Acute appendicitis is the most common surgical indication in the pediatric population, yet its perioperative management remains widely variable.1 Analysis of such variations in surgical management has introduced opportunities for quality improvement (QI) through standardized care. Numerous studies have shown initiation of standardized protocols has led to more efficient resource use and decreased inhospital costs, and use of enhanced recovery after surgery (ERAS) protocols has been shown to reduce recovery time by up to 30 percent.2,3
Although ERAS for adult patients is well publicized in literature, multidisciplinary fast-track protocols in pediatric surgery have been slow to generate the same enthusiasm. Recent studies have demonstrated the feasibility of same-day discharge (<24 hours) following laparoscopic appendectomy in children with noncomplicated appendicitis.4-7 However, few pediatric studies have used a standardized protocol that is comprehensive and adopts components from the ERAS bundle applied in caring for the adult population.8
Levine Children’s Hospital (LCH), Charlotte, NC, implemented a QI initiative that uses an enhanced recovery protocol for noncomplicated pediatric appendicitis that was comprehensive (preoperative, intraoperative, postoperative) and took advantage of a dedicated recovery unit. Our goal was to provide a framework for implementation of a multidisciplinary standardized pathway.
Prior to implementation of our QI initiative, the hospital lacked standardized perioperative management for appendicitis, leading to a range of hospital and postoperative lengths of stay (LOS). Preoperative antibiotics were selected based on surgeon preference, while postoperative pain regimens, time to mobilization, and initiation of enteral nutrition were typically nurse driven. Beginning with a common pediatric surgical diagnosis, our goal was to create a standardized perioperative pathway that would reduce interprovider variability, increase compliance with high-quality evidence-based practices, and reduce patient LOS.
Putting the plan in place
LCH is a 235-bed children’s hospital that is affiliated with Atrium Health. As the largest pediatric hospital between Washington, DC, and Atlanta, GA, and the only Level I pediatric trauma center in the region, it serves as the tertiary referral center for pediatric care in North Carolina. In 2017, more than 14,000 perioperative cases were performed at this institution. LCH participates in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Pediatric.
Recent emphasis has been placed on the delivery of value-based care. At our institution, adult ERAS protocols have been implemented in the divisions of colorectal and hepato-pancreato-biliary (HPB) surgery, among others, serving as motivation to providers to initiate a similar protocol in the pediatric patient population. In response to changing health care needs, we adopted the first pediatric surgery fast-track pathway at LCH and introduced a multidisciplinary bundle of initiatives to streamline and standardize high-quality surgical care.
A multidisciplinary team of physicians and nurses was formed, including members of the divisions of pediatric surgery, perioperative nursing, anesthesia, and emergency medicine. At initial planning meetings, team members identified potential areas for intervention based on evidence-based practices as well as perceived barriers to discharge. Current guidelines, such as those for antibiotic regimen, also were used during the planning process. A standard fast-track pathway for noncomplicated appendicitis was created with initiatives to standardize care in each perioperative phase, from diagnosis to discharge. The team discussed the effectiveness and feasibility of implementing each initiative to reach a consensus on fast-track pathway components. A preexisting physical unit adjacent to the operating room was newly designated as the dedicated preoperative and postoperative recovery unit.
In addition, the initial driver of culture change and nursing leadership to implement the pathway was under the direction of a single clinical nursing educator, who was critical to the planning process.
Implementing the pathway
An electronic health record (EHR)-compatible order set (power plan) was created to facilitate identification of fast-track pathway patients and standardize preoperative and postoperative medications given (see Table 1). This order set was introduced to all attendings and surgery residents, who then entered the power plan for all pathway patients.
Table 1. Strategy for implementing ERAS for appendicitis
Initiating a culture change was critical to the implementation and sustainability of the pathway. All staff, including nursing/nursing assistants, emergency department (ED) personnel providers, patient transfer, patient account representatives, environmental services, and guest relations received a one-hour session on the goals/benefits of enhanced recovery and perioperative phases of the noncomplicated appendicitis fast-track pathway. A total of 14 sessions took place and were facilitated by the clinical nurse educator for preoperative/postacute care unit (PACU).
During the implementation process, resource tools were provided in the form of education folders and a question-and-answer board where staff members could seek additional clarification. Nursing supervisors also were readily available for questions during the implementation process. After planning and implementing the pathway, the team met regularly to assess the effectiveness of the QI project and discuss changes to address barriers, following the Plan-Do-Study-Act format.
Resources used and skills needed
The involvement of pediatric surgeons, ED physicians, and perioperative staff was critical to the success of the fast-track pathway; thus, champions from each department contributed input and feedback during the implementation process. The task force met regularly before and during implementation to address feedback and troubleshoot obstacles. A clinical nurse educator for preoperative/PACU was instrumental in leading education sessions for perioperative staff and participating in monthly ED staff meetings and daily huddles prior to implementation.
No additional clinical costs were necessary to implement and maintain the QI program. The designated recovery unit was created from existing space in the PACU area. Although the project received no funding prior to implementation, grants to offset cost of recovery recliners are pending.
The fast-track pathway was implemented June 1, 2017. Patients with ruptured appendicitis intraoperatively were excluded from the pathway. ACS NSQIP Pediatric data and EHRs were used to track results and adherence to the protocol, and fast-track patient outcomes were compared with a historical cohort of outcomes prior to implementation.
