A. Thompson1, H. Glick2, N. Rubalcava3, 4, J. Vernamonti4, 5, K. Speck4 1University Of Michigan, Department Of Health Behavior And Health Education, School Of Public Health, Ann Arbor, MI, USA 2University Of Michigan, Medical School, Ann Arbor, MI, USA 3Creighton University, Department Of Surgery, School Of Medicine Phoenix Regional Campus, Phoenix, AZ, USA 4University Of Michigan, Department Of Pediatric Surgery, C.S. Mott Children’s Hospital, Ann Arbor, MI, USA 5Maine Medical Center, Department Of Surgery, Portland, ME, USA
Introduction:
Surgical repair of pectus excavatum and carinatum in children is associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multi-disciplinary, multi-modal approach designed to fast-track surgical care, but due to obstacles to implementation, there are few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol in pediatric patients with pectus excavatum and carinatum using basics of implementation science.
Methods:
A multi-disciplinary team of stakeholders was assembled from across five different specialties: anesthesia, nursing, information technology, pediatric surgery, and physical therapy (PT). We worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum as well as methods for patient and data capture. Champions from each specialty contributed to creation of the protocol to standardize management throughout all phases of care. Once complete, the surgical champion ensured buy-in for the finalized ERAS protocol and broad teaching was completed with all end users (individuals executing the ERAS protocol).
Results:
The finalized ERAS protocol was broken down into seven phases of care: preoperative clinic, preoperative day of surgery, intraoperative, post anesthesia care unit, floor, post-discharge, and postoperative clinic. The ERAS protocol was implemented broadly by end users focusing on four main areas: pain control, ambulation, diet, and patient/caregiver education. After implementation, an iterative process identified the following improvements: standardization of preoperative education, stronger collaboration with PT, and involvement of our pharmacist.
Conclusion:
Although there are studies highlighting outcomes from ERAS protocols within pediatric surgery, to our knowledge, this is the first study detailing the development and implementation process. Unlike clinical research that often controls for a given context, implementation science focuses on understanding the dynamic context in which the intervention is being introduced. Furthermore, the use of implementation science for this ERAS protocol was key to the identification of barriers and facilitators for project leadership, education dissemination, and patient capture in the pre-implementation, implementation, and post-implementation phases. Moreover, the utilization of an iterative process was important in ensuring ERAS protocol compliance and assessing opportunities for process improvement. The outlined features of implementation science can serve as a model for future ERAS protocols in pediatric surgery across a diverse range of practice settings.
