The Use of Sequential Surveys to Shorten Implementation Time for Healthcare System-Level Enhanced Recovery After Surgery (ERAS) Pathways.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) pathways improve healthcare quality, safety, and cost-effectiveness. We hypothesized that the RAND Method (a hybrid Delphi approach), involving anonymous sequential surveys and face-to-face meetings, would allow for more rapid agreement and initiation of new ERAS pathways. METHODS: Using the ERAS Society guidelines for cesarean section as a baseline, our institution's ERAS Leadership Team (ELT) compiled published literature and institutional practices to design a 32-component survey that was sent to obstetricians, nurse midwives, anesthesiologists, pharmacists, and nurses. Components that did not reach 90% consensus were included in a second survey the following week, and meetings were held to review results. At the conclusion of this process, time to agreement was retrospectively compared to the colorectal ERAS pathway process at this institution. RESULTS: ERAS pathway components were compiled and reviewed by 121 stakeholders at 7 hospitals using iterative surveys with review meetings over a 13-week period. Survey response rates were 61% and 50% in the initial and follow-up surveys, respectively. There was agreement on 28/32 and 32/32 items on the initial and follow-up surveys. Using the RAND Method, time to agreement decreased by 54.1% (24 vs 13 weeks) compared to prior system-wide efforts to standardize the colorectal surgery ERAS pathway. DISCUSSION: With rapidly expanding healthcare systems, effective methods to gain consensus and adopt ERAS pathways are critical to implementation of ERAS guidelines. We demonstrate that the RAND Method allows for a transparent and efficient means of agreement across a diverse group of clinicians practicing in several settings.

A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education.

BACKGROUND: Clinical experiences, quantified by case logs, are an integral part of pediatric anesthesiology fellowship programs. Accreditation of pediatric anesthesiology fellowships by the Accreditation Council of Graduate Medical Education (ACGME) and establishment of case log reporting occurred in 1997 and 2009, respectively. The specialty has evolved since then, but the case log system remains largely unchanged. The Pediatric Anesthesiology Program Directors Association (PAPDA) embarked on the development of an evidence-based case log proposal through the efforts of a case log task force (CLTF). This proposal was part of a larger consensus-building process of the Society for Pediatric Anesthesia (SPA) Task Force for Pediatric Anesthesiology Graduate Medical Education. The primary aim of case log revision was to propose an evidence-based, consensus-driven update to the pediatric anesthesiology case log system. METHODS: This study was executed in 2 phases. The CLTF, composed of 10 program directors representing diverse pediatric anesthesiology fellowship programs across the country, utilized evidence-based literature to develop proposed new categories. After an approval vote by PAPDA membership, this proposal was included in the nationally representative, stakeholder-based Delphi process executed by the SPA Task Force on Graduate Medical Education. Thirty-seven participants engaged in this Delphi process, during which iterative rounds of surveys were used to select elements of the old and newly proposed case logs to create a final revision of categories and minimums for updated case logs. The Delphi methodology was used, with a two-thirds agreement as the threshold for inclusion. RESULTS: Participation in the Delphi process was robust, and consensus was almost completely achieved by round 2 of 3 survey rounds. Participants suggested that total case minimums should increase from 240 to 300 (300-370). Participants agreed (75.86%) that the current case logs targeted the right types of cases, but requirements were too low (82.75%). They also agreed (85.19%) that the case log system and minimums deserved an update, and that this should be used as part of a competency-based assessment in pediatric anesthesia fellowships (96%). Participants supported new categories and provided recommended minimum numbers. CONCLUSIONS: The pediatric anesthesiology case log system continues to have a place in the assessment of fellowship programs, but it requires an update. This Delphi process established broad support for new categories and benchmarked minimums to ensure the robustness of fellowship programs and to better prepare the pediatric anesthesiology workforce of the future for independent clinical practice.

A Consensus-Driven Approach to Redesigning Graduate Medical Education: The Pediatric Anesthesiology Delphi Study.

