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PREMED PERKS!  A COST-BENEFIT ANALYSIS OF INTRANASAL DEXMEDETOMIDINE ON KEY QUALITY OUTCOMES: AN IMPROVEMENT BUSINESS CASE

A.Norris, T. Blanks

Nottingham University Hospitals NHS Trust, UK

Background/Context

Peri-operative anxiety has a significant effect on paediatric patients undergoing elective surgery[1], it also impacts healthcare systems daily at our tertiary paediatric centre. Peri-operative anxiolysis may require pharmacological interventions; the administration and impact of which should be measured against domains of healthcare quality to ensure that we are choosing the best option for our patients and doing so with the greatest financial efficiency.

Problem

Key quality outcomes such as patient/caregiver experience, length of stay and post-operative pain have been demonstrated to be worse in paediatric patients with peri-operative anxiety[2], including at our trust. In May 2023 last year we introduced intranasal dexmedetomidine(IN-DEX) premedication as an improvement initiative; a patient/caregiver questionnaire demonstrated improved experience outcomes and increased effectiveness of IN DEX (92%(22/24) compared with oral midazolam 76%(16/21)) in keeping with meta analyses[3]. We therefore proceeded to analyse other outcomes, associated benefits and cost effectiveness of this change in comparison to our previous first-line agent, oral midazolam.

Strategy for Change

During a 4-month period from June-September 2023 all elective day-case paediatric cases were retrospectively reviewed and three groups identified: “NO-PREMED”- no pre-medication(n=1470), “MIDAZ”- oral Buccolam prefilled syringes 0.5mg/kg(n=33) or “IN-DEX”- intranasal dexmedetomidine 2-4mcg/kg via atomiser(n=126). Outcomes analysed between groups were: (a) drug & equipment costs - compared to the corresponding 4-month period in 2022; (b) ward length of stay(LOS) and indicative cost; (c) requirement for rescue opioids; (d) patient safety.

Measure of Improvement

10.8%(159/1629) children received a premedication. (a)IN-DEX cost £3/child vs average £30/child with MIDAZ, introduction of IN-DEX made a total cost saving of £3,402/4months compared to 2022 (where 136/1557 received premedication with midazolam), demonstrating a total indicative cost alternative saving of £12,879 per annum. (b) Average time following recovery to discharge with NO PREMED of 54 minutes, IN-DEX 52 minutes vs MIDAZ 71 minutes, indicating a yearly total LOS saving of 160 bed hours with a cost equivalent saving of £5,283 per annum. (c) Requirement for rescue opioids post-operatively in 22%(324/1470) of NO-PREMED, 7%(9/126) IN-DEX vs 27%(9/33) MIDAZ. (d)There were no critical incidents related to premedication reported in this cohort.

Lessons Learnt/Message

Following the introduction of IN-DEX, we have demonstrated a total indicative cost saving of £18,162 per annum for our trust. It also highlights the benefits of IN-DEX on requirement for post-operative opioids - 20% fewer patients compared to MIDAZ, as well as reducing LOS post-recovery by 25% - in line with those with NO-PREMED. In combination with our previously reported improved experience outcomes, this demonstrated change forms a strong case for ongoing effective use of IN-DEX as our first line premedication for the anxious/stressed child. We have begun collecting prospective data on other key outcomes such as theatre efficiency, anaesthetic time and rates of emergence delirium.

References:

[1] Stanzel,A. (2022). Paediatric Medical Traumatic Stress (PMTS) following surgery - J. Child Adolesc Trauma. Vol 15(3):795-809.

[2] Muhly,T. (2020). A Systematic Review Of Outcomes Reported In Pediatric Perioperative Research - Pediatric Anesthesia. Vol 30 11:1166-1182.

[3] Tervonen.M. (2020). Systematic Review and Meta Analysis Found That Intranasal Dexmedetomidine Was Safe And Effective Sedation - ActaPaediatrica. Vol 109(10):2008-2016.