Question for nurses. - Page 2

[kate3]

Sorry if it's a lame question, but what's "time out" (before the circ procedure)?

Not a lame question, and it has already been answered correctly. Time outs prior to surgery have been instituted at many hospitals in response to wrong sided surgery (which should never happen). Everything stops. In the case of a circ (at the hospital where I worked and later had students), the MD and RN check for a signed consent and check all baby tags against the chart and the consent. Both the MD and RN have to sign off that all forms of ID were verified. The protocol at this particular hospital included a topical anesthetic cream 30 minutes prior to procedure, so that gets checked as well. It was a huge process but because there were so many steps involved, it provided multiple checks and balances for correct procedures.

And the reason patients get asked so many times if they want a circ is not because the staff wants to do them. Actually, they are a huge inconvience and a scheduling nightmare in a busy nursery. Circs are the #1 thing to ask about because they are scheduled 24 hours in advance, require meds to be sent up from the pharmacy, require a wait time after consent (so parents can change their mind), and need to be coordinated with the nursery and OB schedule. They can't be done as a spur of the moment thing.

[Fellow Traveler]

Originally Posted by kate3

And the reason patients get asked so many times if they want a circ is not because the staff wants to do them. Actually, they are a huge inconvience and a scheduling nightmare in a busy nursery. Circs are the #1 thing to ask about because they are scheduled 24 hours in advance, require meds to be sent up from the pharmacy, require a wait time after consent (so parents can change their mind), and need to be coordinated with the nursery and OB schedule. They can't be done as a spur of the moment thing.

I understand that it takes time to get meds for instance but then why can't they ask once (better to never ask) and then accept that no mean no? It's on the form when you come in you should never hear a word about it again.

[Yulia_R]

Originally Posted by kate3

Not a lame question, and it has already been answered correctly. Time outs prior to surgery have been instituted at many hospitals in response to wrong sided surgery (which should never happen). Everything stops. In the case of a circ (at the hospital where I worked and later had students), the MD and RN check for a signed consent and check all baby tags against the chart and the consent. Both the MD and RN have to sign off that all forms of ID were verified. The protocol at this particular hospital included a topical anesthetic cream 30 minutes prior to procedure, so that gets checked as well. It was a huge process but because there were so many steps involved, it provided multiple checks and balances for correct procedures.

And the reason patients get asked so many times if they want a circ is not because the staff wants to do them. Actually, they are a huge inconvience and a scheduling nightmare in a busy nursery. Circs are the #1 thing to ask about because they are scheduled 24 hours in advance, require meds to be sent up from the pharmacy, require a wait time after consent (so parents can change their mind), and need to be coordinated with the nursery and OB schedule. They can't be done as a spur of the moment thing.

Thanks for the explanation! I must say though that there is no excuse for asking parents more than once no matter what the reason might be.

[brant31]

Originally Posted by kate3

And the reason patients get asked so many times if they want a circ is not because the staff wants to do them. Actually, they are a huge inconvience and a scheduling nightmare in a busy nursery. Circs are the #1 thing to ask about because they are scheduled 24 hours in advance, require meds to be sent up from the pharmacy, require a wait time after consent (so parents can change their mind), and need to be coordinated with the nursery and OB schedule. They can't be done as a spur of the moment thing.

I'm not doubting for a moment that what you say is true in your area.

However, the repeated questioning about circumcision goes back several decades now, well before anyone used anesthesia or observed surgical procedures for circumcision. In fact, my MD contacts tell me that even today, only about 10% of US hospitals place neonatal circumcision in the "surgery" category, requiring the formalities and checks and balances that go with that. The rest consider MIC to be a "procedure", much like lancing a boil or removing a splinter, so it can be done spur-of-the-moment and consent doesn't seem like that big a deal.

Indeed, still only a minority (a large minority now) of doctors and hospitals use anesthesia for neonatal circumcision and it was only a decade ago that the issue even really arose on the AAP's radar. Almost every peer of mine was circumcised with no anesthesia whatsoever -- true of the vast majority of US males alive today.

