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Pediatric Preoperative Preparation

“The Eagle Has Landed” or Not?

Lauro, Helen Victoria MD, MPH, MSEd, FAAP

doi: 10.1213/ANE.0000000000000631
Editorials: Editorial
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From the Department of Anesthesiology, State University of New York Downstate Medical Center, Brooklyn, New York.

Accepted for publication December 14, 2014.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Helen Victoria Lauro, MD, MPH, MSEd, FAAP, Department of Anesthesiology, State University of New York Downstate Medical Center, 450 Clarkson Ave., Brooklyn, NY 11203. Address e-mail to helen.lauro@downstate.edu.

Preoperative preparation programs are the bedrock of anesthetic care for the pediatric patient. A mere 25 years ago, formal tools for preoperative preparation programs were limited. At that time, the best that hospitals could offer parents and children was a preoperative tour and possibly informational videos.1–3 In recent years, there has been an explosion in the availability of other modalities to reduce pediatric preoperative anxiety and negative maladaptive behaviors, such as child life preparation programs, clown doctors, role play, video games, tablet device distraction, and home-grown Internet or DVD preparation information. Unfortunately, these offerings are not practical or cost-effective for many institutions. The efficacy and relative merits of many of these modalities have not been rigorously evaluated, leaving the pediatric anesthesiologist to wonder which of the options from this seemingly endless menu is worth an investment of time, money, and effort. The relentless pressure to reduce costs further complicates this decision.

It is no surprise that many public hospitals, smaller community hospitals, and ambulatory care centers consider staffing of pediatric preoperative preparation programs, whether by attending or resident physicians and nurses, too costly. A recent national survey of children’s hospitals in the United States found that while all responding institutions operated day surgery programs, 90% of the time preoperative education consisted only of information provided by staff nurses either in person or by telephone. Standard mail was the major method of communication with families with a few facilities using e-mail to transmit additional educational material. The use of online educational programs to deliver information about surgery and anesthesia and DVDs was reported by a few programs.4 This is particularly disheartening, given the proven efficacy of hospital-based preoperative preparation programs to reduce patient and parental anxiety. Ultimately, variability in financial and human resources for pediatric preoperative preparation programs translates to inconsistencies in delivered information provided to parents and children prior to the date of surgery.

Unfortunately, there is no real precedent for reimbursing educational programs that provide preoperative preparation. Preoperative programs are often bundled into care or negotiated as part of a contract with the hospital to cover the personnel needed to provide the program. As part of the perioperative surgical home concept, there are initiatives for the anesthesiologist to improve outcomes involving proactive collaborative efforts directed toward patient selection, education, rehabilitation, and postoperative care. However, there are no consistent payment models for these types of programs, and to date, payment for preoperative preparation programs remains bundled for most facilities.

The evolution of preoperative preparation programs over the past quarter century bears similarities to the history of space flight, starting with the primitive Sputnik and progressing with the Mercury and Gemini missions. Many of us recall the New York Times headline “Men Walk on Moon.” In this issue of Anesthesia & Analgesia, Kain et al.5 describe the development and rigorous evaluation of a tailored anesthesia pediatric preoperative preparation program, for children and parents, that is Internet-based. This is followed by a randomized controlled study6 comparing the WebTIPS intervention to standard preparation. Analogous to these historic Apollo missions, we may ask of WebTIPS “Has the Eagle finally landed?” Could WebTIPS revolutionize the way pediatric preparation programs are provided?

