ENhanced Recovery in CHildren Undergoing Surgery (ENRICH-US)

Assessing Effectiveness and Implementation of a Perioperative Enhanced Recovery Protocol for Children Undergoing Gastrointestinal Surgery

The institution of perioperative Enhanced Recovery Protocols (ERPs) has been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but data in pediatric populations are lacking. The Assessing Effectiveness and Implementation of a Perioperative Enhanced Recovery Protocol for Children Undergoing Gastrointestinal Surgery, which has the short title "ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US)," study is a multicenter, pragmatic, prospective study, using a stepped wedge cluster randomized controlled trial design. The study is designed to test the adoption, effectiveness, and generalizability of a newly developed, 21-element ERP for children undergoing elective gastrointestinal surgery.

Study Overview

• Status: Completed
• Conditions: Crohn's Disease; Ulcerative Colitis; Inflammatory Bowel Disease
• Intervention / Treatment: Procedure: Perioperative surgical care

Detailed Description

The purpose of this study is to learn more about the clinical effectiveness and to examine obstacles to implementing a Perioperative Enhanced Recovery Protocol (ERP) in pediatric surgery. ERPs are evidence-based interventions that have been developed among adult surgical populations, but implementation of ERPs and data in pediatric populations are lacking. To address this need, we have designed a multicenter, prospective study entitled ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US). This study is designed to test the adoption, effectiveness, and generalizability of a pediatric specific 21-element ERP intervention for children recovering from surgery compared with usual care. All other peri-operative care in this study will not be modified from usual care pathways, including medications.

The basic elements of the ENRICH-US intervention are very similar to the elements of most adult ERPs and include perioperative counseling and education, mindfulness training, maintenance of euvolumia through limited perioperative fasting and limited intraoperative fluid resuscitation, early enteral intake, early mobilization, limited opioid use, and non-routine use of surgical drains and tubes. Elements span the preadmission and pre-, intra-, and post-operative phases of care. The concurrent use of these integrative healthcare interventions results in a markedly improved patient care experience that minimizes the physiologic stress of surgery and hastens recovery. These ERPs have been found to decrease hospital length of stay, in-hospital costs, complications, and help patients recover sooner after surgery. Though each ERP element is independently simple, implementation of the combined elements likely will require substantial redesign of the systems and processes of care to assure a high level of coordination among surgery, anesthesia, and nursing clinicians.

This prospective study involves multiple sites and uses a stepped-wedge, cluster-randomized, controlled study design of the ENRICH protocol in pediatric patients undergoing elective GI surgery. The cluster-randomized trial design is ideally suited for pragmatic intervention implementation. A hybrid, type 2 study design will be used with equal focus on evaluating the effectiveness and the implementation. The study will optimize implementation using the National Implementation Research Network's five Active Implementation Frameworks (AIFs), which identify competency, organization, and leadership as drivers of implementation and empower team collaboration and facilitate rapid-cycle evaluation. The five AIFs used as key tools to achieve high-fidelity and sustainable implementation will include patient-stakeholder input in all steps of the improvement process and a Learning Collaborative (LC) with rapid-cycle data feedback.

The study, by taking place in the setting where patients receive usual clinical care by usual clinicians, using data primarily from existing data sources (e.g., EHR), having minimal eligibility criteria, and recruiting all eligible pediatric patients undergoing GI surgery delivery, fulfills most of the pragmatic qualities to understand the real-world performance and implications of the intervention. The nature of this trial does not allow for subjects (patients or clinicians) to be blinded.

The study will enroll patients at 18 US hospitals ("sites") that participate in the Pediatric Surgery Research Collaborative (PedSRC), a cooperative group of pediatric surgeons and researchers committed to performing clinical research in pediatric surgery. All sites offer comprehensive, inpatient, pediatric services, including surgical services. The PedSRC represents one of the largest pediatric surgical networks for collaboration and research.

The 18 sites will be randomly assigned to one of three clusters for the stepped wedge design with each cluster, in turn, being randomly assigned to an intervention start period. Given that many sites have already initiated some ERP elements, a study design that randomizes sites or patients to a control arm without any ERP elements is not feasible. The stepped-wedge design was selected, in part, to ease the practical challenges of concurrently coordinating training and data collection across the 18 sites.

The ENRICH-US study provides a unique opportunity to accelerate, yet evaluate the adoption of ERP elements for pediatric GI patients, thus improving surgical care for this high-risk population by rapidly incorporating ERPs into practice, using the five AIFs. This study will serve as a model for future pediatric surgical quality improvement implementation efforts.

