Abstract：
BACKGROUND: Enhanced Recovery After Surgery (ERAS) was established in 2001 for adult patients undergoing complex procedures. ERAS in adult ambulatory surgery later followed with similar positive outcomes. For the pediatric population, ERAS implementation has shown promising results in complex surgeries such as bladder reconstruction. Its application in pediatric ambulatory surgery has only recently been reported. We hereby report a Quality Improvement initiative in implementing an Enhanced Recovery Protocol (ERP) for pediatric urology in an ambulatory surgery center.
METHODS: A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used.
RESULTS: The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged.
CONCLUSIONS: This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.
METHODS: A project was launched to evaluate and implement enhanced recovery elements into an institutional Enhanced Recovery Protocol (ERP). These included reliance on peripheral nerve blocks for all inguinal and genital cases and reduction of opioids intraoperatively and postoperatively. Improvements were placed into a project plan broken into one preparation phase to collect baseline data and three implementation phases to enhance existing and implement new elements. The implementation phase went through iterative Plan-Do-Study-Act (PDSA) cycles for all sub-projects. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify plans as needed. The primary outcome measures selected were percent intraoperative opioid use, percent opioid prescribing, mean PACU length of stay, and average number of opioid doses prescribed. Secondary outcome measures were mean maximum pain score in PACU, PACU rescue rate for PONV, and patient/family satisfaction scores. Post-implementation data for 18 months was included for evaluation. Statistical process control methodology was used.
RESULTS: The total number of participants was 3306: 561 (baseline), 220 (Phase 1) 356 (Phase 2) and 527 (Phase 3), 1642 (post-implementation). Intraoperative opioid use was eliminated in >99% of cases. Post-operative opioid prescribing was reduced from 30% to 15% of patients. The number of opioid doses was also reduced from an average of 7.6 to 6.1 doses. There was no change for the mean maximum pain score in the recovery room despite elimination of opioids. Patient/family satisfaction scores were high and sustained throughout the period of study (9.8/10). Balancing measures such as return to the operating room within 30 days and return to the emergency department within 7 days were unchanged.
CONCLUSIONS: This QI project demonstrated the feasibility of a pediatric enhanced recovery protocol in a urology ambulatory surgery setting. With implementation of this protocol, intraoperative opioid use was virtually eliminated, and opioid prescribing was reduced without affecting pain scores or post-operative complications.
摘要：
背景：2001年为接受复杂手术的成年患者建立了增强术后恢复（ERAS）。成人非卧床手术的ERAS后来获得了类似的阳性结果。对于儿科人群，ERAS的实施在膀胱重建等复杂手术中显示出了有希望的结果。它在儿科门诊手术中的应用最近才有报道。我们在此报告在门诊手术中心实施儿科泌尿外科增强恢复方案（ERP）的质量改进计划。
方法：启动了一个项目，以评估和实施机构增强恢复协议（ERP）中的增强恢复要素。这些措施包括所有腹股沟和生殖器病例对周围神经阻滞的依赖以及术中和术后阿片类药物的减少。将改进纳入项目计划，分为收集基线数据的一个准备阶段和三个实施阶段，以加强现有和实施新要素。实施阶段经历了所有子项目的迭代计划-Do-Study-Act（PDSA）周期。小组对策是基于现有证据。使用共识程序来解决分歧。每月举行会议以分享实时数据，收集新的反馈，并根据需要修改计划。选择的主要结果指标是术中阿片类药物使用百分比，阿片类药物处方百分比，平均PACU停留时间，和处方阿片类药物的平均剂量。次要结果指标是PACU的平均最大疼痛评分，PONV的PACU救援率，和患者/家属满意度得分。18个月的实施后数据被纳入评估。使用统计过程控制方法。
结果：参与者总数为3306：561（基线），220（第1阶段）356（第2阶段）和527（第3阶段），1642(实施后)。术中阿片类药物的使用在>99%的病例中被消除。术后阿片类药物处方从30％减少到15％的患者。阿片类药物剂量的数量也从平均7.6剂减少到6.1剂。尽管消除了阿片类药物，但恢复室的平均最大疼痛评分没有变化。在整个研究期间，患者/家属满意度得分很高，并且持续（9.8/10）。30天内返回手术室和7天内返回急诊科等平衡措施不变。
结论：这个QI项目证明了在泌尿外科门诊手术环境中儿科强化康复方案的可行性。随着该协议的实施，术中阿片类药物的使用几乎被消除，阿片类药物处方减少,且不影响疼痛评分或术后并发症.
方法：启动了一个项目，以评估和实施机构增强恢复协议（ERP）中的增强恢复要素。这些措施包括所有腹股沟和生殖器病例对周围神经阻滞的依赖以及术中和术后阿片类药物的减少。将改进纳入项目计划，分为收集基线数据的一个准备阶段和三个实施阶段，以加强现有和实施新要素。实施阶段经历了所有子项目的迭代计划-Do-Study-Act（PDSA）周期。小组对策是基于现有证据。使用共识程序来解决分歧。每月举行会议以分享实时数据，收集新的反馈，并根据需要修改计划。选择的主要结果指标是术中阿片类药物使用百分比，阿片类药物处方百分比，平均PACU停留时间，和处方阿片类药物的平均剂量。次要结果指标是PACU的平均最大疼痛评分，PONV的PACU救援率，和患者/家属满意度得分。18个月的实施后数据被纳入评估。使用统计过程控制方法。
结果：参与者总数为3306：561（基线），220（第1阶段）356（第2阶段）和527（第3阶段），1642(实施后)。术中阿片类药物的使用在>99%的病例中被消除。术后阿片类药物处方从30％减少到15％的患者。阿片类药物剂量的数量也从平均7.6剂减少到6.1剂。尽管消除了阿片类药物，但恢复室的平均最大疼痛评分没有变化。在整个研究期间，患者/家属满意度得分很高，并且持续（9.8/10）。30天内返回手术室和7天内返回急诊科等平衡措施不变。
结论：这个QI项目证明了在泌尿外科门诊手术环境中儿科强化康复方案的可行性。随着该协议的实施，术中阿片类药物的使用几乎被消除，阿片类药物处方减少,且不影响疼痛评分或术后并发症.