The authors describe the development of the first Web-based tailored preoperative preparation program (WebTIPS) that can be easily accessed from any desktop or mobile device, in an unlimited fashion, by children and parents before the date of surgery.5 WebTIPS was developed based on literature review and conclusions of a multidisciplinary task force of experts in pediatric care and development, rather than an environmental scan of existing Web-based resources. The conceptual framework and content of WebTIPS were subsequently examined by a behavioral medicine, interventions, outcomes expert panel, which is part of the Center for Scientific Review at the National Institutes of Health. A formal needs assessment of practitioners in multiple disciplines, in hospitals and surgery centers, at the University of California, Irvine, and at Yale, to determine preoperative tailored Internet program learning needs, was conducted by the authors. A follow-up article presents a randomized controlled trial comparing children and parents completing the WebTIPS program with controls receiving the standard of care preparation.6 Children were found at entrance to the operating room and with introduction of the anesthesia mask to be less anxious in the WebTIPS group compared with controls. Parents in the WebTIPS group also experienced less anxiety compared with the control group in the preoperative holding area.

There are some limitations of the WebTIPS program that can be considered areas for future research. First, WebTIPS does not allow real-time communication or interactivity, but relies on previously loaded anesthesia preparation information. Such interactivity could enhance personalization and tailoring of interventions. Second, WebTIPS does not incorporate preoperative patient data contained in the individual medical record. Imagine the potential advantages of integrating electronic medical record data into the WebTIPS module made available for access by the anesthesiologist on the day of surgery.

The issue of the cost of initial start-up for WebTIPS programs and software maintenance must be considered. This might present a significant barrier to widespread adoption of this technology by some institutions. It is unclear whether professional societies would be prepared to offer discounts or subsidies to public hospitals or small facilities for purchase and maintenance of the software program. The authors postulate that charges could also be based on number of children and parents using WebTIPS. Regardless of the business model, smaller hospitals that are not primary children’s hospitals and do not perform high volumes of pediatric surgical outpatient cases might not have any economic incentive to participate.

WebTIPS certainly has importance as a theoretical construct and may be a game changer in the way institutions address comprehensive perioperative care for children and their parents. However, it remains to be seen whether tailored customized Internet preparation programs such as WebTIPS will be useful to the clinician, cost-effective in reducing preoperative anxiety, and applicable outside traditional hospital settings, such as free-standing surgery centers, and result in improved outcomes compared with traditional methodologies. A formal cost-benefit analysis is required. It is also unclear how this program could improve, assimilate with, or replace programs that are currently offered by many larger institutions.

In conclusion, WebTIPS has the potential to provide evidence-based pediatric preoperative preparation, provided implementation and maintenance software costs are not prohibitive, particularly to public and community hospitals. Has the Eagle landed? Maybe. Time will tell.

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DISCLOSURES

Name: Helen Victoria Lauro, MD, MPH, MSEd, FAAP.

Contribution: This author wrote and prepared the manuscript.

Attestation: Helen Victoria Lauro approved the final manuscript.

This manuscript was handled by: James A. DiNardo, MD.

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REFERENCES

1. Karl HW, Pauza KJ, Heyneman N, Tinker DE. Preanesthetic preparation of pediatric outpatients: the role of a videotape for parents. J Clin Anesth. 1990;2:172–7
2. Kain ZN, Mayes LC, O’Connor TZ, Cicchetti DV. Preoperative anxiety in children. Arch Pediatr Adolesc Med. 1996;150:1238–45
3. Cassady JF Jr, Wysocki TT, Miller KM, Cancel DD, Izenberg N. Use of a preanesthetic video for facilitation of parental education and anxiolysis before pediatric ambulatory surgery. Anesth Analg. 1999;88:246–50
4. Heckmann M, Beauchesne MA. Pediatric perioperative education current practices: a national survey of children’s hospitals in the United States. J Perioper Pract. 2013;23:100–6
5. Kain ZN, Fortier MA, Chorney JM, Mayes L. Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): development. Anesth Analg. 2015;120:905–14
6. Fortier MA, Bunzli E, Walthall J, Olshansky E, Saadat H, Santistevan R, Mayes L, Kain ZN. Web-based tailored intervention for preparation of parents and children for outpatient surgery (WebTIPS): formative evaluation and randomized controlled trial. Anesth Analg. 2015;120:915–22
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