Original Research—Pediatric Otolaryngology
Developing a Nurse-Delivered Frenulotomy Service Katie Rose, MBChB, MPhil1, Anand V. Kasbekar, BMBS, DOHNS, FRCS1, Alison Flynn, MSc1, and Sujata De, MBBS, FRCS1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objectives. Tongue tie (ankyloglossia) describes a short lingual frenulum that can lead to breastfeeding difficulties. It affects between 4% and 10% of infants and can be treated by frenulotomy. We developed a nurse-delivered frenulotomy service at a tertiary pediatric hospital and audited our results. Study Design. Observational study. Setting. Tertiary pediatric hospital. Subjects and Methods. An outpatient tongue tie clinic was set up by an ear, nose, and throat consultant. Tongue tie division was undertaken using a standard technique without the need for anesthesia or analgesia, as per National Institute for Health and Care Excellence guidelines. Subsequently, a senior nurse was trained to undertake the clinic independently and saw most referrals. Patient satisfaction data were collected via questionnaires. Results. Referrals to the service increased from 57 (2009) to 296 (2012). Outcome data from outpatient frenulotomy are discussed. Parent satisfaction measures were similar for both nurse- and doctor-delivered treatment. If all frenulotomies were undertaken in nurse-delivered clinics, a total of £3830 could have been saved in 2012, compared with the cost of doctor-delivered care. Conclusion. A nurse-delivered outpatient frenulotomy service is a safe and cost-effective method of delivering such care. We have demonstrated reduced costs and reduced waiting times without compromising patient satisfaction or the quality of care provided.
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(1) 149–152 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814554554 http://otojournal.org
of the tongue and particularly the inability to protrude the tongue. Studies have shown tongue tie to affect between 4% and 10% of infants.1,2 The condition can lead to difficulties with breastfeeding, particularly difficulties with latching onto the breast and developing a successful sucking mechanism. This in turn can lead to poor calorie intake with failure to gain weight and problems for the mother including pain and increased risks of mastitis due to poor drainage of milk from the breast. In many cases breastfeeding becomes difficult and a switch to bottle feeding may occur, which in turn may have considerable effects on the mother-baby dyad.3 There is growing evidence of the need for treatment of tongue tie and the efficacy of existing treatments.3-5 Recent literature has demonstrated that infants with tongue tie are at increased risk of breastfeeding difficulties; one particular study found difficulties in 25% of infants with tongue tie, compared with 3% in a control group.1 It has been recommended that these infants be given early referral to an experienced clinician for further assessment.3 A recent double-blind, randomized controlled trial found a significant improvement in breastfeeding following frenulotomy (immediate division) compared with placebo (nondivision) (P \ .02).5 A further randomized controlled trial found that of those infants with tongue tie and breastfeeding difficulties, 95% improved following frenulotomy compared with a control group.6 When an association between tongue tie and breastfeeding difficulties has been made, there is strong evidence that frenulotomy results in rapid improvement in those symptoms within a few days.3 In view of the current economic climate, as well as demands upon doctors’ time and a drive to improve access to services, there has been a rapid expansion of the role of nurses, and particularly the development of nurse practitioners and nurse consultants.7 A recent systematic review concluded that the use of nurse practitioners as a first point
Keywords ankyloglossia, tongue tie, frenulotomy 1
Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
Received April 25, 2014; revised September 3, 2014; accepted September 17, 2014.
This article was presented as an oral presentation at the British Association of Paediatric Otorhinolaryngology (BAPO) Conference; September 20, 2013; Greenwich, London, UK.