If circumcisions really are a great inconvenience to hospitals, one would think that many of them would say to parents "you must indicate your intent to circumcise at admission or it won't be done". Very simple language. Most of us on this forum are trying our darnedest to get hospitals out of the neonatal circumcision business altogether, as it does not conform to general surgical guidelines (no diagnosis, inconsistent or inadequate anesthesia usage, performed outside of specialty, solicitation of surgery on minors is illegal in most if not all states, and no tissue pathology follow-up to confirm dx).

It is modern medicine's oddest anomaly.

[kate3]

I understand that it takes time to get meds for instance but then why can't they ask once (better to never ask) and then accept that no mean no? It's on the form when you come in you should never hear a word about it again.

I completely understand how you feel. But it really isn't that staff doesn't respect that no means no. I know it feels this way, but it isn't a matter of not wanting to honor the parents' wishes. Yes, the information is in the chart, but patient's charts don't travel. They need to be in a secured location due to privacy regulations. During a busy shift in which you are responsible for multiple mom/baby dyads, it becomes impossible to commit every detail about every patient to memory. So unfortunately, patients do get asked more than once about a variety of things.

The purpose of my post was not to start an arguement or debate over whether hospitals should offer circs. I think everyone on this board has the same mindset about that issue. It was to offer insight as to how a large, busy nursery works and why certain things happen the way they do. I also understand that hospitals are unpopular at MDC, so for many people no explaination that I could offer would ever be adequate. But hopefully I have taken some of they mystery out of hospital care, whether you agree with it or not

[Yulia_R]

a brainstorm idea...

I wonder if it would make a difference if L&D nurses of a particular hospital sat down, discussed the issue and then would bring to their boss the fact that soliciting an unnecessary plastic surgery on newborn SEVERAL times neither ethical nor acceptable and figure out a way how to avoid it (perhaps something as simple as putting a temporary sticker on the door of male babies that are not to be circ'd...ANY sticker, like a balloon, a flower or a teddybear (and of course all nurses will be aware that if they see this flower sticker on the door, the baby is to be kept intact and parents aren't to be asked again). This way there is no need to rush to the charts and confirm every time as there is no need to ask parents multiple times. After the baby is discharged the sticker can be easily removed.

[Yulia_R]

oh and...

Instead of multiple conformation about keeping a boy intact, you can keep asking this question those parents who chose to cut. I'd imagine if a parent is being asked the same question whether they want to circ again and again it can give them a feeling that it's no longer common and they may ask a nurse for her oppinion and perhaps change their mind.

[Fyrestorm]

Why are they asking in the first place? Isn't it unethical to solicit cosmetic surgery? Shouldn't parents have to specifically seek it out?

Oh...right...Like I stated in the other thread...it's that $300 coupon on every boys penis

[Yulia_R]

kate3, so what do you think about my sticker idea? It is SO simple and easy to implement and will cost the hospital about 20 cents per baby.

[Crunchy Frog]

Yulia, I had exactly the same thought while I was reading this. What would be the difficulty of simply putting an extra card on the bassinet, or an extra bracelet of a particular color on the baby indicating he was not to be circed. That way the nurse or doctor would only have to glance at the baby, know that he wasn't to be circed, and just not bother anyone.

And kate3, I'm sure they are a big inconvenience to the hospitals, but I would guess that the money that they make from them more than makes up for it.

If it was really just an inconvenience and liability risk, the most sensible thing to do would be to stop doing them and allow parents who wanted it to arrange for it at the office of a doctor who would provide that service following discharge.

[2lilsweetfoxes]

I like the idea of marking the baby and room that the baby is not to be circumcised, except with marking the room: what if it is a mixed room--2 boys, of different parents, one mom wants her son circ'd and the other doesn't. So, something to say "pay attention! make sure you aren't taking the wrong boy!"

Of course, I'd like it better if it won't be done before discharge, if at all. But, we can't inconvenience parents any more than necessary. Or, if you don't want to mark the room (privacy issues and all that jazz), then assume it isn't to be done and if the parents want it, THEY will seek it out.

