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

This is a prospective audit of analgesic and antiemetic use for day case circumcisions at a quaternary paediatric hospital in the UK. Previous evidence has suggested that 30-40% of unplanned readmissions were secondary to pain or nausea. The authors hypothesised that improvement in these parameters could reduce readmission rates.

Four interventions were selected including the use of higher concentration of local anaesthetic for penile blocks, intravenous dexamethasone (analgesic and antiemetic properties) and perioperative paracetamol combined with maximum safe dose of NSAID. This was based on evidence from the Association of Paediatric Anaesthetists of Great Britain and Ireland for procedure specific pain management in 2012.

The use of analgesia and antiemetics in 54 patients were audited prospectively over a 3-month period in 2016. The audit was duplicated a year later (56 patients) following a targeted quality improvement initiative which included education.

Results were as follows:
1. Increase in combined paracetamol & NSAID use from 61% to 80%
2. Reduction in opioid use from 44% to 9%
3. Increase in use of higher concentration of local anaesthetic (0.5% levobupivacaine) for penile blocks from 13% to 47%
4. Regional use remained 100% with no real difference between technique applied
5. Increase use of dexamethasone from 46% to 70%

The readmission rate showed an overall reduction from 2% to 1.33%. This included a 10 month period post implementation of intervention with no readmissions, followed by a spike in August 2017 which was attributed to new surgical trainees starting.

Take home message

This demonstrates a simple means of auditing and instituting department change. Although reduction in readmission rates were low, any reduction is resource saving for a hospital and health care system alike. It also demonstrates, that although anaesthetic technique contributes to a patient’s postoperative course, there also many other variables that are hard to account or compensate for fully.
Reviewed by: Sorcha Evans