A
Corresponding Author: Katie Rose, MBChB, MPhil, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK. Email: [email protected]
nkyloglossia (tongue tie) is a congenital condition in which the lingual frenulum is abnormally short, tight, or near the tongue tip, resulting in reduced mobility
Downloaded from oto.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 18, 2015
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Otolaryngology–Head and Neck Surgery 152(1)
Table 1. Summary of Patient Demographics for Consultant- and Nurse-Led Clinics.a
Total number in group Sex (male/female) Median age at procedure, days (range)
Consultant-Led Clinic
Nurse-Led Clinic
P Value
54 28/26 21(7-115)
51 29/22 18 (7-145)
.606 .663
a There were no significant differences in the distribution of sex or age in the consultant- and nurse-led clinics, when compared using Mann-Whitney U and chi-square tests, respectively.
of contact in primary care led to high levels of patient satisfaction and high-quality care.7 Uppal and colleagues8 demonstrated that providing basic otological procedures by a specialist nurse reduced cost by £75.28 per patient seen, compared with the cost of a conventional outpatient clinic appointment. We describe how we developed a nurse-delivered frenulotomy service at a tertiary pediatric hospital and audited our results and patient satisfaction. This is the first study in the United Kingdom to look at the cost of a frenulotomy service in neonates and infants by comparing treatment by an ear, nose, and throat (ENT) consultant verses a specialist ENT nurse. We also provide satisfaction data to investigate whether parents’ views differ when being treated by a nurse versus a doctor.
Methods This study was given approval by the Audit Department at Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom. An outpatient ‘‘tongue tie clinic’’ was set up at a tertiary children’s hospital (Alder Hey Children’s NHS Foundation Trust, Liverpool, UK) run by an ENT consultant (S.D.). Referrals were received from midwives, general practitioners, and patients themselves. Patients were seen in clinic if there was concern regarding tongue tie at age less than 6 months, regardless of whether it was related to problems with breastfeeding. If aged over 6 months, children would be seen in the general ENT clinic. At the clinic, a discussion took place between parent and clinician regarding whether frenulotomy was likely to relieve problems. If deemed appropriate, frenulotomy was performed without local anesthesia according to the guidelines of the National Institute for Health and Care Excellence.4 Ten months after the service was set up, a senior (Band 8) ENT nurse consultant (A.F.) was formally trained to undertake the clinic and observed 10 frenulotomies being performed by the ENT consultant (S.D.). The nurse consultant (A.F.) was then observed undertaking 15 consultations and frenulotomies prior to undertaking the clinic independently. Patient satisfaction questionnaires were designed based on the validated Commission for Health Improvement questionnaire.9 Questions elicited information on specific breastfeeding difficulty, outcome of procedure related to breastfeeding, referral source, speed of appointment, explanation of diagnosis, necessity of treatment (as deemed by
the parent), timing of treatment, appearance of department, and overall experience. The questionnaire also asked whether the parent would recommend the service to other parents and solicited general comments as well as thoughts on good aspects and areas for improvement. Responses were either free text or were based on a visual analog score of 0 to 10. Questionnaires were given to parents or guardians following the procedure and were anonymous. Questionnaires were given to consecutive cases over a period of 1 year once the nurse-led clinic was established. The number of cases seen over the 3-year period and costing data were obtained from the hospital information team.