Clinicians, staff, and patient advocates participated only as part of the implementation Learning Collaborative and interviews. These individuals were not enrolled as study participants and therefore do not appear in enrollment, Participant Flow, Baseline Characteristics, or Outcome Measures.

Clarification of Study Participants: ENRICH-US used a stepped-wedge, cluster-randomized design in which clinical sites (18) were the units of assignment. Participants are counted under the study phase active at their site at the time of surgery; thus Baseline (248), Implementation (156), and Sustainability (193) reflect exposure groups rather than cluster membership. All 597 pediatric patients who completed consent/assent were enrolled. Learning Collaborative clinicians, staff, and patient advocates participated only in implementation activities/interviews, were not enrolled research participants, were not randomized, and did not contribute demographic, clinical, or PRO data. Therefore, they are not included in Enrollment, Participant Flow, Baseline Characteristics, Outcome Measures, or Adverse Events.

• Study Type: Interventional
• Enrollment (Actual): 597
• Phase: Phase 3

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Chicago, Illinois, United States, 60611
      • Northwestern University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 10 years to 18 years (Child, Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Pediatric patients ages 10-18
• Undergoing elective (non-emergency) gastrointestinal/colorectal surgical procedures

Exclusion Criteria:

• Children undergoing emergent/urgent gastrointestinal/colorectal surgical procedures
• Patients/families who cannot read and write English or Spanish

