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Nurse Practitioner Led Newborn Circumcision Clinic: A Safe and Cost Effective Practice
Vivian W. Williams, MSN, RN, CPNP1, Debra Lajoie, JD, PhD, MSN, RN2, Courtney Porter, MPH, CPHQ3, Tanya Logvinenko, PhD4, Katherine Tecci, MBA5, Caleb Nelson, MD1, Carlos Estrada, MD, MBA1.
1Department of Urology Boston Children's Hospital, Boston, MA, USA, 2Surgical Programs Boston Children's Hospital, Boston, MA, USA, 3Cardiovascular and Critical Care Boston Children's Hospital, Boston, MA, USA, 4Department of Urology Boston Children's Hospital and ICCTR, Boston, MA, USA, 5Perioperative Services Boston Children's Hospital, Boston, MA, USA.

BACKGROUND:
The Nurse Practitioner (NP) Led Newborn Circumcision Clinic (NCC), developed in 2016, provides clamp-style, or GOMCO technique, circumcision to newborns without general anesthesia. There is a paucity of research regarding outcomes, satisfaction, and the cost benefit of such NP led clinics. The purpose of this study is to describe the impact of the NCC including family satisfaction, clinical and demographic characteristics, and cost benefits.
METHODS:
This study utilizes a mixed method approach to describe the impact of the NCC using survey methodology to describe family satisfaction, a single center retrospective chart review to describe clinical and demographic characteristics and outcomes, and a charge comparison between operating room (OR) and NCC circumcisions. Family satisfaction was assessed by a six question survey and analyzed using descriptive statistics and conventional content analysis to identify themes that emerged from open ended questions. The study's findings were compared to a study by El Bcheraoui et al. (2014) describing adverse events in 1.4 million male circumcisions. A charge comparison was performed by comparing median technical and professional charges for a circumcision in the OR (OR time, anesthesia time, supplies, pharmacy, recovery, and pathology) to charges in the NCC.
RESULTS:
On a scale from 1 to 5, overall responses for the parent satisfaction survey (20.5% response rate) ranged from 4.10 to 4.82. Of the 234 patients reviewed, the median age and weight of patients was 4.3(3.0-6.0) weeks and 4.39(3.99, 5.00) kilograms. Of the patients with a comorbidity (30.3%), the most common were related to prematurity (42.3%). The most common reason for referral was concern for anatomical abnormality of the penis (53.8%). Of these patients, 58.3% had normal anatomy amenable to clamp-style circumcision. The average length of procedure was 20 minutes. Ten patients (4.3%) had bleeding during the recovery period which was treated with StatSeal. Two patients (0.9%) had bleeding after discharge requiring Emergency Department evaluation and application of a pressure dressing. No patients in our cohort experienced penile amputations, infections, strictures, intraoperative bleeding, or wounds. In comparison to El Bcheraoui et al., there was no significant difference in the rate requiring revision circumcision (0.85% vs 0.39%, p=0.23). While the rate of bleeding (5.1%) was significantly different (5.1% vs 0.2%, p<0.001), all of the patients who had bleeding required minor interventions (topical medication or pressure dressing). Comparison of charges in the OR versus NCC revealed a savings of 92.9%.
CONCLUSIONS:
Our study highlights the positive impact of our NP led NCC including high family satisfaction, safe and quality patient outcomes as compared to a national sample, and cost benefits as compared to OR circumcision. Critical to the success of the NCC is appropriately selecting patients, an NP training program, and interdisciplinary collaboration. This innovative ambulatory clinic offers another option for select infants who were not immediately circumcised in the newborn period. By expanding opportunities for NPs to practice to the full extent of their education and expertise, our institution
continues to develop opportunities to improve access to care, control costs, and increase patient, family, and staff satisfaction.


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