[tennisdude23]

Originally Posted by Crunchy Frog

Yulia, I had exactly the same thought while I was reading this. What would be the difficulty of simply putting an extra card on the bassinet, or an extra bracelet of a particular color on the baby indicating he was not to be circed. That way the nurse or doctor would only have to glance at the baby, know that he wasn't to be circed, and just not bother anyone.

And kate3, I'm sure they are a big inconvenience to the hospitals, but I would guess that the money that they make from them more than makes up for it.

If it was really just an inconvenience and liability risk, the most sensible thing to do would be to stop doing them and allow parents who wanted it to arrange for it at the office of a doctor who would provide that service following discharge.

I always questioned the notion that hospitals/doctors make a lot of money from circumcisions. I guess this might vary from hospital to hospital, but I sort of think that the time, preparation, and overall inconvenience of these surgeries nulls the monetary benefits. In economics, you have this basic idea of marginal cost/marginal benefit, meaning that the more of a good/service you produce, the additional benefit for each good/service will decrease over time while the costs increase. Granted, this is just a model which does not necessarily always apply to the real world, but I would venture to say that in a hypothetical hospital setting where a lot of circumcisions are performed, the cost of time, preparation, and post op. observation would actually outweigh the potential benefits of the surgery (whether that be monetary or health) for all parties involved: infant, doctor, hospital, etc. For example, the more time a doctor spends on circumcisions that's less time he/she is providing a beneficial service to other patients. It also means more medication for the babies, medication that could be used much more efficiently in other settings. The point is that there are a lot of hidden costs to circumcision, costs that not only affect male infants, but also the doctors and hospitals. Do these costs outweigh the benefits, well, that's the unknown. Anyway, this is just some food for thought and perhaps an interesting research question.

[2lilsweetfoxes]

Originally Posted by tennisdude23

I always questioned the notion that hospitals/doctors make a lot of money from circumcisions. I guess this might vary from hospital to hospital, but I sort of think that the time, preparation, and overall inconvenience of these surgeries nulls the monetary benefits. In economics, you have this basic idea of marginal cost/marginal benefit, meaning that the more of a good/service you produce, the additional benefit for each good/service will decrease over time while the costs increase. Granted, this is just a model which does not necessarily always apply to the real world, but I would venture to say that in a hypothetical hospital setting where a lot of circumcisions are performed, the cost of time, preparation, and post op. observation would actually outweigh the potential benefits of the surgery (whether that be monetary or health) for all parties involved: infant, doctor, hospital, etc. For example, the more time a doctor spends on circumcisions that's less time he/she is providing a beneficial service to other patients. It also means more medication for the babies, medication that could be used much more efficiently in other settings. The point is that there are a lot of hidden costs to circumcision, costs that not only affect male infants, but also the doctors and hospitals. Do these costs outweigh the benefits, well, that's the unknown. Anyway, this is just some food for thought and perhaps an interesting research question.

I think that is something to consider. However, many hospitals have a certain time slot in which all circumcisions are performed in the neonate wing. So, they want as many boys as possible to make it "worth their while".

[major_mama11]

In my place of work, HepB vaccination and circumcision do require specific consent forms, and time outs before a circ, as was mentioned up-thread. Doctors dictate an operative note as they do after other surgeries. Medications given in the delivery room (Vit K, erythromycin ointment) are under the consent that mom signs when she is admitted. However, if mom and dad specify in birth plan that they do not want either of these, they will not be given.

I personally am very careful about consents and verbally verifying whether parents realize what they are signing, as I have heard of a baby being circed against parents' wishes at my previous place of work (parents were non-English speakers, and signed the consent without realizing what they were signing ).

Incidentally, one of the pediatricians where I work always goes out of her way to emphasize to parents beforehand that circ is not medically necessary and is purely a cosmetic procedure. (although it seems to fall on deaf ears, at least in my region)

I like the idea of an extra bracelet or something to identify babies that are to be left alone... I know I was sick of being asked by each health care person if I was going to circ my son, and I didn't even deliver in a hospital!

[tennisdude23]

Originally Posted by 2lilsweetfoxes

I think that is something to consider. However, many hospitals have a certain time slot in which all circumcisions are performed in the neonate wing. So, they want as many boys as possible to make it "worth their while".

