Implementing Change: Sustaining Enhanced Recovery After Surgery Protocols in Pediatric Surgery Using Iterative Assessments.

INTRODUCTION: While Enhanced Recovery After Surgery (ERAS) protocols are becoming more common in pediatric surgery, there is still little published about protocol compliance and sustainability. METHODS: This is a prospective observational study to evaluate the compliance of an ERAS protocol for pectus repair at a large academic children's hospital. Our primary outcome was overall protocol compliance at 1-y postimplementation of the ERAS protocol. Our comparison group included all pectus repairs for 2 y before protocol implementation. RESULTS: Overall protocol compliance at 12 mo was 89%. Of the 16 pectus repairs included in the ERAS protocol group, 94% (n = 15) and 94% (n = 15) received preoperative acetaminophen and gabapentin, respectively, which was significantly greater than the historical control group (P < 0.001). For the intraoperative components analyzed, only the intrathecal morphine was significantly different than historical controls (100% versus 49%, P < 0.001). Postoperatively, the time from operating room to return to normal diet was shorter for the ERAS group (0.53 d versus 1.16 d, P < 0.001). There was no significant difference in readmission rates between the two groups. CONCLUSIONS: ERAS protocol compliance varies based on phase of care. Solutions to sustain protocols depend on the institution and the patient population. However, the utilization of implementation science fundamentals was invaluable in this study to identify and address areas for improvement in protocol compliance. Other institutions may adapt these strategies to improve protocol compliance at their centers.

Closing the Gap: Evaluation of Gender Disparities in Urology Resident Operative Autonomy and Performance.

OBJECTIVE: Gender disparities have demonstrated influence on several areas of medical trainee academic performance and surgeon professional attainment. The impact of gender on perceived operative autonomy and performance of urology residents is not well understood. This single-institution pilot study explores this relationship by evaluating urology faculty and resident assessment of resident operative autonomy and performance using the Society for Improving Medical Professional Learning app. DESIGN: Using Society for Improving Medical Professional Learning, trainees in a single urology residency program were assessed in operative cases on three scales (autonomy, performance, and case complexity). Intraoperative assessments were completed by both faculty and residents (self-evaluation). Respective evaluations were compared to explore differences in ratings by gender. SETTING: University of Michigan Health, Ann Arbor, MI. PARTICIPANTS: University of Michigan Urology Residents and Faculty. RESULTS: A total of 516 evaluations were submitted from 18 urology residents and 20 urology faculty. Self-reported ratings among female and male residents did not differ significantly for autonomy (p = 0.20) or performance (p = 0.82). Female and male residents received overall similar autonomy ratings that were not significantly different from female faculty (p = 0.66) and male faculty (p = 0.81). For female residents, there was no significant difference in performance ratings by faculty gender (p = 0.20). This finding was consistent when the resident was male (p = 0.70). CONCLUSIONS: At our institution, there is no overall gender-based difference in self-rated or faculty-rated operative autonomy or performance among urology trainees. Understanding relevant facets of institutional culture as well as educational strategies between faculty and residents may identify factors contributing to this outcome.

Quantifying Healthcare Utilization and Delay in the Treatment of Gastric Stenosis Following Sleeve Gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is the most common bariatric procedure performed. The incidence of gastric sleeve stenosis (GSS) is up to 4%, with a rising prevalence given increasing popularity of this surgery. GSS is best treated with pneumatic balloon dilation (PBD), but the diagnosis is not always straightforward, oftentimes leading to an extensive diagnostic workup. The aims of the current study were to quantify delay to treatment and overall healthcare utilization during this delay in patients with GSS following SG. METHODS: This was a retrospective review of a prospectively collected database including patients with SG diagnosed with GSS between October 2017 and September 2020. The primary outcome was time between symptom development and treatment with PBD. Secondary outcomes included total healthcare utilization as reflected by the number and charges of imaging and emergency room (ER) visits. RESULTS: Forty-five patients were included in the analysis; 37 (82%) were female. The mean (± SD) time to treatment was 755 (± 713) days. The probability of receiving treatment at 1, 2, and 3 years was 37%, 62%, and 76%, respectively. The mean (± SD) abdominal CT scans, radiographs, and UGIS between symptoms and PBD were 1.3 ± 2.0, 1.2 ± 1.6, and 1.2 ± 1.0, respectively. The mean number of ER visits was 1.9 ± 2.5 (range 0-8). The average number of diagnostic non-therapeutic upper endoscopies was 1.6 ± 1.5. The mean (± SD) total charges were $16,473 ± 15,173. CONCLUSION: Patients who develop GSS following SG experience significant delay in diagnosis and management, reflected by multiple imaging studies, emergency department visits, and non-therapeutic procedures.