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: ENRICH-US Implementation- early; Baseline, pre-intervention data will be collected. This phase consists primarily of individual-level patient (ages 10-18 years undergoing elective GI surgery) data collection. This phase involves abstraction of existing electronic health records data by the Site Coordinator about current, standard perioperative care received by patients. Patients and parents will complete web-based HRQoL assessments preoperatively, and 5 days and 4-6 weeks post-operatively. Site-specific barriers and facilitators to implementation will be assessed by semi-structured, telephone interviews, conducted by each Site's PI and Coordinator. Intervention phase will span 12 months with an implementation curriculum. Sites will be randomized to this implementation phase based on stepped-wedge cluster assignment. A sustainability phase will collect post intervention data.	Procedure: Perioperative surgical care; The ENRICH-US Protocol includes perioperative counseling and education, maintaining euvolumia through limited perioperative fasting and limited intraoperative fluid resuscitation, early enteral intake and mobilization, limited use of opioids, and non-routine use of surgical drains and tubes. Elements span the pre-, intra-, and post-operative experience for patients and involve care coordination among surgery, anesthesia, and nursing providers. Though individually simple, the concomitant implementation of the combined elements results in a markedly improved patient care experience that mitigates the physiologic stress of surgery and hastens recovery.
Active Comparator: ENRICH-US Implementation- mid; Baseline, pre-intervention data will be collected. This phase consists primarily of individual-level patient (ages 10-18 years undergoing elective GI surgery) data collection. This phase involves abstraction of existing electronic health records data by the Site Coordinator about current, standard perioperative care received by patients. Patients and parents will complete web-based HRQoL assessments preoperatively, and 5 days and 4-6 weeks post-operatively. Site-specific barriers and facilitators to implementation will be assessed by semi-structured, telephone interviews, conducted by each Site's PI and Coordinator. Intervention phase will span 12 months with an implementation curriculum. Sites will be randomized to this implementation phase based on stepped-wedge cluster assignment. A sustainability phase will collect post intervention data.	Procedure: Perioperative surgical care; The ENRICH-US Protocol includes perioperative counseling and education, maintaining euvolumia through limited perioperative fasting and limited intraoperative fluid resuscitation, early enteral intake and mobilization, limited use of opioids, and non-routine use of surgical drains and tubes. Elements span the pre-, intra-, and post-operative experience for patients and involve care coordination among surgery, anesthesia, and nursing providers. Though individually simple, the concomitant implementation of the combined elements results in a markedly improved patient care experience that mitigates the physiologic stress of surgery and hastens recovery.
Active Comparator: ENRICH-US Implementation- late; Baseline, pre-intervention data will be collected. This phase consists primarily of individual-level patient (ages 10-18 years undergoing elective GI surgery) data collection. This phase involves abstraction of existing electronic health records data by the Site Coordinator about current, standard perioperative care received by patients. Patients and parents will complete web-based HRQoL assessments preoperatively, and 5 days and 4-6 weeks post-operatively. Site-specific barriers and facilitators to implementation will be assessed by semi-structured, telephone interviews, conducted by each Site's PI and Coordinator. Intervention phase will span 12 months with an implementation curriculum. Sites will be randomized to this implementation phase based on stepped-wedge cluster assignment. A sustainability phase will collect post intervention data.	Procedure: Perioperative surgical care; The ENRICH-US Protocol includes perioperative counseling and education, maintaining euvolumia through limited perioperative fasting and limited intraoperative fluid resuscitation, early enteral intake and mobilization, limited use of opioids, and non-routine use of surgical drains and tubes. Elements span the pre-, intra-, and post-operative experience for patients and involve care coordination among surgery, anesthesia, and nursing providers. Though individually simple, the concomitant implementation of the combined elements results in a markedly improved patient care experience that mitigates the physiologic stress of surgery and hastens recovery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Length of Stay (LOS)	Measured in days from surgery to discharge	During hospitalization, up to a maximum of 14 days.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Prolonged LOS (>6 Days)	Binary variable derived from LOS; > 6 days = Yes.	Up to 30 days postoperatively. Baseline (Pre-Implementation) Phase: January 2019 - February 2021. Implementation Phase: March 2021 - October 2022. Sustainability Phase: November 2022 - December 2023.
Time to Regular Diet	Days from surgery until first documented tolerance of regular diet in EHR	Up to 30 days postoperatively. Baseline (Pre-Implementation) Phase: January 2019 - February 2021. Implementation Phase: March 2021 - October 2022. Sustainability Phase: November 2022 - December 2023.
Intraoperative Fluid Use	Total volume of intraoperative crystalloid fluid administered, as abstracted from the anesthesia record.	During surgery (intraoperative period).
Opioid Use During Hospitalization (MME/Day)	Average daily opioid use during hospitalization, converted to morphine milligram equivalents (MME/day).	During the index hospitalization, from admission through discharge.
Opioid Prescribed at Discharge	Number of participants who were prescribed an opioid medication at the time of hospital discharge.	At hospital discharge.
Surgical Complications (Any)	Composite of surgical, infectious, pulmonary, vascular, neurologic, and renal complications; each participant counted once per category.	During hospitalization, up to a maximum of 14 days.
Multiple Complications (> 1)	Participants experiencing > 1 distinct postoperative complication.	During hospitalization, up to a maximum of 14 days.
30-day Readmission	Any unplanned hospital readmission within 30 days of discharge after index surgery. Events were abstracted from medical records and categorized as yes/no. Values are reported by study phase as number and percentage of participants readmitted.	Up to 30 days postoperatively. Baseline (Pre-Implementation) Phase: January 2019 - February 2021. Implementation Phase: March 2021 - October 2022. Sustainability Phase: November 2022 - December 2023.
Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health Scale (Preoperative)	Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health T-score before surgery. The PROMIS Pediatric Global Health Scale (PGH-7) is a validated, standardized patient-reported outcome measure assessing overall physical, mental, and social health in children and adolescents. Scores are reported as T-scores standardized to the U.S. pediatric population, with a mean of 50 and standard deviation of 10. Possible scores typically range from approximately 20 to 80. Higher T-scores indicate better global health. The PROMIS Pediatric Global Health T-score was assessed preoperatively within 30 days prior to surgery and summarized by study phase.	Preoperative assessment within 30 days before surgery.
Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health (Postoperative)	The PROMIS Pediatric Global Health Scale (PGH-7) is a validated, standardized patient-reported outcome measure assessing overall physical, mental, and social health in children and adolescents. Scores are reported as T-scores standardized to the U.S. pediatric population, with a mean of 50 and standard deviation of 10, and a typical range of approximately 20 to 80. Higher T-scores indicate better global health. The PROMIS Pediatric Global Health T-score was assessed postoperatively at 2-4 weeks after surgery and summarized by study phase.	Postoperative assessment at 2-4 weeks after surgery.
Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (Preoperative)	The PROMIS Pediatric Pain Interference Scale is a validated patient-reported outcome measure assessing the extent to which pain interferes with physical, emotional, and social functioning in children and adolescents. Scores are reported as standardized T-scores with a mean of 50 and standard deviation of 10, with a typical range of approximately 30 to 80. Higher T-scores indicate greater pain interference (worse outcome). Pain interference T-scores were assessed preoperatively within 30 days prior to surgery and summarized by study phase.	Preoperative assessment within 30 days before surgery.
Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Pain Interference (Postoperative)	The PROMIS® Pediatric Pain Interference Scale is a validated patient-reported outcome measure assessing the extent to which pain interferes with physical, emotional, and social functioning in children and adolescents. Scores are reported as standardized T-scores with a mean of 50 and standard deviation of 10, with a typical range of approximately 30 to 80. Higher T-scores indicate greater pain interference (worse outcome). Pain interference T-scores were assessed postoperatively at 2-4 weeks after surgery and summarized by study phase.	Postoperative assessment at 2-4 weeks after surgery.