BACKGROUND: Pediatric anesthesiology fellowship education has necessarily evolved since Accreditation Council for Graduate Medical Education (ACGME) accreditation in 1997. Advancements in perioperative and surgical practices, emerging roles in leadership, increasing mandates by accreditation and certification bodies, and progression toward competency-based education-among other things-have created pressure to enrich the current pediatric anesthesiology training system. The Society for Pediatric Anesthesia (SPA) formed a Task Force for Pediatric Anesthesiology Graduate Medical Education that included key leaders and subject matter experts from the society. A key element of the Task Force's charge was to identify curricular and evaluative enhancements for the fellowship program of the future. METHODS: The Task Force executed a nationally representative, stakeholder-based Delphi process centered around a fundamental theme: "What makes a pediatric anesthesiologist?" to build consensus among a demographically varied and broad group of anesthesiologists within the pediatric anesthesiology community. A total of 37 demographically and geographically varied pediatric anesthesiologists participated in iterative rounds of open- and close-ended survey work between August 2020 and July 2021 to build consensus on the current state, known deficiencies, anticipated needs, and strategies for enhancing national educational offerings and program requirements. RESULTS: Participation was robust, and consensus was almost completely achieved by round 2. This work generated a compelling Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis that suggests more strengths and opportunities in the current Pediatric Anesthesiology Graduate Medical Education program than weaknesses or threats. Stakeholders agreed that while fellows matriculate with some clinical knowledge and procedural gaps, a few clinical gaps exist upon graduation. Stakeholders agreed on 8 nonclinical domains and specific fundamental and foundational knowledge or skills that should be taught to all pediatric anesthesiology fellows regardless of career plans. These domains include (1) patient safety, (2) quality improvement, (3) communication skills, (4) supervision skills, (5) leadership, (6) medical education, (7) research basics, and (8) practice management. They also agreed that a new case log system should be created to better reflect modern pediatric anesthesia practice. Stakeholders further identified the need for the development of standardized and validated formative and summative assessment tools as part of a competency-based system. Finally, stakeholders noted that significant departmental, institutional, and national organizational support will be necessary to implement the specific recommendations. CONCLUSIONS: A Delphi process achieved robust consensus in assessing current training and recommending future directions for pediatric anesthesiology graduate medical education.

A Comparison of Adult and Pediatric Enhanced Recovery after Surgery Pathways: A Move for Standardization.

BACKGROUND: Enhanced recovery protocols (ERP) are a multimodal approach to standardize perioperative care. To substantiate the benefit of a pediatric-centered pathway, we compared outcomes of children treated with pediatric ERP (pERP) versus adult (aERP) pathways. We aimed to compare components of each pathway to create a new comprehensive pERP to reduce variation in care. METHODS: Retrospective study of children (≤18 y) undergoing elective colorectal surgery from August 2015 to April 2019 at a single institution managed with pERP versus aERP. Multivariable linear and logistic regression, adjusting for demographics and operation characteristics, were used to compare outcomes. RESULTS: Out of 100 hospitalizations (72 patients) were identified, including 37 treated with pERP. pERP patients were, on average, younger (13 versus 16 y), more likely to be ASA III (70% versus 30%), and more likely to receive regional (32% versus 3%) or neuraxial (35% versus 8%) anesthesia. Epidural use was an independent risk factor for longer length of stay (P = 0.000). After adjustment, pERP patients had similar LOS and time to oral intake, but shorter foley duration. pERP patients used significantly fewer opioids and were less likely to return to the operating room within 30 d. 30-d readmissions and ED visits were also lower, but this was not statistically significant. CONCLUSIONS: At our institution, data from both ERPs contributed formation of a synthesized pathway and reflected the pERP approach to opioid utilization and the aERP approach to earlier enteral nutrition.

The impact of standard postoperative opioid prescribing guidelines on racial differences in opioid prescribing: A retrospective review.

BACKGROUND: Racial disparities in opioid prescribing are widely documented, though few studies assess racial differences in the postoperative setting specifically. We hypothesized standard opioid prescribing schedules reduce total opioids prescribed postoperatively and mitigate racial variation in postoperative opioid prescribing. METHODS: This is a retrospective review of adult general surgery cases at a large, public academic institution. Standard opioid prescribing schedules were implemented across general surgery services for common procedures in late 2018 at various timepoints. Interrupted time series analysis was used to compare mean biweekly discharge morphine milligram equivalents prescribed in the preintervention (Jan-Jun 2018) versus postintervention (Jan-Jun 2019) periods for Black and White patients. Linear regression was used to compare mean difference in discharge morphine milligram equivalents among White and Black patients in each study period, while controlling for demographics, chronic opioid use, and procedure/service. RESULTS: A total of 2,961 cases were analyzed: 1,441 preintervention and 1,520 postintervention. Procedural frequencies, proportion of Black patients (17% Black), and chronic opioid exposure (7% chronic users) were similar across time periods. Interrupted time series analysis showed significantly lower mean level of morphine milligram equivalents prescribed postintervention compared with the predicted nonintervention trend for both Black and White patients. Adjusted analysis showed on average in 2018 Black patients received significantly higher morphine milligram equivalents than White patients (+19 morphine milligram equivalents, 95% confidence interval 0.5-36.5). There was no significant difference in 2019 (-8 morphine milligram equivalents, 95% confidence interval -20.5 to 4.6). CONCLUSION: Standard opioid prescribing schedules were associated with the elimination of racial differences in postoperative opioid prescribing after common general surgery procedures, while also reducing total opioids prescribed. We hypothesize standard opioid prescribing schedules may mitigate the effect of implicit bias in prescribing.