Results In November 2009, S.D. started the ‘‘tongue tie service’’ independently and saw 57 patients in the first 12 months. In the following 10 months, starting November 2010, A.F. was formally trained in clinic and was observed performing procedures as described above. In September 2011, A.F. undertook all clinics independently. Satisfaction questionnaires were given to consecutive patients who had the procedure over a 1-year period once the nurse-led clinic had been established. A total of 162 questionnaires were given out and 105 were completed, 54 from the consultant-delivered group and 51 from the nursedelivered group. Demographic data are summarized in Table 1. Age of patients ranged from 7 days to 5 months, although 77% were younger than 1 month. Demographic details (age and sex of patients) were similar in those who did and those who did not complete the satisfaction survey. At the time of tongue tie division, 70% (38/54) of infants in the consultant-delivered group were breastfeeding compared with 51% (26/51) in the nurse-delivered group (Table 2). In some cases, difficulties in breastfeeding had led to a switch to bottle feeding prior to the appointment. As the outpatient frenulotomy service developed, babies were seen if they had a tongue tie diagnosed by a health professional or if there was parental concern. This occurred regardless of breastfeeding difficulties. This would account for the lower numbers of patients breastfeeding at the time of clinic appointment in the nursedelivered group. In patients without breastfeeding difficulties, frenulotomy was still completed according to parental wishes, often due to parental anxiety regarding the possibility of future difficulties (such as difficulties with speech). There is some evidence that tongue tie release in infancy may lead to fewer
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Table 2. Summary of Outcome Data for Consultant- and Nurse-Led Clinics. Consultant-Led Clinic Breastfeeding at time of clinic appointment, n (%) Breastfeeding difficulties at time of clinic appointment, n (% of those breastfeeding) Outcome immediately following procedure, n (%) Improvement in breastfeeding No improvement in breastfeeding Too early to tell Median satisfaction scores: 0 = very poor; 10 = excellent (range) Speed of appointment Explanation of procedure Timing of treatment Necessity of treatment Appearance of ear, nose, and throat department Overall experience
speech articulation problems compared with children with untreated tongue tie.10 Of the infants breastfeeding at the time of clinic appointment, 89% (34/38) and 88% (23/26) in the consultant- and nurse-delivered groups were having difficulties breastfeeding, respectively (Table 2). The most common problem encountered was difficulty with latching onto the breast. Other commonly encountered problems included problems with sore nipples, sucking, and the infant being slow to feed. A total of 62% (21/34) of the consultant-delivered group and 70% (16/23) of the nurse-delivered group reported that the procedure led to immediate improvement in problems with feeding. In 2 cases in the consultantdelivered group and 1 case in the nurse-delivered group, the procedure did not lead to improvement as the infant had already been converted to bottle feeding and it was difficult to return to breastfeeding. This was primarily related to the time taken to be seen in the tongue tie clinic. In the remaining patients, any improvement was too early to tell (Table 2). Scoring on criteria such as timing of treatment, explanation of procedure, appearance of ENT department, and overall experience was similar in the consultant- and nursedelivered groups (Table 2). All variables were scored between 0 (very poor) and 10 (excellent). Each clinic appointment is scheduled for 20 minutes. Costing data obtained from the hospital information team indicate that 20 minutes of consultant time in 2010 cost £22.40, compared with £9.46 for senior (Band 8A) nurse time. Other costs of the service include managerial running of the clinic, secretarial and receptionist time, retrieval of medical records, portering services, and risk management. Costs of a health care assistant who was able to assist the consultant or senior nurse during the procedure were also included. Total cost of frenulotomy as part of an outpatient service was calculated to be £73.42 when completed by a
Nurse-Led Clinic
38 (70) 34 (89)
26 (51) 23 (88)
21 (62) 2 (6) 11 (32)
16 (70) 1 (4) 6 (26)
10 (0-10) 10 (5-10) 10 (0-10) 10 (3-10) 8 (3-10) 10 (5-10)
10 10 10 10 9 10
(2-10) (5-10) (2-10) (2-10) (4-10) (5-10)
consultant and £60.48 when completed by a senior nurse. Other than the cost of the consulting time, all other costs remained equal regardless of whether the clinic was run by the consultant or nurse.