The reduction in median total hospital LOS and postoperative LOS are illustrated in Figure 1. Following implementation of the protocol, postoperative and total hospital LOS declined by 59 percent and 39 percent, respectively, without an accompanying increase in postoperative readmissions or complications. Compared with the median average LOS of two days (1.4–3.1) reported by a study looking at practices in more than 30 pediatric hospitals,1 our results showed a median hospital LOS of 14.7 hours following protocol implementation. More than 67 percent of fast-track protocol patients were discharged home within eight hours of the operation. Another 23 percent of patients who had operations after 10:00 pm were discharged home immediately after morning rounds.
Figure 1. Median LOS pre- and post-pathway implementation
The changes in antibiotic treatment regimen, dexamethasone administration, urinary catheter utilization, and rescue pain medication are illustrated in Figure 2. Compared with historical control patients, 86.9 percent of fast-track patients received the standardized dose of preoperative antibiotics in the preoperative holding area. Use of an intraoperative urinary catheter also was significantly decreased by more than 30 percent after protocol implementation.
Figure 2. Changes in perioperative management, pre- and post-pathway implementation
Coordination with anesthesia resulted in a significant increase in the pre-induction administration of dexamethasone. Similarly, improved compliance with administration of ondansetron and ketorolac led to a significant reduction in postoperative nausea and vomiting indicated by a number of patients requiring antiemetics in the designated postoperative unit. Use of a stepwise multimodal analgesia regimen resulted in a 37 percent reduction in intravenous narcotics given postoperatively.
Following discharge, nurses made follow-up phone calls to 91.8 percent of patients at 24 hours and 7–10 days. Only 9.2 percent of fast-track pathway patients elected to follow up in the office; in comparison, all pre-pathway patients were scheduled for a postoperative clinic follow-up with a 41.4 percent no-show rate. Following implementation of our protocol, average direct variable costs per patient decreased from $3,116 to $2,982—a 4.3 percent decrease in patient cost. Over the monitored period, net cost savings were $8,174.
Barriers to implementation encountered during the initial phase included ensuring patients were admitted to the designated unit. Patients admitted to other inpatient floors where nurses were unfamiliar with the fast-track pathway were less likely to be compliant. After identification of the problem, numerous changes, including direct communication with bed management, were made to address potential contributing factors. Pediatric surgery residents instructed ED charge nurses to admit patients to the fast-track unit while charge nurses in the designated unit monitored the ED board for patients with appendicitis. As staff members became increasingly familiar with pathway components and were able to observe direct benefits in enhanced patient recovery, the culture change and increased provider buy-in led to fewer setbacks over time.
Tips for others
- Find the right team. Assembling a multidisciplinary team with input from key providers was instrumental to the success of our QI intervention. In particular, buy-in from surgeons and perioperative nursing ensured patients with noncomplicated appendicitis were started on the fast-track pathway. Team members also were able to educate other staff and help drive the implementation process.
- Engage patients and providers. In addition to educating providers and ancillary staff, brochures and visual aids provided patients and family members with information on the goals of enhanced recovery and set patient expectations for postoperative care.
- Make simple, sustainable changes. To implement a pathway with multiple components dependent on the ordering physician, we created a standardized power plan that bundled all nursing orders and medications, including preoperative antibiotics, postoperative analgesia, and anti-emetics. The power plan simplified the admission orders for physicians and minimized interprovider variability at our teaching hospital with different residents rotating through pediatric surgery each month.
- Solicit regular feedback/communication. Team members met every three months during pathway implementation to troubleshoot setbacks, respond to staff feedback, and evaluate progress. Initial results were shared with perioperative staff to highlight early improvements resulting from pathway changes and further encourage culture change.
- Shift the culture to a nursing-driven recovery and discharge process. This major change resulted from the recognition that nurses were able to assess patients for discharge readiness more frequently than surgeons who were limited to seeing patients between cases. Enabling nurses to initiate conditional discharge orders once patients met pre-set criteria allowed for earlier discharge and reduced LOS.
- Newman K, Ponsky T, Kittle K, et al. Appendicitis 2000: Variability in practice, outcomes, and resource utilization at thirty pediatric hospitals. J Pediatr Surg. 2003;38(3):372-379.
- Roulin D, Donadini A, Gander S, et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg. 2013;100(8):1108-1114.
- Feldman LS, Lee L, Fiore J Jr. What outcomes are important in the assessment of Enhanced Recovery after Surgery (ERAS) pathways? Can J Anesth. 2015;62(2):120-130.
- Bensard DD, Hendrickson RJ, Fyffe CJ, Careskey JM, Azizkhan RG. Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway. J Laparoendosc Adv Surg Tech A. 2009;19(Suppl 1):S81-86.
- Farach SM, Danielson PD, Walford NE, Hamel RP Jr, Chandler NM. Same-day discharge after appendectomy results in cost savings and improved efficiency. Am Surg. 2014;80(8):787-791.
- Putnam LR, Levy SM, Johnson E, et al. Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy. Surgery. 2014;156(2):455-461.
- Aguayo P, Alemayehu H, Desai AA, Fraser JD, St Peter SD. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res. 2014;190(1):93-97.
- Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV. Enhancing recovery in pediatric surgery: A review of the literature. J Surg Res. 2016;202(1):165-76.