Medical Professional Publications

Adenoidectomy Protocols Cut Hospital Stays and Costs While Maintaining Quality and Safety

Children who have frequent throat infections are often left with enlarged glands, called adenoids, at the back of the roof of their mouths. When enlarged adenoids obstruct breathing or clog the Eustachian tubes and cause ear infections, the glands may be surgically removed.

Newly-developed standardized care for young children undergoing adenoid surgery significantly shortened their length of stay in the hospital without compromising safety and quality, physician-researchers at Nationwide Children’s Hospital have found.

In a preliminary study, the care, called a perioperative surgical home protocol, also saved families about 30 percent in hospital charges and reduced pharmacy charges, the researchers found

The researchers explain the protocol they developed and the results in a study published in the International Journal of Pediatric Otorhinolaryngology.

“We were successful: kids were safe, families were happy and many saved money from not staying overnight,” says Vidya Raman, MD, an anesthesiologist at Nationwide Children’s and lead author of the study. “To make it work, we communicate and collaborate from the moment patients register to come to surgery to the time they go home.”

The protocol is as follows:

  1. Preadmission-testing registered nurses and faculty anesthesiologists review patient histories and identify eligible patients, age 16 months to 35 months. Children with sleep disordered breathing or sleep apnea are not eligible due to the potential complications they face from the surgery.
  2. Pediatric otolaryngologists introduce and explain the protocol to parents. Families or the medical team can reject participation.
  3. On the day of surgery, the protocol includes a paper checklist to complete, to ensure all patients have met eligibility standards.
  4. A standardized order including pre-operative and post-operative nursing instructions and eligible medications is placed in the electronic medical records.  
  5. Patients receive at least three hours of post-operative monitoring to address post-operative issues prior to discharge.
  6. Prior to discharge, caregivers watch a short and to-the-point video, telling them what to watch for and when they should call the doctor. The video is available on YouTube at:
  7. An attending anesthesiologist makes a follow-up phone call the evening after surgery to check on the patient and ask caregivers for feedback on the discharge process.

“The key is to make sure parents have the tools they need to navigate the system, feel connected, know what to expect and answer their questions,” says Dr. Raman, who is also a clinical associate professor of anesthesiology at The Ohio State University College of Medicine.

The protocol is discontinued at any stage if family members, physicians or nurses become uncomfortable with the standardized care for the child.

In a comparison among patients, 79 percent of children who were treated under the protocol were discharged the same day as surgery, 21 percent were admitted overnight and none required a longer stay. Among the control group, 51 percent were discharged the day of surgery, 47 percent admitted overnight and 2 percent required extended admission.

No major morbidity or mortality occurred in either group. The researchers found that 6 percent of children in each group returned to the emergency department within 30 days, mostly due to concerns about pain and fever.

While 59 percent of families reported being comfortable with being discharged home, the researchers say they have work to do to make more feel at ease and confident. The main reason parents gave for feeling uncomfortable with the process was the idea of having surgery and going home the same day. In fact, that was the most common reason given by parents who declined to even enroll their children in the protocol during the study.

Dr. Raman and her colleagues are studying how to allay that concern. In an effort to further improve efficiency, the team is investigating ways to discern ahead of time which children are likely to go home the day of surgery from those who need to stay overnight. She is also working with urology and colorectal surgeons, developing similar standardized protocols for their patients.

“There’s nothing novel,” Dr. Raman says. “We’re trying to standardize approaches to care to maximize outcomes, cost and satisfaction of families, without cutting corners.”

Citation: Raman VT, Tumin D, Uffman J, Thung AK, Burrier C, Jatana KR, Elmaraghy C, Tobias JD. Implementation of a perioperative surgical home protocol for pediatric patients presenting for adenoidectomy. International Journal of Pediatric Otorhinolaryngology. 2017 Oct;101:215-222.

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