Discussion The NHS has suffered due to the global economic downturn, and cost-saving measures are always welcomed by NHS trusts. The development of our nurse-delivered, outpatient service for infants with tongue tie has demonstrated cost savings compared with service delivered by a consultant doctor. Patient satisfaction was found to be similar between consultant- versus nurse-delivered clinics, which is important in how NHS trusts are judged and rewarded financially. Recent literature has found strong evidence that frenulotomy often results in rapid improvement of symptoms in infants with tongue tie and breastfeeding difficulties and recommends prompt referral for treatment in this group of patients.3 A recent systematic review found that frenulotomy appeared to provide some long-term benefits, with more than 50% of mothers still breastfeeding 3 months after the procedure.11 One limitation of our study is the timing with which the questionnaires were given out. A total of 62% of those in the consultant-delivered group and 70% in the nursedelivered group reported that the procedure led to improvement in problems with breastfeeding. This was reported immediately after the clinic appointment when the mother was allowed to breastfeed the baby after frenulotomy. The true percentage of those who see improvement is likely to be higher as improvement is seen up to 48 hours and occasionally longer after frenulotomy.3 Patient satisfaction was high among parents. More than 99% (104/105) of parents reported that they would recommend the service to others in a similar situation. The only negative comments received in both the doctor- and nurse-
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Otolaryngology–Head and Neck Surgery 152(1)
delivered groups involved cases in which bottle feeding had already been started due to difficulties with breastfeeding. In 3 particular cases, the mother had found it impossible to resume breastfeeding due to the duration of bottle feeding prior to the clinic appointment. Suggestions and comments made centered on the need for greater awareness of the clinics, particularly in neonatal units and general practices where the problem is first encountered. A systematic review of studies comparing care from nurse practitioners versus general practitioners in a primary care setting found patient satisfaction to be increased when care was provided by nurse practitioners, with similar health outcomes.7 Our study has found similar patient satisfaction measures in care provided by a consultant compared with a senior nurse in the case of infants with tongue tie. We believe a nursedelivered service leads to reduced costs and reduced waiting times without compromising the quality of care provided. At present we do not have a formal guideline regarding the development of nurse-led procedures such as frenulotomy, and the development and assessment of such a service as described in this study were competency based. Amir et al12 described the development of a formal training and credentialing program aimed at midwives and lactation consultants to enable them to independently undertake frenulotomy in Australia. A similar program in the United Kingdom or elsewhere could facilitate the wider implementation of a nurse-led service. Costing data revealed a £12.94 saving per appointment in the nurse-delivered service compared with the consultantdelivered service. Numbers referred to the service have increased each year since the service was implemented 3 years ago, as awareness has increased. The latest data demonstrate that 296 outpatient frenulotomy divisions were undertaken between October 2011 and September 2012 between S.D. and A.F. Based on these data, if all tongue ties were undertaken in nurse-delivered clinics, over 1 year a total of £3830.24 could be saved. The financial benefits would be expected to increase as use of the service increases, secondary to wider knowledge of the availability of the service by midwives, general practitioners, and parents themselves. A further financial factor pertains to frenulotomies performed under general anesthetic in the operating theater, typically in older children for indications such as problems with speech development or cosmetic reasons. Costs incurred in these cases are in the region of 10 times greater than the cost of a clinic appointment. We have described the development of a senior nurse– delivered, outpatient frenulotomy service that demonstrated reduced costs and reduced waiting times, without any compromise in patient satisfaction or the quality of care provided, compared with traditional consultant-delivered care.
Author Contributions Katie Rose, initial design of the study, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Anand V. Kasbekar, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Alison Flynn, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Sujata De, initial design of the study, data acquisition and analysis, preparation and presentation of data, preparation of manuscript.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
References 1. Messner AH, Lalakea L, Aby J, Macmahon J, Bair E. Ankyloglossia incidence and associated feeding difficulties. Arch Otolaryngol Head Neck Surg. 2000;126:36-39. 2. Ricke LA, Baker NJ, Madlon-Kay DJ, DeFor TA. Newborn tongue-tie: prevalence and effect on breast-feeding. J Am Board Fam Pract. 2005;18:1-7. 3. Kumar M, Kalke E. Tongue-tie, breastfeeding difficulties and the role of frenotomy. Acta Paediatr. 2012;101:687-689. 4. Division of Ankyloglossia (Tongue-Tie) for Breastfeeding. London, UK: National Institute for Health and Clinical Excellence; 2005. 5. Berry J, Griffiths M, Westcott C. A double-blind, randomized, controlled trial of tongue-tie division and its immediate effect on breastfeeding. Breastfeed Med. 2012;7:189-193. 6. Hogan M, Westcott C, Griffiths M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health. 2005;41:246-250. 7. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819-823. 8. Uppal S, Jose J, Banks P, Mackay E, Coatesworth AP. Costeffective analysis of conventional and nurse-led clinics for common otological procedures. J Laryngol Otol. 2004;118:189-192. 9. Survey Indicator Methodology Outpatients Survey 2003 & Emergency Survey 2003. Commission for Health Improvement (CHI). http://www.nhssurveys.org/Filestore/documents/Outpatients_ dev_report_v2.pdf. 10. Dollberg S, Manor Y, Makai E, Botzer E. Evaluation of speech intelligibility in children with tongue tie. Acta Paediatr. 2011;100:125-127. 11. Finegan V, Long T. The effectiveness of frenulotomy on infant-feeding outcomes: a systematic literature review. Evidence Based Midwifery. 2013;11:40-45. 12. Amir LH, James JP, Kelso G, Moorhead AM. Accreditation of midwife lactation consultants to perform infant tongue-tie release. Int J Nurs Prac. 2011;17:541-547.
