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Quality Improvement Protocol to Reduce Excessive Postoperative Recovery Following Cleft Palate Repair
Balvindar Kaur1, Geoff Frawley1,2,3, David Chong2,4
1Department of Paediatric Anaesthesia and Pain Management, Royal Childrens Hospital, Melbourne, Australia.
Insights
Implementing a multimodal analgesic protocol, selective arm splint use, and dexmedetomidine infusion significantly reduced post-anesthetic care unit (PACU) stay for infants undergoing cleft palate repair. These interventions also decreased adverse respiratory events and intensive care admissions.
Area of Science:
- Pediatric Anesthesiology
- Surgical Quality Improvement
- Pain Management
Background:
- Cleft palate repair in infants often leads to postoperative pain and respiratory issues.
- This can result in extended post-anesthetic care unit (PACU) stays, delaying feeding and increasing hospitalization duration.
Purpose of the Study:
- To reduce post-anesthetic care unit (PACU) length of stay after primary cleft palate repair.
- To decrease the incidence of pain, respiratory complications, and unplanned intensive care admissions.
Main Methods:
- A quality improvement study involving iterative Plan-Do-Study-Act (PDSA) cycles.
- Interventions included a multimodal analgesic protocol, selective use of arm splints, and intraoperative dexmedetomidine infusion.
- Primary outcome was mean PACU length of stay; secondary outcomes included pain, respiratory events, and intensive care admissions.
Main Results:
- The combined interventions reduced mean PACU stay by 16% (anesthetic standardization), 15% (arm splints), and 11% (dexmedetomidine).
- Pain incidence requiring opiate intervention was 31% overall, with a 26% incidence during the dexmedetomidine phase.
- Perioperative adverse respiratory events decreased significantly with dexmedetomidine (12%), and unplanned pediatric intensive care admissions dropped from 7.3% to 1.2%.
Conclusions:
- The integrated approach effectively reduced prolonged PACU stays.
- These anesthetic and care strategies are sustainable and applicable to other cleft palate repair centers.
Background:
Primary cleft palate repair in infants is frequently associated with postoperative pain and respiratory complications. As a result, prolonged post-anesthetic care unit (PACU) length of stay is common, which in turn delays time to first feed and may increase hospital length of stay.
Setting:
Tertiary Institutional.
Participants:
Infants < 36 months of age who underwent primary repair of cleft palate between March 2016 and December 2024.
Method:
A multidisciplinary quality improvement (QI) study incorporating a series of iterative Plan-Do-Study-Act (PDSA) cycles focused on anesthetic management of children undergoing cleft palate repair at The Royal Children's Hospital. The primary components of the interventions were: (1) implementation of a consistent multimodal analgesic protocol, (2) selective use of above-elbow arm splints, and (3) intraoperative infusion of dexmedetomidine. The primary outcome measure was mean PACU length of stay. Secondary outcomes were the incidence of pain or distress, airway obstruction, hypoxemia, or unplanned intensive care admission.
Results:
Four hundred and thirty-four patients (mean 14.7 months, 10.1 kg weight) were included. Standardization of the anesthetic approach resulted in a 16% reduction in mean PACU stay, rationalization of the use of the arm splint stage a 15% reduction, and intraoperative dexmedetomidine an 11% reduction in PACU stay. The overall incidence of pain or distress requiring opiate intervention was 31% with no significant reductions in incidence with anesthetic standardization (32%), rationalization of splint use (32%) and dexmedetomidine infusion (26%). Overall, 23% of patients had a perioperative adverse respiratory event in the first hour post-surgery with a significant reduction in the dexmedetomidine phase (12%) but non-significant decreases in other phases. Unexpected pediatric intensive care intervention was reduced from 7.3% to 1.2% with significant reductions in the splint and dexmedetomidine phases.
Conclusions:
The three components of this study combined to effectively reduce excessive PACU stay. Implementation of these recommendations is expected to be sustainable in the future and could be applied by other units involved in cleft palate repair.
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