Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population.
We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction.
Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence.
A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33 % had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70 %, Mitrofanoff appendicovesicostomy in 52 %, Monti ileovesicostomy in 15 %, and antegrade continence enema channel in 38 %. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51 % followed by a "lack of time, money, or clinical resources" in 36 %. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved.
The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers.
ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.
Journal of pediatric urology. 2023 Dec 30 [Epub ahead of print]
Andrew C Strine, David I Chu, Megan A Brockel, Duncan T Wilcox, Gino J Vricella, Douglas E Coplen, Erica J Traxel, Rajeev Chaudhry, Brian A VanderBrink, Elizabeth B Yerkes, Yvonne Y Chan, Nicholas E Burjek, Rebecca S Zee, C D Anthony Herndon, Jennifer J Ahn, Paul A Merguerian, Bhalaajee Meenakshi-Sundaram, Adam J Rensing, Dominic Frimberger, Kyle O Rove, PURSUE Study Group
Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. Electronic address: ., Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA., Department of Anesthesiology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA., Department of Pediatric Urology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA., Division of Pediatric Urology, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA., Division of Pediatric Urology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA., Division of Pediatric Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA., Division of Pediatric Urology, Children's Health Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA., Department of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA., Division of Urology, Children's Hospital of Richmond at VCU, Richmond, VA, USA., Department of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA., Department of Urology, Oklahoma Children's Hospital at OU Health, University of Oklahoma, Oklahoma City, OK, USA.