Implementation of an Enhanced Recovery After Surgery Pathway for Pediatric Surgical Oncology using Quality Improvement Methodology.

Abstract

Enhanced recovery after surgery (ERAS) pathways have demonstrated significant benefits, but often face challenges in implementation due to the scope of process measures and multidisciplinary buy-in required. This study aimed to standardize surgical care for children undergoing solid tumor resection by implementing an ERAS for Tumor (ERAST) pathway. Our ERAST pathway consisted of 20 process measures. Plan-Do-Study-Act (PDSA) cycles were utilized, including implementing standardized pre- and postoperative orders, data-enabled electronic progress note templates, and multidisciplinary preoperative team huddles. Our primary outcome was 80% adherence to protocol process measures. Secondary outcomes included hospital length-of-stay (LOS) and opioid usage. Balancing measures included readmission and/or emergency room visits within 30 days post-procedure. Over 15 months, 57 patients (63 surgeries) were included. Median adherence to process measures was 89.5%. Intraoperative fluid administration decreased from 12.19 to 5.97 ml/kg/h (p < 0.001). Intraoperative opioid use in abdominal cases fell from 0.37 to 0.24 OME/kg (p = 0.0008); postoperative opioid use dropped from 0.16 to 0.04 OME/kg/day (p < 0.001). Thoracic cases saw post-operative opioid use decrease from 0.30 to 0.13 OME/kg/day (p = 0.0017). Median LOS decreased for laparotomy (4.48-2.87 days), thoracotomy (3.37-2.26 days), and thoracoscopy (1.60-1.15 days), all p < 0.001. There was no difference in readmission and/or emergency room visits pre/post ERAST for all cases. The ERAST pathway achieved high protocol adherence and led to significant reductions in opioid use and LOS, without worsening balancing measures. This demonstrates the effectiveness of multidisciplinary, protocol-driven recovery pathways in pediatric surgical oncology.