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Developing a Nurse-Delivered Frenulotomy Service Katie Rose, MBChB, MPhil1, Anand V. Kasbekar, BMBS, DOHNS, FRCS1, Alison Flynn, MSc1, and Sujata De, MBBS, FRCS1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objectives. Tongue tie (ankyloglossia) describes a short lingual frenulum that can lead to breastfeeding difficulties. It affects between 4% and 10% of infants and can be treated by frenulotomy. We developed a nurse-delivered frenulotomy service at a tertiary pediatric hospital and audited our results. Study Design. Observational study. Setting. Tertiary pediatric hospital. Subjects and Methods. An outpatient tongue tie clinic was set up by an ear, nose, and throat consultant. Tongue tie division was undertaken using a standard technique without the need for anesthesia or analgesia, as per National Institute for Health and Care Excellence guidelines. Subsequently, a senior nurse was trained to undertake the clinic independently and saw most referrals. Patient satisfaction data were collected via questionnaires. Results. Referrals to the service increased from 57 (2009) to 296 (2012). Outcome data from outpatient frenulotomy are discussed. Parent satisfaction measures were similar for both nurse- and doctor-delivered treatment. If all frenulotomies were undertaken in nurse-delivered clinics, a total of £3830 could have been saved in 2012, compared with the cost of doctor-delivered care. Conclusion. A nurse-delivered outpatient frenulotomy service is a safe and cost-effective method of delivering such care. We have demonstrated reduced costs and reduced waiting times without compromising patient satisfaction or the quality of care provided.
Otolaryngology– Head and Neck Surgery 2015, Vol. 152(1) 149–152 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814554554 http://otojournal.org
of the tongue and particularly the inability to protrude the tongue. Studies have shown tongue tie to affect between 4% and 10% of infants.1,2 The condition can lead to difficulties with breastfeeding, particularly difficulties with latching onto the breast and developing a successful sucking mechanism. This in turn can lead to poor calorie intake with failure to gain weight and problems for the mother including pain and increased risks of mastitis due to poor drainage of milk from the breast. In many cases breastfeeding becomes difficult and a switch to bottle feeding may occur, which in turn may have considerable effects on the mother-baby dyad.3 There is growing evidence of the need for treatment of tongue tie and the efficacy of existing treatments.3-5 Recent literature has demonstrated that infants with tongue tie are at increased risk of breastfeeding difficulties; one particular study found difficulties in 25% of infants with tongue tie, compared with 3% in a control group.1 It has been recommended that these infants be given early referral to an experienced clinician for further assessment.3 A recent double-blind, randomized controlled trial found a significant improvement in breastfeeding following frenulotomy (immediate division) compared with placebo (nondivision) (P \ .02).5 A further randomized controlled trial found that of those infants with tongue tie and breastfeeding difficulties, 95% improved following frenulotomy compared with a control group.6 When an association between tongue tie and breastfeeding difficulties has been made, there is strong evidence that frenulotomy results in rapid improvement in those symptoms within a few days.3 In view of the current economic climate, as well as demands upon doctors’ time and a drive to improve access to services, there has been a rapid expansion of the role of nurses, and particularly the development of nurse practitioners and nurse consultants.7 A recent systematic review concluded that the use of nurse practitioners as a first point
Keywords ankyloglossia, tongue tie, frenulotomy 1
Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
Received April 25, 2014; revised September 3, 2014; accepted September 17, 2014.
