was a significant decrease in methadone duration of use in IOD patients from 15.3 ± 8.7 days at baseline to 9.5 ± 3.7 days during phase 1 (p = 0.002), to 8.1 ± 3.7 days on phase 2 (reduction not significant, p = 0.106) of this evaluation. Additional opioid bolus doses were significantly lower from baseline to phase 1 (5.5 ± 5.1 vs. 1.8 ± 2.3, p = 0.001) and from phase 1 to phase 2 (1.8 ± 2.3 vs. 0.2 ± 1.5, p = 0.003). For the remaining outcomes, differences were not observed among the evaluation periods, except for the total cumulative fentanyl dose, which was reduced from 2.8 ± 3.7 mg/kg at baseline to 1 ± 1 mg/kg only during phase 1 (p = 0.017).
  
  
  CONCLUSIONS
  Introduction of a standardized, hospital-based clinical practice guideline for children with IOD reduced the length of exposure to opioids and improved opioid AS management.
authors.affiliation: Cardon Children's Medical Center, Mesa, Arizona.
authors.forename: Rima
authors.initials: R
authors.lastname: Abdouni
authors.affiliation: Cardon Children's Medical Center, Mesa, Arizona.
authors.forename: Teri
authors.initials: T
authors.lastname: Reyburn-Orne
authors.affiliation: King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
authors.forename: Tarek H
authors.initials: TH
authors.lastname: Youssef
authors.affiliation: Cardon Children's Medical Center, Mesa, Arizona.
authors.forename: Imad Y
authors.initials: IY
authors.lastname: Haddad
authors.affiliation: Banner University Medical Center - Phoenix, Phoenix, Arizona.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Gerkin
keywords: methadone; opioid-related disorders; pediatric intensive care unit; quality improvement; treatment protocols