Author: Michael Vlessides
Enhanced recovery pathways can be successfully implemented for complex hip and pectus excavatum surgeries in children, according to a team of researchers. Among the benefits observed after such a pathway was instituted at Vanderbilt University Medical Center (VUMC) were reduced postoperative pain and nausea and vomiting (PONV), earlier mobility, decreased hospital length of stay, and lower cost.
“Our adult hospital has been very active with adult enhanced recovery protocols and the perioperative surgical home,” said Andrew Franklin, MD, MBA, the director of pediatric pain management at VUMC, in Nashville, Tenn. “Many of the same concepts apply, and a lot of the same practices that we employ in adult enhanced recovery protocols can be easily translated to pediatric protocols.”
Dr. Franklin and his colleagues hypothesized that the implementation of enhanced recovery protocols for pediatric surgery would improve both the quality of recovery and financial metrics, all while affording a more rapid return to proper physical functioning and an improved surgical experience for the patient.
As with any other enhanced recovery protocol, the first step in the process for pediatric patients included formalizing interdisciplinary collaboration to improve the overall perioperative experience. “In the past, surgical teams, anesthesia teams and nursing teams have mostly functioned in silos where they engage in their own specific processes and they focus on their own tasks,” Dr. Franklin told Anesthesiology News. “But when we put together these protocols, we found that we all need to work together, and the patients definitely benefit from that.”
Yet, as Dr. Franklin noted, involvement extends beyond the traditional players. “We often think this is a physician-led initiative, but there are more stakeholders, all of whom can contribute in a positive manner,” he said. “So this includes everyone from clinic schedulers to clinic nurses to nurse practitioners.”
As Dr. Franklin reported at the 2018 Perioperative Leadership Summit of the Association of Anesthesia Clinical Directors, the enhanced recovery protocol was divided into four phases for each procedure: planning, preoperative, intraoperative and postoperative. For the complex hip surgery protocol, the investigators used gabapentin, acetaminophen, oxycodone and scopolamine patch (if indicated) preoperatively. Intraoperatively, they turned to infusions of lidocaine, propofol, aminocaproic acid and ketamine, along with spinal blockade.
While each enhanced recovery phase was customized to the surgery at hand, they also had commonalities, particularly in the planning and preoperative phases. “With children, preoperative optimization is really all about expectation setting and helping them to understand what will happen throughout the surgical procedure, and what kinds of pain they might experience and for how long,” Dr. Franklin explained.
The effects of the protocols were far-reaching and significant (Table).
|Table. Effect of Enhanced Recovery Protocol on Pediatric Surgery|
|Without Enhanced Recovery||With Enhanced Recovery||P Value|
|Length of stay, days|
|Intraoperative morphine equivalents/kg|
|Total crystalloid/kg, mL|
|PONV, postoperative nausea and vomiting|
One of many benefits of the two protocols was the impact they had on hospital throughput, Dr. Franklin said. “When we take aggregate data from all those cases that we’ve done over the past two years, we’ve delivered well over 125 bed days back to the hospital. And that is something easily measurable and quantifies the value our service provides to the hospital.”
Equally interesting were the experiences of several children who underwent bilateral procedures, one before and one after implementation of the enhanced recovery protocol, allowing them to serve as their own informal controls. “They said that the enhanced recovery experience was completely different, like night and day,” Dr. Franklin said.
“Whereas before they were nauseated and couldn’t get out of bed until postoperative day 2, after we started the protocol we would see these kids first thing in the morning and they would be awake, eating breakfast, getting their shoes on and about to go to physical therapy,” he said.
Enhanced Pathway Saves Time
Even though the implementation of an enhanced recovery protocol may seem like a daunting task to some institutions, Dr. Franklin said it didn’t need to be so. “The key is to go for the low-hanging fruit. Starting with an early success will help establish that these sorts of things can be worthwhile in your hospital,” he added. “Then you can gain further support down the line.” Tracking success is an equally important component of implementing a new protocol because it also helps demonstrate process viability to hospital administrators.
Finally, Dr. Franklin pointed out that although institutions are sometimes hesitant to implement enhanced recovery protocols because they require more time, the VUMC experience proved otherwise. “We actually found that we were completing these operations 30 minutes faster after we instituted the protocols because everyone knew exactly what needed to happen and when, so there was a lot less waiting around. And then when kids are leaving the hospital faster, there’s a lot of cost savings there, too.”
Given these results, Michael P. Puglia II, MD, PhD, wondered what is preventing some institutions from implementing enhanced recovery protocols. “The beneficial effects of multimodal analgesia, PONV prevention, care coordination and preoperative optimization in patient satisfaction and outcomes have been known for a long time,” said Dr. Puglia, a clinical lecturer in anesthesiology and pediatric anesthesiology at the University of Michigan Medical School, in Ann Arbor. “Yet in 2018, achieving all of these metrics is an experimental variable and not the norm.
“Franklin and colleagues have once again shown that we can do better in the delivery and value of the care we provide to our children and families every day,” Dr. Puglia continued. “These data provide a compelling argument that we need to shift our definition of ‘standard of care’ and beg the question why this has not happened yet.
“As a system preparing for a paradigm shift in our care delivery model, we will need to ensure we have the training, motivation, resources and outcomes data to get it right, as well as the insight of when to deviate from our new standard of care,” he said.