This article was presented as an oral presentation at the British Association of Paediatric Otorhinolaryngology (BAPO) Conference; September 20, 2013; Greenwich, London, UK.
A
Corresponding Author: Katie Rose, MBChB, MPhil, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP, UK. Email: [email protected]
nkyloglossia (tongue tie) is a congenital condition in which the lingual frenulum is abnormally short, tight, or near the tongue tip, resulting in reduced mobility
Downloaded from oto.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 18, 2015
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Otolaryngology–Head and Neck Surgery 152(1)
Table 1. Summary of Patient Demographics for Consultant- and Nurse-Led Clinics.a
Total number in group Sex (male/female) Median age at procedure, days (range)
Consultant-Led Clinic
Nurse-Led Clinic
P Value
54 28/26 21(7-115)
51 29/22 18 (7-145)
.606 .663
a There were no significant differences in the distribution of sex or age in the consultant- and nurse-led clinics, when compared using Mann-Whitney U and chi-square tests, respectively.
of contact in primary care led to high levels of patient satisfaction and high-quality care.7 Uppal and colleagues8 demonstrated that providing basic otological procedures by a specialist nurse reduced cost by £75.28 per patient seen, compared with the cost of a conventional outpatient clinic appointment. We describe how we developed a nurse-delivered frenulotomy service at a tertiary pediatric hospital and audited our results and patient satisfaction. This is the first study in the United Kingdom to look at the cost of a frenulotomy service in neonates and infants by comparing treatment by an ear, nose, and throat (ENT) consultant verses a specialist ENT nurse. We also provide satisfaction data to investigate whether parents’ views differ when being treated by a nurse versus a doctor.
Methods This study was given approval by the Audit Department at Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom. An outpatient ‘‘tongue tie clinic’’ was set up at a tertiary children’s hospital (Alder Hey Children’s NHS Foundation Trust, Liverpool, UK) run by an ENT consultant (S.D.). Referrals were received from midwives, general practitioners, and patients themselves. Patients were seen in clinic if there was concern regarding tongue tie at age less than 6 months, regardless of whether it was related to problems with breastfeeding. If aged over 6 months, children would be seen in the general ENT clinic. At the clinic, a discussion took place between parent and clinician regarding whether frenulotomy was likely to relieve problems. If deemed appropriate, frenulotomy was performed without local anesthesia according to the guidelines of the National Institute for Health and Care Excellence.4 Ten months after the service was set up, a senior (Band 8) ENT nurse consultant (A.F.) was formally trained to undertake the clinic and observed 10 frenulotomies being performed by the ENT consultant (S.D.). The nurse consultant (A.F.) was then observed undertaking 15 consultations and frenulotomies prior to undertaking the clinic independently. Patient satisfaction questionnaires were designed based on the validated Commission for Health Improvement questionnaire.9 Questions elicited information on specific breastfeeding difficulty, outcome of procedure related to breastfeeding, referral source, speed of appointment, explanation of diagnosis, necessity of treatment (as deemed by
the parent), timing of treatment, appearance of department, and overall experience. The questionnaire also asked whether the parent would recommend the service to other parents and solicited general comments as well as thoughts on good aspects and areas for improvement. Responses were either free text or were based on a visual analog score of 0 to 10. Questionnaires were given to parents or guardians following the procedure and were anonymous. Questionnaires were given to consecutive cases over a period of 1 year once the nurse-led clinic was established. The number of cases seen over the 3-year period and costing data were obtained from the hospital information team.
