Improving pain score and restraint duration during circumcision.

Abstract

The American Academy of Pediatrics (AAP) recommends providing adequate analgesia during circumcision. Ring block is the most effective method of analgesia, while topical crème (EMLA: lidocaine and prilocaine topical) alone is ineffective. We conducted a quality improvement (QI) project. The aim was to reduce pain scores and restraint duration during circumcision by 20% from baseline over six months.

Methods: We followed the standard QI process using PDSA cycles and standard QI charts.

Results: Our preintervention data over six weeks revealed significantly higher pain scores if residents performed the procedure or if EMLA was used compared to nerve block. Our intervention included but was not limited to having a new policy to stop using EMLA and have residents watch a video on ring block before performing the procedure. Data collected over subsequent 3.5 months showed that the mean restraint time was reduced by 29% by attendings and by 15% by residents, the use of EMLA cream was eliminated, mean pain score was reduced by 82% when performed by residents and by 20% by attendings, and pain score above 3 was reduced by 100% by residents and attendings. We conducted a sustainability phase over two months. We demonstrated the sustainability of reduced restraint time among attendings but to a lesser extent among residents and the sustainability of mean pain score among both.

Conclusions: We conclude that improving effective analgesia during circumcision can be achieved and sustained using the QI project.