Yes, this addresses the issue of efficiency, but "time is money" as they say and I would argue that as more time is allocated to circumcisions, the less time there is for other beneficial procedures. The marginal costs of this so called "no free lunch" principle increase over time while the benefits decrease, no matter how efficient the hospital may be. Time here is just one example. There are a lot of things to consider as well, the "hidden costs" as I termed it, which I speculate null most of the monetary benefits. Again, I'm purely speculating, but I feel this simple economic model is quite applicable in this situation as well as to many other facets of circumcision.

[Yulia_R]

I think the idea of an extra bracelet is absolutely AWESOME! And is something very cheap and easy to do! Plus it stays on the baby even if he ends up in a nersery or somewhere else in the hospital.

[jessjgh1]

my post went poof, but I had wanted to say that I'm also in MA and I think each individual hospital makes up their protocol as the 2 I had my children at both had blanket policies and were very different.
I don't think there is much standardization and some hospitals are going to have better policies than others. I've said before that finding the best policies and finding a way to present them to hospital admins may be one way to make some changes and iwth the accidental circumcision in the FL hospital hitting the media, it would be a good opportunity.

(for example the other thread that is being discussed about circs happening in the NICU- I'm pretty sure some NICU's just will not do them at all till the child is released from nicu- seems fairly obvioius that something like that should not be too hard to implement and makes a lot of medical and practical sense)
Jessica

[2lilsweetfoxes]

Originally Posted by tennisdude23

Yes, this addresses the issue of efficiency, but "time is money" as they say and I would argue that as more time is allocated to circumcisions, the less time there is for other beneficial procedures. The marginal costs of this so called "no free lunch" principle increase over time while the benefits decrease, no matter how efficient the hospital may be. Time here is just one example. There are a lot of things to consider as well, the "hidden costs" as I termed it, which I speculate null most of the monetary benefits. Again, I'm purely speculating, but I feel this simple economic model is quite applicable in this situation as well as to many other facets of circumcision.

I was going on how it seems at all the hospitals I delivered at, there was a "set time". When I had my first (a girl), they had a circumcision class. This was effectively the announcement: "The circumcision class is starting in fifteen minutes in the conference room. All parents are required to attend. No infants permitted." Tell me, does this make it sound like it is optional? Even parents of girls were thinking they were required to attend (for informational purposes--or they were going to go into general care, also). I ended up asking the nurse if parents of girls or boys who were not to be circumcised were required to attend. She said no, because the boys are circumcised while the parents are in the class. Talk about not having a chance to change your mind or if you send Junior to the nursery to attend the class--and you never intended him be circumcised--by the time your realize it, he'll have been cut. I think that is why, 2 years later when DS was born, parents had to seek it out at the nurses desk, make the arrangements, etc. But, when I went to check out twenty four hours after his birth, upon realizing he was intact (going over circ care, and I said he wasn't done) the nurse exclaimed in horror: "the doctor that does the circumcisions has left for the day! I'm so sorry. You can either stay an extra day or come back sometime in the next two weeks--but make an appointment. We can even have you swing up here Wednesday morning at his three-day checkup and we'll take care of it." With my third, a girl also, I did not pay attention.

[NSmomtobe]

Originally Posted by Yulia_R

I think the idea of an extra bracelet is absolutely AWESOME! And is something very cheap and easy to do! Plus it stays on the baby even if he ends up in a nersery or somewhere else in the hospital.

Or naked (away from his charts) and strapped down to a circumstraint. I had to say it.

Yes, the bracelet is a good idea. Babies already have ID bracelets that stay on at all times, so it could be a coloured band in addition to that. In one hospital I visited recently, I noticed that some patients had orange bracelets in addition to their ID bracelets. I asked what the orange bracelets meant, and the nurse said, "Allergies." I'm not sure how that helped because it certainly wasn't specific as to which allergies people had, but I guess it was enough to ensure that the doctor or nurse double checked with the patient or chart before administering medication. A newborn baby with a red or a blue bracelet indicating "no circ" could similarly cause the doctors to stop and double check that they were following the right instructions.