Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative
Inside Out Medicine implemented a patient flow model that incorporates an enhanced recovery program (ERP). This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Using the patient flow model and platform for delivering education, preoperative and postoperative surveys.
The team had expanded the pool of active ERAS elements from 11 to 16 (out of a possible 19 elements). The mean PACU length of stay (LOS) demonstrated significant reduction. No change was seen for the mean maximum pain score in PACU or surgical complication rates. 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.
Anesthesia & Analgesia. 2022 Dec 1;135(6):1271-1281.
doi: 10.1213/ANE.0000000000006256.
Lynn D Martin 1, Jennifer L Chiem 2, Elizabeth E Hansen 2, Daniel K Low 2, Kayla Reece 3, Corrie Casey 3, Christina S Wingate 2, Leah K Bezzo 2, Paul A Merguerian 4, Sanjay R Parikh 5, Srinivas M Susarla 5, Vikas N O'Reilly-Shah 2
-
From the Departments of Anesthesiology & Pain Medicine and Pediatrics.
Anesthesiology & Pain Medicine, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington.
Department of Perioperative Services, Seattle Children's Hospital, Seattle, Washington; and Departments of.
Otolaryngology.
Plastic Surgery, Seattle Children's Hospital/University of Washington School of Medicine, Seattle, Washington.
ABSTRACT
-
Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described.
-
A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. 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 countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores.
-
Phase 1
Four existing ERP elements (preoperative: (1) patient family education and (2) patient selection/optimization; postoperative: (3) opioid utilization and (4) oral feeding resumption) were selected for enhancement. Current patient education included written materials (commonly limited to English) given in the preoperative clinic visit, which were re-enforced in a preoperative phone call 3 days before surgery and in the postanesthesia care unit (PACU) as part of the discharge instructions. Utilizing a commercially available software tool (Inside Out Care [IOC], Seattle, WA), parents enrolled to receive on-line access to educational materials for the surgical procedure and day-of-surgery expectation 14 days before scheduled surgery. This on-line information, translatable into more than 50 separate languages, gave parents on-demand access to important perioperative information. Physicians also used parental responses to a preoperative IOC survey to augment information from the electronic medical record (EMR) to screen patient acuity and make necessary referrals (ie, child life service consultation) to optimize preparations. Both postoperative measures had trackable data, so the team also elected to use IOC and ask parents to complete daily postoperative logs of (1) pain assessment/opioid use and (2) resumption of feeding.
Three new ERP elements (2 preoperative and 1 postoperative) were slated for implementation. First, to reduce preoperative fasting, parents were instructed to give a clear carbohydrate liquid to the patients 3 hours before scheduled surgery start. Second, to assure effective preemptive analgesia, parents were instructed to give their normal age-based dose of oral acetaminophen with the clear liquids noted above. Patients not receiving home acetaminophen would be offered it on arrival in the ASC. Finally, while intraoperative nausea/vomiting prophylaxis was standardized, the care team had no existing standard for rescue postoperative nausea/vomiting (PONV) treatment in the PACU. The team standardized the PONV rescue treatment (diphenhydramine 0.5–1 mg/kg, max dose 12.5 mg).
Phase 2
Regional anesthesia, including the use of peripheral nerve catheters (PNC), has been an integral component of our multimodal analgesia efforts to minimize opioid use. Baseline practice included video and verbal instructions on the day of surgery followed by daily physician phone calls (hospital regional anesthesia attending) for the duration of use of the PNC plus 1 day. The team recommended enhancing this element using IOC. Parents could access PNC information on demand (pre and postoperatively) and input daily log information (pain scores, opioid use, etc).
Two new ERP elements were slated for launch. (1) Hypothermia prevention (defined as temperature <36°C) was discussed by the team. As many cases are of short surgical duration, no intraoperative temperature measurement was common. Consensus was reached to follow standard temperature maintenance practices and assess the first temperature measure in the PACU. (2) While intravenous fluid had been standardized (lactated ringers), the volume administrated had not. A euvolemia consensus agreement was reached to give only maintenance fluids intraoperatively since prolonged fasting should be reduced in phase 1; however, clinicians were allowed to administer fluid boluses when assessment suggested hypovolemia.
Phase 3
Three ERP enhancements were scheduled. (1) In a phase 1 PDSA cycle, it was recommended that preoperative screening could be transitioned to our Preanesthesia Surgical Service (PASS), the preoperative clinic for hospital surgeries. (2) To help address preoperative and postoperative anxiety and pain, a mindfulness module was added to IOC. (3) Prophylactic antibiotics in baseline state are called out in the surgical timeout and administered and recorded by an anesthesia provider before surgical incision. Enhancement of these processes included (a) surgical call out in the morning huddle highlighting which cases would require antibiotics and (b) a preoperative order written in the EMR by the surgeon and completed and recorded by the anesthesia provider.
One new preoperative ERP element was defined for implementation. Specifically, preprocedure strengthening through physical therapy referral was deemed appropriate for a subpopulation (sports medicine cases).
-
The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. 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.
-
This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.
“Using Inside Out Care [IOC], parents enrolled to receive on-line access to educational materials for the surgical procedure and day-of-surgery expectation 14 days before scheduled surgery. This on-line information, translatable into more than 50 separate languages, gave parents on-demand access to important perioperative information.
Physicians also used parental responses to a preoperative IOC survey to augment information from the electronic medical record (EMR) to screen patient acuity and make necessary referrals (ie, child life service consultation) to optimize preparations. Both postoperative measures had trackable data, so the team also elected to use IOC and ask parents to complete daily postoperative logs of (1) pain assessment/opioid use and (2) resumption of feeding.”