<p><strong>BACKGROUND: </strong>Although patient-controlled analgesia (PCA) is an effective pain control modality, there is a lack of large studies on PCA safety in pediatric patients. This study compared the delivery of morphine either via intravenous route (morphine IV) or via PCA device (morphine PCA) on risk of cardiopulmonary resuscitation (CPR) and mechanical ventilation (MV) using a large administrative database.</p>

<p><strong>METHODS: </strong>We assembled a retrospective cohort of pediatric inpatients between 5 and 21 years old in 42 children's hospitals between 2007 and 2011 from the Pediatric Health Information System. After propensity score matching, we created matched cohorts of morphine PCA and morphine IV patients, in both surgical and non-surgical samples, who were similar on demographic, clinical, and hospital-level factors. We examined if PCA administration was associated with greater likelihood of CPR or MV up to 2 days after drug administration.</p>

<p><strong>RESULTS: </strong>Surgical and non-surgical patients administered morphine PCA generally had lower odds of having MV on the baseline day and up to 2 days after PCA exposure, though these estimates were not statistically significant. Similarly, PCA exposure was associated with about 20-44% lower odds of same day CPR in both surgical and non-surgical patients, with a slightly greater reduction in the odds of CPR in the surgical patients.</p>

<p><strong>CONCLUSION: </strong>In this large pediatric inpatient population, morphine administered via PCA device for surgical and non-surgical pain was not associated with an increased risk of receiving CPR or MV, and was associated with slightly better safety outcomes than intravenous morphine.</p>

<p><strong>BACKGROUND: </strong>Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is associated with significant pain and prolonged hospitalization. There is evidence that early mobilization and multimodal analgesia can accelerate functional recovery and reduced length of stay (LOS). Using these principles, we implemented a quality improvement initiative to enable earlier functional recovery in our AIS-PSF population.</p>

<p><strong>METHODS: </strong>We designed and implemented a standardized rapid recovery pathway (RRP) with evidence-based management recommendations for children aged 10 to 21 years undergoing PSF for AIS. Our primary outcome, functional recovery, was assessed using statistical process control charts for LOS and average daily pain scores. Our process measures were medication adherence and order set utilization. The balancing measure was 30-day readmission rate.</p>

<p><strong>RESULTS: </strong>We included 322 patients from January 1, 2011 to June 30, 2015 with 134 (42%) serving as historical controls, 104 (32%) representing our transition population, and 84 (26%) serving as our RRP population. Baseline average LOS was 5.7 days and decreased to 4 days after RRP implementation. Average daily pain scores remained stable with improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days) after RRP implementation. In the second quarter of 2015, gabapentin (91%) and ketorolac (95%) use became routine and order set utilization was 100%. Readmission rates did not increase as a result of this pathway.</p>

<p><strong>CONCLUSIONS: </strong>Implementation of a standardized RRP with multimodal pain management and early mobilization strategies resulted in reduced LOS without an increase in reported pain scores or readmissions.</p>

<p><strong>CONTEXT: </strong>Appropriate use of opioids is essential to manage moderate-to-severe pain in children safely and effectively, yet published guidance regarding opioid treatment for pediatric patients is limited, potentially resulting in excessive variation in opioid use in pediatric patients across hospitals in the U.S.</p>

<p><strong>OBJECTIVES: </strong>The aim was to evaluate hospital variation in opioid use in pediatric inpatients.</p>

<p><strong>METHODS: </strong>Using data from the Pediatric Health Information System and the Premier Perspective Database regarding all pediatric inpatients in 626 hospitals, we examined hospital variation in opioid use and the length of opioid use, adjusting for patient demographic and clinical characteristics and for hospital type (children's vs. general) and hospital patient volume, using multilevel generalized linear regression modeling.</p>

<p><strong>RESULTS: </strong>Overall, 41.2% of all pediatric hospitalizations were exposed to opioids. Among the exposed patients, the mean length of exposure was 4.6 days. Exposure proportion and exposure length varied substantially across hospitals, even after accounting for patient demographic and clinical characteristics, hospital type and hospital patient volume, especially among terminal hospitalizations. For patients discharged alive vs. died, the adjusted exposure percentage for each hospital ranged from 0.7% to 99.1% (interquartile range [IQR]: 35.3%-59.9%) vs. 0.1% to 100.0% (IQR: 29.2%-66.2%), respectively, and the adjusted exposure length ranged from 1.0 to 8.4 days (IQR: 2.2-2.7 days) vs. 0.9 to 35.2 days (IQR: 4.0-7.4 days).</p>

<p><strong>CONCLUSION: </strong>The substantial hospital-level variation in opioid use in pediatric inpatients suggests room for improvement in clinical practice.</p>