Impact of Pediatric Tonsillectomy Guidelines on Clinical Practice

by Ravindhra G. Elluru, MD, PhD •

What impact have the pediatric tonsillectomy guidelines, published by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) in January 2011, had on the individual practicing clinician?

Bottom line: To achieve a higher adherence to clinical practice guidelines and to reduce variability, we must understand the rationale utilized by those clinicians who choose not to adhere, and we must develop additional processes to foster compliance.

Background: Despite the fact that tonsillectomy is the most common operative procedure performed in the United States, considerable variation exists in management and resource utilization. Clinical practice guidelines contain specific guidance, each emphasized at different levels. “Strong recommendations” are those that show clear benefits that exceed the risk for harm if the recommendation is followed.

Study design: Case series with chart review.

Setting: Multi-hospital network.

Synopsis: This study sought to identify the adherence rate of individual clinicians to two strong recommendations made in the 2011 AAO-HNS Guidelines for Tonsillectomy in Children and Adolescents: 1) intravenous intraoperative administration of a single dose of dexamethasone, and 2) avoidance of the routine use of perioperative antibiotics. The study was conducted within Intermountain Healthcare, a not-for-profit, vertically integrated multi-hospital healthcare system. A case series of 15,950 children aged one to 18 years undergoing same-day surgery adenotonsillectomy between 2008 and 2014 was reviewed to determine whether dexamethasone and/or antibiotics were given in the hospital. The frequency of administration of these two drugs was compared among surgeons and hospitals in the years before and after the guidelines were published.

Before guidelines were published, 98.4% received dexamethasone, compared with 98.9% after guideline publication. Furthermore, 16.1% received antibiotics prior to the guidelines and 13.8% after. Prior to the guidelines, 36% of surgeons routinely gave antibiotics; after the guidelines, 26% continued to give antibiotics at least 50% of the time. Most clinicians appear to have administered dexamethasone routinely even prior to the guidelines; however, a significant number of clinicians administered antibiotics both prior to and after the guidelines.

Citation: Padia R, Olsen G, Henrichsen J, et al. Hospital and surgeon adherence to pediatric tonsillectomy guidelines regarding perioperative dexamethasone and antibiotic administration. Otolaryngol Head Neck Surg. 2015;153:275-280.