Collaborators and Investigators

• Sponsor: Northwestern University
• Collaborators: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

Publications and helpful links

General Publications

• Raval MV, Wymore E, Ingram ME, Tian Y, Johnson JK, Holl JL. Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial. Trials. 2020 Nov 16;21(1):926. doi: 10.1186/s13063-020-04851-9.
• Smith CJ, Schafer WLA, Wilberding MJ, Reiter A, Sullivan GA, Hu A, Holl JL, Balbale SN, Blake SC, Close S, Davis TL, Johnson JK, Raval MV. Fidelity of Enhanced Recovery Protocol Implementation With Assessment of Hospital-Specific Materials. J Surg Res. 2024 Oct;302:469-475. doi: 10.1016/j.jss.2024.07.087. Epub 2024 Aug 20.
• Balbale SN, Schafer WLA, Davis TL, Blake SC, Close S, Sullivan GA, Reiter AJ, Hu AJ, Smith CJ, Wilberding MJ, Johnson JK, Holl JL, Raval MV. A mixed-method approach to generate and deliver rapid-cycle evaluation feedback: lessons learned from a multicenter implementation trial in pediatric surgery. Implement Sci Commun. 2023 Jul 18;4(1):82. doi: 10.1186/s43058-023-00463-x.
• Raval MV, Tian Y, Schafer W, Balbale SN, Perez MN, Ingram ME, Lehane A, Smith CJ, Sullivan GA, Reiter AJ, Hu A, Borst JM, Blake SC, Close S, Davis TL, Essner BS, Heiss KF, Huang LW, Wymore E, Paniagua-Perez D, Engelhardt KM, Graffy PM, Johnson JK, Lillehei CW, Gray BW, Goldstein SD, Short SS, Pandya SR, Taylor JA, Gayer C, Goldin AB, Boelig MM, Rialon KL, Jancelewicz T, Lipskar AM, Jafri M, Tracy ET, Harting MT, Sulkowski JP, Ham PB 3rd, Vali K, Cina RA, Schindel DT, Islam S, Teeple EA, Shah SR, Gosain A, Rothstein DH, Brockel MA, Chown J, Holl JL. Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial. JAMA Surg. 2026 Jul 1;161(7):670-680. doi: 10.1001/jamasurg.2026.1382.

Study record dates

Study Major Dates

• Study Start (Actual): July 1, 2020
• Primary Completion (Actual): November 6, 2024
• Study Completion (Actual): November 6, 2024

Study Registration Dates

• First Submitted: August 7, 2019
• First Submitted That Met QC Criteria: August 15, 2019
• First Posted (Actual): August 19, 2019

Study Record Updates

• Last Update Posted (Actual): August 7, 2026
• Last Update Submitted That Met QC Criteria: July 15, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Keywords: Implementation; Quality Improvement; Pediatric Surgery; Enhanced Recovery Protocols; Gastrointestinal Surgery
• Additional Relevant MeSH Terms: Intestinal Diseases; Digestive System Diseases; Gastrointestinal Diseases; Colonic Diseases; Gastroenteritis; Colitis; Colitis, Ulcerative; Crohn Disease; Inflammatory Bowel Diseases
• Other Study ID Numbers: Pro00039201; R01HD099344 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: All data collected during the study will be made available such that further advancement of ERP principles will be made possible by building upon these data. In addition to the peer-reviewed publication of study results and the dissemination of findings through publicly available websites, blogs, and newsletters, the PI and Biostatistics Director will create a patient-deidentified data set that will be made publicly available to researchers. We have included a request for funds to curate this dataset for public use. It will include clinical data and outcomes collected through REDCap for the complete ENRICH-US study, as well as, raw data for the PedsQL health-related quality of life surveys. All data will be fully de-identified. A copy of the study protocol, data definition dictionary, and public use file with instructions will also be generated for ease of use. Data will be made available in a format that will easily be used in mainstream software analysis packages (e.g., ASCII, SAS).

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No