Results In November 2009, S.D. started the ‘‘tongue tie service’’ independently and saw 57 patients in the first 12 months. In the following 10 months, starting November 2010, A.F. was formally trained in clinic and was observed performing procedures as described above. In September 2011, A.F. undertook all clinics independently. Satisfaction questionnaires were given to consecutive patients who had the procedure over a 1-year period once the nurse-led clinic had been established. A total of 162 questionnaires were given out and 105 were completed, 54 from the consultant-delivered group and 51 from the nursedelivered group. Demographic data are summarized in Table 1. Age of patients ranged from 7 days to 5 months, although 77% were younger than 1 month. Demographic details (age and sex of patients) were similar in those who did and those who did not complete the satisfaction survey. At the time of tongue tie division, 70% (38/54) of infants in the consultant-delivered group were breastfeeding compared with 51% (26/51) in the nurse-delivered group (Table 2). In some cases, difficulties in breastfeeding had led to a switch to bottle feeding prior to the appointment. As the outpatient frenulotomy service developed, babies were seen if they had a tongue tie diagnosed by a health professional or if there was parental concern. This occurred regardless of breastfeeding difficulties. This would account for the lower numbers of patients breastfeeding at the time of clinic appointment in the nursedelivered group. In patients without breastfeeding difficulties, frenulotomy was still completed according to parental wishes, often due to parental anxiety regarding the possibility of future difficulties (such as difficulties with speech). There is some evidence that tongue tie release in infancy may lead to fewer
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Table 2. Summary of Outcome Data for Consultant- and Nurse-Led Clinics. Consultant-Led Clinic Breastfeeding at time of clinic appointment, n (%) Breastfeeding difficulties at time of clinic appointment, n (% of those breastfeeding) Outcome immediately following procedure, n (%) Improvement in breastfeeding No improvement in breastfeeding Too early to tell Median satisfaction scores: 0 = very poor; 10 = excellent (range) Speed of appointment Explanation of procedure Timing of treatment Necessity of treatment Appearance of ear, nose, and throat department Overall experience
speech articulation problems compared with children with untreated tongue tie.10 Of the infants breastfeeding at the time of clinic appointment, 89% (34/38) and 88% (23/26) in the consultant- and nurse-delivered groups were having difficulties breastfeeding, respectively (Table 2). The most common problem encountered was difficulty with latching onto the breast. Other commonly encountered problems included problems with sore nipples, sucking, and the infant being slow to feed. A total of 62% (21/34) of the consultant-delivered group and 70% (16/23) of the nurse-delivered group reported that the procedure led to immediate improvement in problems with feeding. In 2 cases in the consultantdelivered group and 1 case in the nurse-delivered group, the procedure did not lead to improvement as the infant had already been converted to bottle feeding and it was difficult to return to breastfeeding. This was primarily related to the time taken to be seen in the tongue tie clinic. In the remaining patients, any improvement was too early to tell (Table 2). Scoring on criteria such as timing of treatment, explanation of procedure, appearance of ENT department, and overall experience was similar in the consultant- and nursedelivered groups (Table 2). All variables were scored between 0 (very poor) and 10 (excellent). Each clinic appointment is scheduled for 20 minutes. Costing data obtained from the hospital information team indicate that 20 minutes of consultant time in 2010 cost £22.40, compared with £9.46 for senior (Band 8A) nurse time. Other costs of the service include managerial running of the clinic, secretarial and receptionist time, retrieval of medical records, portering services, and risk management. Costs of a health care assistant who was able to assist the consultant or senior nurse during the procedure were also included. Total cost of frenulotomy as part of an outpatient service was calculated to be £73.42 when completed by a
Nurse-Led Clinic
38 (70) 34 (89)
26 (51) 23 (88)
21 (62) 2 (6) 11 (32)
16 (70) 1 (4) 6 (26)
10 (0-10) 10 (5-10) 10 (0-10) 10 (3-10) 8 (3-10) 10 (5-10)
10 10 10 10 9 10
(2-10) (5-10) (2-10) (2-10) (4-10) (5-10)
consultant and £60.48 when completed by a senior nurse. Other than the cost of the consulting time, all other costs remained equal regardless of whether the clinic was run by the consultant or nurse.