Wide range of perioperative drugs and doses used in inguinal hernia repairs for premature infants.

OBJECTIVE: Characterize the types and doses of commonly administered perioperative drugs in inguinal hernia (IH) repair for premature infants. STUDY DESIGN: Single-center, retrospective cohort study. RESULTS: In total, 112 premature infants underwent IH repair between 2010 and 2015. Twenty-one drugs were used during IH repair, with each infant receiving a median seven drugs. Acetaminophen (88%), bupivacaine (84%), cisatracurium (74%), sevoflurane (72%), and propofol (71%) were the most commonly used agents. Thirty-two infants underwent additional procedures with IH repair. Additional procedures were not associated with a higher number of perioperative drugs, however infants with additional procedures were exposed to higher cumulative doses of cisatracurium (p < 0.001) and fentanyl (p = 0.002). CONCLUSION: There is wide variability in the drugs and doses used for a common surgical procedure in this population, even within a single center. Future research should focus on the safety and efficacy of the most commonly used perioperative drugs described in this study.

The opioid epidemic in pediatrics: a 2020 update.

PURPOSE OF REVIEW: Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain. RECENT FINDINGS: Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review. SUMMARY: We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.

Implementation of a pediatric enhanced recovery pathway decreases opioid utilization and shortens time to full feeding.

BACKGROUND: We hypothesized that an enhanced recovery after surgery (ERAS) pathway for pediatric patients undergoing surgery for inflammatory bowel disease (IBD) would be beneficial. METHODS: This is a single institution retrospective comparative study comparing patients treated with an ERAS pathway to consecutive patients in a Preimplementation Cohort (PIC) with similar open and laparoscopic surgeries for IBD. The pathway emphasized minimal preoperative fasting, multimodal and regional analgesia, and early enteral nutrition after surgery. Primary endpoints were time to 120 mL of PO intake (POI), length of stay (LOS), opioid utilization, and 30-day surgical outcomes. Continuous and categorical variables were compared (p < 0.05). RESULTS: There were 23 PIC and 28 ERAS patients with similar demographic data and surgical and anesthetic approaches. ERAS patients experienced a significant increase in the use of regional anesthesia, faster time to POI, and a nonsignificant decrease in mean LOS. ERAS patients had decreased total and daily opioid use with similar complication rates. CONCLUSION: This study demonstrates the effectiveness of a pediatric ERAS pathway for IBD patients requiring laparoscopic and (unique to this study) open surgery. The study demonstrates that opioid utilization and time to feeding can be positively impacted using ERAS pathways without negatively impacting outcomes. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Substantial postoperative pain is common among children undergoing laparoscopic appendectomy.

BACKGROUND: Laparoscopic appendectomy is one of the most common surgical procedures performed in children. However, to our knowledge, the postoperative pain experience of children undergoing laparoscopic appendectomy has never been described. In this study, we assessed the postoperative pain experience of children undergoing laparoscopic appendectomy. METHODS: A retrospective chart review of children aged 9-17 years undergoing laparoscopic appendectomy at a large academic medical center from 2004 to 2010 was performed. Demographic and clinical characteristics and self-reported pain scores (0-10 numeric rating scale) during hospitalization were abstracted from the medical record. Pain scores ≥4 were classified as moderate or severe. If ≥60% of pain ratings were moderate or severe during a specified time period (e.g., particular postoperative day), then the child was defined as experiencing substantial pain during that time. Pain outcomes were summarized using descriptive statistics. Secondary analyses assessed the predictors of substantial postoperative pain. RESULTS: Hundred and eighty-six children underwent laparoscopic appendectomy during the study period. One in three children experienced substantial postoperative pain on the day of surgery, and one in five children continued to have substantial pain the next day. Commonly available clinical and demographic characteristics were poor predictors of substantial postoperative pain. CONCLUSION: These preliminary data suggest that substantial postoperative pain is common in children undergoing laparoscopic appendectomy. More studies of postoperative pain outcomes among children undergoing laparoscopic appendectomy and other common pediatric surgical procedures are needed.

Perioperative crystalloid and colloid fluid management in children: where are we and how did we get here?

It has been more than 50 yr since the landmark article in which Holliday and Segar (Pediatrics 1957;19:823-32) proposed the rate and composition of parenteral maintenance fluids for hospitalized children. Much of our practice of fluid administration in the perioperative period is based on this article. The glucose, electrolyte, and intravascular volume requirements of the pediatric surgical patient may be quite different than the original population described, and consequently, use of traditional hypotonic fluids proposed by Holliday and Segar may cause complications, such as hyperglycemia and hyponatremia, in the postoperative surgical patient. There is significant controversy regarding the choice of isotonic versus hypotonic fluids in the postoperative period. We discuss the origins of perioperative fluid management in children, review the current options for crystalloid fluid management, and present information on colloid use in pediatric patients.