A baseline assessment of enhanced recovery protocol implementation at pediatric surgery practices performing inflammatory bowel disease operations

Abstract

Background: Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations.

Methods: To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation.

Results: The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers.

Conclusions: Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption.

Level of evidence: Level III.

Type of study: Mixed-methods survey.

Keywords: Crohn's disease; Enhanced recovery; Enhanced recovery protocol; Inflammatory bowel disease; Recovery; Ulcerative colitis.

Conflict of interest statement

The authors have no financial or personal disclosures or conflicts of interest.

Copyright © 2020 Elsevier Inc. All rights reserved.

Figures

Fig. 1.

List of sites participating in the enhanced recovery protocol implementation trial in no particular order and their location.

Fig 2.

Baseline enhanced recovery protocol element implementation by patient encounter phase and associated barriers.