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Completion of an Enhanced Recovery Program for Ambulatory Pediatric Urology in a Pediatric Surgery Center: A Quality Improvement Initiative
Paul A. Merguerian, MD, MS, Lynn Martin, MD, MBA, Daniel Low, MD, Nicolas Fernandez, MD PhD, Mark Cain, MD.
Seattle Children's Hospital, Seattle, WA, USA.

Background: Enhanced Recovery After Surgery (ERAS) established in 2001 initially focused on in patients undergoing complex procedures. Beneficial impacts of ERAS practices in adult ambulatory surgery have been reported. The evidence for ERAS in children is limited. In 2018, a multi-disciplinary expert panel developed a pediatric-specific enhanced recovery protocol that included 19 preoperative, intraoperative, and postoperative elements. There are currently no published reports implementing ERAS in pediatric ambulatory surgery. We hereby report a Quality Improvement initiative implementing an Enhanced Recovery Program (ERP) for pediatric urology in our ambulatory surgery center. Methods: A team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). These elements included reliance on peripheral nerve blocks for all inguinal and genital cases, eliminating opioids intraoperatively, reducing outpatient opioid prescribing, and preventing hypothermia. Improvements were placed into a project plan broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures were mean PACU length of stay, percent intraoperative opioid use, percent opioid prescribing and number of doses. Secondary outcome measures were mean maximum pain score in PACU and patient/family satisfaction scores. Statistical process control methodology was used. Results: Total number of patients enrolled were 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3). The team had expanded the pool of active ERP elements from 11 to 16/19. Results are depicted graphically below. Intraoperative opioid use has been eliminated in 98% of cases. Surgical post op opioid prescribing was reduced to 12% of patients. Number of doses was also reduced to 6 doses. There was no change in mean maximum pain score in PACU. Post operative nausea and vomiting was eliminated. Hypothermia was reduced to 1%. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% 5.7%). Patient/family and provider engagement/compliance were high. Balancing measures such as return to the operating room within 30 days, return to the emergency department within 7 days was unchanged. Conclusions: This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting and its benefits in reducing PACU stay, reducing post operative nausea and vomiting, eliminating intraoperative opioid use, reducing opioid prescribing without affecting pain scores and post operative complications. Additional studies are needed to determine the relevance of this project to other institutions.



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