Background & Goals
The National Center for Health Statistics estimates that about 64% of newborn boys undergo circumcision in the United States. Evaluation of current evidence by The American Academy of Pediatrics indicates that health benefits of newborn male circumcision outweigh the risks, thus supporting access to this procedure for families who choose it.
More than 5% of infants have been reported to require hospitalization to address a wide range of health conditions for a period of time immediately following birth. A challenge has long existed for infants born with medical comorbidities which preclude immediate newborn circumcision and for families who elect newborn circumcision following hospital discharge. Unless an infant had a circumcision performed in the immediate newborn period prior to hospital discharge, the only option in many healthcare settings has been to schedule the procedure at age 1 year or older in an operating room under general anesthesia. In 2017, the US Food and Drug Administration (FDA) recommended limiting exposure to general anesthesia in children younger than 3 years given evidence that cumulative anesthetic exposures may negatively affect brain development in children.
Additionally, surgical pre-procedure planning most often requires family caregivers to take additional time away from work and family responsibilities to complete a pre-operative visit, return a second time for the procedure itself, await the completion of post-anesthesia care after surgery, and return for a follow-up visit resulting in both additional costs and greater burden of care for families.
Our nurse practitioner team, with the support of our urology surgical physician colleagues, sought to develop a novel, holistic, family-centered ambulatory care model to mitigate these challenges. In collaboration with families and communities to understand their healthcare needs through Boston Children’s Hospital’s Family Advisory Committees and other community partnerships, we heard the challenges parents faced when they could not obtain a circumcision prior to their newborn’s initial hospital discharge. Parents also expressed additional concerns their child would now require an operating room procedure with additional risks of general anesthesia for a procedure which, had there been different circumstances, would have been done under a local anesthetic in a procedural setting closer to the time of their child’s birth.
The Transforming Post-Hospitalization, Newborn Circumcision Care Through a Nurse Practitioner-Led Care Delivery Model (NCC) was developed to transform traditional practices and to introduce nurse-led, holistic, child and family-focused interventions to provide circumcisions.
The model integrates holistic family and child-centered care delivery practices with attention to intended procedural outcomes. This approach prioritizes newborn comfort, procedurally sound care, and family support through attention to each child’s well-being, parental anxiety, and intentional design to reduce the potential latent risks of early childhood anesthesia, societal and family costs, and the family caregiving time burden and disruption associated with traditional circumcision practices.
In addition, the NCC team developed the Atlas of Healing after Newborn Circumcision (2019) to support families with home care after newborn circumcision. This Atlas is a teaching tool that chronicles normal circumcision healing and is available for use by healthcare providers. The use of this tool was shown to decrease post-operative parent anxiety and facilitate early identification of follow-up care needs after a surgical circumcision. An ongoing program of research and quality improvement has been established to continue to understand and further strengthen clinical outcomes.
Evidence of Success
The NCC has a high level of family satisfaction, few adverse outcomes, and provides both quality and cost benefits in contrast to circumcision procedures completed within an operative setting with general anesthesia. The NCC was created in 2016, with close to 800 circumcisions performed to date over the most recent five years. No documented events were noted in 95.6% of the study cohort at the follow up visit, with penile adhesions noted as the most common concern.
Cost savings of 92.9% were achieved for circumcisions completed in the NCC compared to those completed under general anesthesia by physician providers in traditional operating room settings. Furthermore, key family caregiver benefits including reductions in time away from work for parents related to a less burdensome pre-procedural screening process and reductions in insurance co-pays were also realized.
References and Resources
An Act promoting a resilient health care system that puts patients first, MA Bill S.2984, 191st.
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