Why focus on paediatric tonsillectomy?

Tonsillectomy and adenoidectomy (T&A) are the most common surgeries in childhood.¹

The Fourth Australian Atlas of Healthcare Variation found geographic variation in the rates of tonsillectomy across Australia, including in Victoria. Six of the 10 local areas with the highest rates of tonsillectomy in 2017–18 were in Victoria.²

There is also variation in rates of unplanned readmission after T&A in Victoria.³ Unplanned readmission rates are greater for tonsillectomy than with any other type of surgery in children.¹ A Victorian study showed that 10% of children who have had tonsillectomy present to an emergency department within 30 days of surgery and 5.8% are readmitted.⁴

Unplanned readmission after paediatric T&A is a Victorian Government Budget measure⁵ that health services use to monitor their performance. However, before the project, interpretation of the data was challenging for health services, as the metric did not accurately capture when children were readmitted at a different hospital to where they had their surgery.

In 2018, SCV started a two-year project, Reducing clinical variation in paediatric adenotonsillectomy One of the first goals of the project was to improve the accuracy of the data, so that it captured readmissions to any hospital after paediatric T&A. This enabled each health service to better understand their true rates of readmissions.

Libby White, Senior Project Officer, SCV

‘When health services have high rates of readmission after paediatric tonsillectomy, the impact across the healthcare system is significant, given the numbers of children who have tonsil surgery.’

Gathering the participants

SCV established an expert working group to inform strategic directions for the project. An expression of interest process was used to seek pilot sites to participate in the project. ENT surgeons, paediatricians, nursing staff and anaesthetists came together to co-design a project to reduce readmissions after T&A.

Drilling down into the data

Before the project started in 2018, readmission rates for T&A were calculated from the Victorian Admitted Episodes Dataset and showed variation across the state. The data showed that 10% of the 70 hospitals in Victoria that performed T&A had readmission rates higher than expected for these surgeries.⁶

Associate Professor Gillian Nixon, Clinical Lead for the project, paediatric respiratory and sleep physician, Monash University

‘The project brought together clinicians and allowed them to step back and look at the data. We found that the T&A readmission data only covered readmission to the same hospital – but a substantial proportion of hospitals are not able to readmit children after hours. Early in the project we focused on improving the quality of the data through data linkage … Now each service can see the readmission rates for their own patients – regardless of where they are readmitted – and how they compare to the state rate.’

Looking for underlying causes

The working group examined local and international studies of reasons for unplanned readmission after T&A. Inadequate pain management is a substantial reason for readmission,^{4, 7} with evidence that parents’ use of pain medication falls on day 3 after the surgery.⁸ Discharge instructions and telephone calls after surgery can support parents to better manage their child’s pain.^8-10

Libby White, Senior Project Officer, SCV

‘Some clinicians from our participating health services described that at times parents and carers found it challenging to understand what medications were needed to manage their child’s pain at home after tonsillectomy. Some parents also reported it was difficult to keep track of when they had given medication to their child and to remember when to give it next, particularly when their child had several caregivers.’

Develop, test and adapt resources

Representatives from the participating health services developed a change package that provided resources for parents and clinicians. The project provided standard templates for consumer and clinician resources including:

• Fact sheets for families on what to expect before and after T&A
• Videos of children and families sharing their experiences
• A pain management plan that helps families understand what medications to give their child after T&A, to track medications and when to seek help if their child’s pain gets worse
• A script to support clinicians to make postoperative phone calls.

Health services can adapt resources to suit their local needs, add their health service logo and choose which change ideas to test.

As part of the broader Reducing clinical variation in paediatric adenotonsillectomy project SCV also developed consumer and clinician resources to support parents to make a decision about tonsillectomy together with their doctor or surgeon.

Associate Professor Gillian Nixon, Clinical Lead for the project, paediatric respiratory and sleep physician, Monash University

‘Surgeons can have different views about the choice of pain medications, so we decided to leave that section in the pain management plan for each service to fill out, and instead focused on helping parents to understand the instructions around when to give pain relief and when to add an additional medication.’

The project aimed to reduce the rate of readmission after paediatric tonsillectomy by 15% in the participating health services by May 2020.

Five hospitals, including metropolitan, regional, public and private health services, participated in the pilot project from July 2019 to March 2020.

Each health service formed a team of nurses, surgeons, quality managers and clinical directors.

Services used the Model for Improvement¹¹ to design, test and adapt elements of the change package. SCV provided support with regular communication and visits to each health service, and training sessions in improvement science, change management, data collection and interpretation.

Priscilla Stephenson, Clinical Fellow, Paediatric Readmission Collaborative, SCV 

‘By the health services coming together to learn about improvement science, collaborate and share what they had learned at their sites using the Model for Improvement, key lessons were shared and amplified across all sites.’ 

The five health services collected data on:

• Outcome measures – paediatric readmission rates after tonsillectomy
• Process measures – the effectiveness of the process, such as the percentage of families who received fact sheets or a pain management plan before discharge
• Balancing measures – the unintended consequences of the project, such as delays in discharge time associated with additional time required to educate families before discharge.

All five sites were using most elements of the change package by February 2020. Readmission rates decreased across the five sites. The median weekly readmission rate for the five services fell from 4.2% to 0% from January 2020 to March 2020.

Other outcomes were:

• High level of family satisfaction
• Increased clinician awareness of how best to support families
• High-quality resources that hospitals could adapt to suit their own needs
• Increased capacity of clinicians to lead quality improvement projects.

SCV continues to monitor the state-wide rate of unplanned readmissions. The state-wide target rate of 3.7 readmissions per 100 periods of care was achieved in March 2022, compared to 4.7 in June 2019 at the start of the project.¹²

SCV developed an implementation package to support other health services to test and adapt the resources using improvement science methodology.

Priscilla Stephenson, Clinical Fellow, Paediatric Readmission Collaborative, SCV

‘One of the big lessons was that many families didn't fully know what to expect after T&A surgery. Families told us our resources helped them to understand how they could best care for their child at home after tonsillectomy, know what to look out for and when to seek medical advice if they were worried.’