Introduction

Welcome to the APSA Quality and Safety Committee Enhanced Recovery After Surgery (ERAS) Toolkit. This toolkit is intended to help anyone who is interested in improving the care of their patients using ERAS initiatives.

Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.

ERAS Clinical Pathways

ERAS is a multimodal perioperative pathway focusing on three major pillars: preoperative, perioperative and postoperative care, each one with specific stategies. The ERAS bundles include strategies such as abbreviated preoperative fasting, preoperative coaching and expectation management, intraoperative fluid restriction, opioid sparing analgesia and early mobilization and feeding; which both in the adult and pediatric literature, have demonstrated to improve outcomes, reduce hospital length of stay and improve patient and family satisfaction.

Sunrise Children’s Hospital implemented a quality improvement (QI) project following ERAS core principles that serves to improve the care of patients undergoing both elective and urgent pediatric general surgery. While other institutions have started ERAS initiatives focusing on specific types of surgeries or diseases, i.e., colorectal surgery, Sunrise Children’s Hospital applied the principles more broadly given the smaller colorectal volumes. They have a variety of resources including ERAS standards of care, a family handout, amongst others.

Protocol:

• Sunrise ERAS Standards of Care for Pediatric Surgical Patients

Resources:

• Sunrise Children’s Hospital ERAS Provider Information Sheet (Clinic Visit & Preoperative Management and Postoperative Management & Discharge)
• Sunrise Children’s Hospital ERAS Family Handout
• Sunrise Children’s Hospital ERAS Goals & Accomplishments and Discharge Checklists (for patients/parents/families)

Stakeholders: surgeons, anesthesiologists, pediatricians, perioperative nursing teams, scrub technicians, administration (COO, CMO, CNO)

Challenges and solutions:

• Identify surgeon and anesthesia champions.
• Form a multidisciplinary ERAS team with a goal of meeting monthly.
• Make repeated efforts to engage staff in the learning process.
• Have multiple venues to access information such as grand rounds, nursing education conferences, etc.

Submitted by: Erik G. Pearson, MD

Emory/Children’s Healthcare of Atlanta (CHOA) developed an Enhanced Recovery Protocol (ERP) for gastrointestinal surgery which primarily targets older children and adolescents undergoing elective surgery secondary to inflammatory bowel disease (IBD). The initiative was surgeon led, but included a multidisciplinary team which allowed it to get out of the starting blocks.

Protocol:

• CHOA IBD with Surgical Intervention ERAS Guidelines (Pre- and Postoperative Management)

Resources:

• CHOA IBD Order Set
• CHOA ERAS Goals & Accomplishments and Discharge Checklists (for patients/parents/families)

Stakeholders: surgeon-led initiative (Dr. Heiss, Dr. Raval), multidisciplinary team including anesthesia, pain team, preoperative/postanesthesia care unit nursing, floor nursing, pediatric surgical advanced practice nurses, child life/patient advocates, pharmacists, physical therapists

Challenges and solutions: having partners in anesthesia and pain management were critical to getting out of the starting blocks.

Links to pubilished data: [1][2][3][4][5][6][7][8]

Submitted by: Mehul V. Raval, MD, MS

At UPMC Children’s Hospital of Pittsburgh, two ERAS protocol are used: pediatric laparoscopic cholecystectomy and general surgery complex abdominal cases. The goals of these clinical pathways are to optimize the clinical care and maximize clinical outcomes by standardizing preoperative, day of surgery and postoperative care of these pediatric surgical patients. Specifically to the laparoscopic cholecystectomy clinical pathway, the goal is for patients to be consistently ready for discharge on the day of surgery by improving mobilization, minimizing side effects, such as postoperative nausea and vomiting (PONV), adverse events (e.g. severe pain), decreasing length of stay and improving patient/family/nurse satisfaction with their overall clinical care. A significant part of this standardization is to use a multimodal pain approach that includes regional anesthesia techniques or local anesthetic administration at the laparoscopic instrument sites with the aim of reducing the patients’ pain to an acceptable pain level [Numeric Rating Scale (NRS) pain scores less than 4],

Protocol:

• UPMC Children’s Hospital of Pittsburgh ERAS Pathway for Pediatric General Surgery Complex Abdominal Cases
• UPMC Children’s Hospital of Pittsburgh ERAS Protocol for Laparoscopic Cholecystectomy

Stakeholders: surgeons, anesthesiologists, nursing staff, pain management team, hospital administrators including IT support

Challenges and solutions:

• Creating an order set in the EMR has been a challenge.
• Extending this protocol to younger ages will be revealing as there is very little experience with ERAS in younger kids.

