The research team developed procedure-specific algorithms. At first, members of the research team met separately to develop the procedure-specific algorithms; for example, clinical researchers with an expertise in general surgery did not meet initially when developing the PSF in AIS algorithm, and vice versa. Both groups provided final recommendations regarding doses of opioid pills based on clinical considerations and notable risk factors for potential prescription opioid misuse. General surgeons, including both an attending and resident physician to account for different workflows, were consulted over a series of meetings to generate the initial algorithm for laparoscopic cholecystectomies. Once this initial algorithm was developed, it was shared with the paediatrics research team, feedback and recommendations were solicited, and a different, more complex algorithm was developed for AIS patients. The Paediatrics team opted to include a feature in the app to notify the provider that the patient would benefit from formal pain counselling in addition to a recommendation for the opioid prescription. This would occur through affirmative responses to questions such as ‘Is there opioid use within the household in which the patient resides?’ or ‘Has the patient taken any opioids that have not been prescribed to them for more than 5 days in the past 6 months?’, among others. We did not include this feature in the laparoscopic cholecystectomy algorithm due to concern that it may overcomplicate the app and be too time-consuming.
The two decision trees were reviewed by the full research team. Subsequent changes were made based on expert feedback. However, it was evident that the team needed to develop decision trees to be both procedure-specific and patient-specific. The procedures were intrinsically different, and they differed in terms of their length, and degree and duration of expected postoperative pain. Furthermore, adolescents were admitted with caregivers who needed to be included in the decision-making for pain treatment strategies, while adults having cholecystectomies were making decisions regarding pain treatments on discharge on their own.
The laparoscopic cholecystectomy algorithm (used in the General Surgery department) followed a more straightforward approach, with the final decision tree including seven questions with four possible recommendations, including zero need, low need (two pills), average need (five pills) and high need (ten pills) (table 1). The PSF in AIS algorithm (used in the Paediatrics department) was more complex to account for paediatric patients’ age, weight, previous opioid exposure/use and laminectomy levels included. The PSF in AIS algorithm involved 16 questions and 5 possible recommendations: zero need, low need (6–8 pills), low-average need (10–12 pills), average need (18 pills) and high need (24–26 pills) (table 2). All opioid pills were noted to be 5 mg hydrocodone/oxycodone or equivalent.