A simple care bundle to reduce unplanned admission rate for day case pediatric circumcision

Abstract

Summary Background An electronic review of unplanned day case admission rates in our hospital demonstrated an average annual rate for pediatric circumcision of 2%‐3% in recent years with high levels of perioperative strong opiate use. This lay above target unplanned admission rates (<2%) set out by the Royal College of Anaesthetists for day case surgery. A targeted quality improvement initiative was undertaken to improve patient flow through the pediatric day case surgery unit for elective circumcision. Among the reasons for unplanned admission, factors modifiable by the anesthetist (pain, postoperative nausea and vomiting, somnolence) are significant contributors. Methods A prospective audit was undertaken over a 3‐month period. Our practice was compared with evidence‐based analgesic and antiemetic interventions in accordance the Association of Paediatric Anaesthetists of Great Britain and Ireland. Perioperative strong opiate administration rates occurred in 44% of cases. Four strategic interventions were selected based on quality of evidence, ease of implementation, and low cost: selection of higher concentration local anesthetic use for penile blocks, intravenous dexamethasone, and preoperative paracetamol combined with maximum dose nonsteroidal anti‐inflammatory. Results The audit was duplicated a year later demonstrating a significant increase in application of these interventions with a parallel fall in strong opiate use from 44% to 9% and an unprecedented zero unplanned admission rate in our unit for 10 months in a row after implementation. Conclusion Regular scrutiny of patient electronic data helps identify high impact areas for audit and intervention. Unplanned admission in pediatric day case surgery is an area amenable to such targeted intervention.

Reducing postoperative pain in children undergoing strabismus surgery: From bundle implementation to clinical decision support tools

“…Improving postoperative outcomes is a key area of interest for pediatric perioperative teams. Both enhanced recovery after surgery (ERAS) pathways and individual care bundle implementation have been employed to improve perioperative pediatric surgical outcomes. Reducing postoperative pain through targeting perioperative analgesic strategies is often a key component of such initiatives .…”

The Utilization of an Opioid-Free Anesthetic for Pediatric Circumcision in an Ambulatory Surgery Center

“…However, there is scarce literature regarding its use in pediatrics, especially in common urologic procedures such as circumcisions. Recent studies have shown that the unexpected admission rate for pediatric circumcision ranges from 2-3%, likely due to uncontrolled pain and PONV [11]. In another pediatric study, over half of parents reported their child experienced moderate to severe pain postoperatively [12].…”