Links to pubilished data: [9][10][11][12]

Submitted by: Marcus Malek, MD

Additional implementer: Andrew Yeh, MD

Children’s Hospital of Philadelphia (CHOP) has an ERAS protocol for children who undergo total nephrectomy for Wilms tumor. The protocol has gradually evolved since its inception. However, the basic tenets include: managing parental expectations, avoiding the use of a nasogastric tube and starting clear liquids the day of surgery, minimal use of opiates, routine use of ketorolac and early ambulation. Moreover, the use of epidural catheters is discouraged since they are deemed unnecessary and prolong hospital stay. The patients are admitted to the floor postoperatively, avoiding an admission to the pediatric intensive care unit. By using this protocol, the typical postoperative length of stay is two to three days without an increase in complications or returns to the emergency department.

Protocol:

• CHOP Wilms Nephrectomy ERAS Protocol

Stakeholders: patients, parents, nurses, nurse practitioners, surgeons, anesthesiologists, pain team, residents and fellows.

Challenges and solutions:

• Managing parents’ and nurses’ expectations around criteria for discharge.
• Overcoming years of dogma around the concepts of the postoperative ileus, fluid shifts, optimal pain management strategies, etc.
• Creating order sets which would make implementation easier but have been difficult to create given our technology environment and Epic build capabilities.

Links to pubilished data: [13]

Submitted by: Peter Mattei, MD

Additional implementer: Richard Glick, MD

Children’s Hospital Colorado also uses an ERAS protocol for patients following intra-abdominal oncologic procedures. This protocol measures approximately 20 perioperative standardized practices and has definitions to meet each high level process measure. However, it is important to ensure that all stakeholders agree on these definitions to maximize buy in. The use of an evidence based perioperative protocol that involves multimodal pain control, minimizes NPO times, and standardizes postoperative care minimizes variation between patients undergoing surgery. Quality improvement methodologies like Plan, Do, Study, Act (PDSA) cycles are ideal for implementation, allowing one to meet and engage relevant perioperative stakeholders (surgeons, anesthesiologists, perioperative nursing), devise an implementation plan (i.e., regarding scheduling, patient and provider education, implementation/adaptation of relevant ERAS implementation tools) and collect data (audit) to verify the team is adhering to the protocol and to provide feedback to interested parties to optimize care processes.

Protocol:

• Children’s Hospital Colorado ERAS Oncology Protocol

Resources

• Children’s Hospital Colorado ERAS Order Set
• Children’s Hospital Colorado ERAS Patient Handout
• Children’s Hospital Colorado ERAS Patient Checklist
• Children’s Hospital Colorado ERAS QI OR Timeout
  • This particular resource is used to quickly orient the anesthesia, surgical and operating room nursing teams to the ERAS intraoperative goals.

Stakeholders: pediatric surgeons, pediatric urologists, pediatric anesthesiologists, perioperative nursing staff (preop, OR, PACU), floor and service nurses, pharmacists

Challenges and solutions:

• Buy in from different providers can be challenging, particularly with those who may practice differently, or use existing protocols that differ from the ERAS pathway.
• Ongoing perioperative provider education and knowledge is always a concern because there are so many providers at many levels who may interact with a patient undergoing surgery.

Links to pubilished data: [14][15]

Submitted by: Kyle Rove, MD

Additional implementers: Megan Brockel, MD, Nicholas Cost, MD

Recent Research

For additional ERAS-related research, please refer to references .

Additional Resources

ERAS® Society Guidelines

UpToDate: Enhanced recovery after colorectal surgery

UpToDate: Anesthetic management for enhanced recovery after major surgery (ERAS) in adults

SAGES: Pediatric Surgery - Enhanced Recovery for Pediatric Surgery

References