Discussion The NHS has suffered due to the global economic downturn, and cost-saving measures are always welcomed by NHS trusts. The development of our nurse-delivered, outpatient service for infants with tongue tie has demonstrated cost savings compared with service delivered by a consultant doctor. Patient satisfaction was found to be similar between consultant- versus nurse-delivered clinics, which is important in how NHS trusts are judged and rewarded financially. Recent literature has found strong evidence that frenulotomy often results in rapid improvement of symptoms in infants with tongue tie and breastfeeding difficulties and recommends prompt referral for treatment in this group of patients.3 A recent systematic review found that frenulotomy appeared to provide some long-term benefits, with more than 50% of mothers still breastfeeding 3 months after the procedure.11 One limitation of our study is the timing with which the questionnaires were given out. A total of 62% of those in the consultant-delivered group and 70% in the nursedelivered group reported that the procedure led to improvement in problems with breastfeeding. This was reported immediately after the clinic appointment when the mother was allowed to breastfeed the baby after frenulotomy. The true percentage of those who see improvement is likely to be higher as improvement is seen up to 48 hours and occasionally longer after frenulotomy.3 Patient satisfaction was high among parents. More than 99% (104/105) of parents reported that they would recommend the service to others in a similar situation. The only negative comments received in both the doctor- and nurse-
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delivered groups involved cases in which bottle feeding had already been started due to difficulties with breastfeeding. In 3 particular cases, the mother had found it impossible to resume breastfeeding due to the duration of bottle feeding prior to the clinic appointment. Suggestions and comments made centered on the need for greater awareness of the clinics, particularly in neonatal units and general practices where the problem is first encountered. A systematic review of studies comparing care from nurse practitioners versus general practitioners in a primary care setting found patient satisfaction to be increased when care was provided by nurse practitioners, with similar health outcomes.7 Our study has found similar patient satisfaction measures in care provided by a consultant compared with a senior nurse in the case of infants with tongue tie. We believe a nursedelivered service leads to reduced costs and reduced waiting times without compromising the quality of care provided. At present we do not have a formal guideline regarding the development of nurse-led procedures such as frenulotomy, and the development and assessment of such a service as described in this study were competency based. Amir et al12 described the development of a formal training and credentialing program aimed at midwives and lactation consultants to enable them to independently undertake frenulotomy in Australia. A similar program in the United Kingdom or elsewhere could facilitate the wider implementation of a nurse-led service. Costing data revealed a £12.94 saving per appointment in the nurse-delivered service compared with the consultantdelivered service. Numbers referred to the service have increased each year since the service was implemented 3 years ago, as awareness has increased. The latest data demonstrate that 296 outpatient frenulotomy divisions were undertaken between October 2011 and September 2012 between S.D. and A.F. Based on these data, if all tongue ties were undertaken in nurse-delivered clinics, over 1 year a total of £3830.24 could be saved. The financial benefits would be expected to increase as use of the service increases, secondary to wider knowledge of the availability of the service by midwives, general practitioners, and parents themselves. A further financial factor pertains to frenulotomies performed under general anesthetic in the operating theater, typically in older children for indications such as problems with speech development or cosmetic reasons. Costs incurred in these cases are in the region of 10 times greater than the cost of a clinic appointment. We have described the development of a senior nurse– delivered, outpatient frenulotomy service that demonstrated reduced costs and reduced waiting times, without any compromise in patient satisfaction or the quality of care provided, compared with traditional consultant-delivered care.
Author Contributions Katie Rose, initial design of the study, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Anand V. Kasbekar, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Alison Flynn, data acquisition and analysis, preparation and presentation of data, preparation of manuscript; Sujata De, initial design of the study, data acquisition and analysis, preparation and presentation of data, preparation of manuscript.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
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