Improving Outcomes through Implementation of an Infant Spinal Anesthesia Program for Urologic Surgery Patients

Abstract

Introduction: Spinal anesthesia has a long history as an effective and safe technique to avoid general anesthesia in infants undergoing surgery. However, spinal anesthesia was rarely used as the primary anesthetic in this population at our institution. This healthcare improvement initiative aimed to increase the percentage of successful spinal placements as the primary anesthetic in infants undergoing circumcision, open orchidopexy, or hernia repair from 11% to 50% by December 31, 2019, and sustain that rate for 6 months.

Methods: An interdisciplinary team created a key driver diagram and implemented the following interventions: education of nurses, surgeons, and patient families; focused anesthesiologist training on the infant spinal procedure; premedication; availability of supplies; and surgical schedule optimization. The team collected data retrospectively by reviewing electronic medical records (Cerner, North Kansas City, Mo.). The primary outcome was the percentage of infants undergoing circumcision, open orchidopexy, or hernia repair who received a successful spinal as the primary anesthetic. The team tracked this measure and evaluated using a statistical process control chart.

Results: Between August 1, 2018, and February 29, 2020, researchers identified 470 infants (235 preintervention and 235 postintervention) who underwent circumcision, open orchidopexy, or inguinal hernia repair. Following the interventions in this project, there was a statistically significant increase in successful spinal placement from 11% to 45% (P < 0.0001).

Conclusion: This quality improvement project successfully increased the percentage of patients receiving spinal anesthesia for specific surgical procedures by increasing the number of patients who underwent successful spinal anesthesia placement.

Fig. 1.

Fishbone diagram.

Fig. 2.

Key driver diagram.

Fig. 3.

Percentage of successful spinal anesthesia placements in infants undergoing circumcision, open orchidopexy, or inguinal hernia repair. Note: Intervention 1 was the education of nurses, surgeons, and families. Intervention 2 was anesthesiologist training. Intervention 3 incorporated patient premedication as part of the standard of care. Intervention 4 was increasing supply availability. Finally, intervention 5 was OR schedule optimization—additional information regarding these interventions in Methods.

Fig. 4.

Percentage of successful spinal anesthesia placements as a percent of total attempts.Note: Intervention 1 was the education of nurses, surgeons, and families. Intervention 2 was anesthesiologist training. Intervention 3 incorporated patient premedication as part of the standard of care. Intervention 4 was increasing supply availability. Finally, intervention 5 was OR schedule optimization—additional information regarding these interventions in Methods.

Fig. 5.

Process measure—the percentage of patients who attempted spinal anesthesia placement who received premedication. Note: additional information regarding these interventions in Methods.