Implementation and sustainability of an enhanced recovery pathway in pediatric bladder reconstruction: Flexibility, commitment, teamwork

Abstract

Introduction: Although enhanced recovery pathways (ERP) provide a safe and effective way to improve the recovery of children undergoing bladder reconstruction, ERPs have not been widely adopted in pediatric urology. We describe a quality improvement initiative and outcomes after implementing a 24-element ERP at a single, freestanding children's hospital.

Study design: Multiple stakeholder meetings were planned and executed, initially with pediatric practitioners with ERP experience to understand potential implementation barriers then with anesthesiologists, nurses, case managers, and other ancillary staff to draft our institution-specific ERP. A standardized order set was generated to improve ERP adherence. ERP adherence audits and cyclic performance evaluations held every 6-9 months facilitated continuous pathway refinement. Patient outcomes were compared with a pre-ERP historic cohort.

Results: Time from initial ERP planning to first implementation was 7 months. ERP was implemented in twenty consecutive patients undergoing bladder reconstruction (median age 11.3 years, range 4.1-21.1) who were compared to twenty consecutive pre-ERP patients (median age 11.4 years, range 7.7-25.1). Median post-operative length of stay (LOS) significantly decreased from 9 days (range 2-31) pre-ERP to 4 days (range 3-29) post-ERP (p < 0.05). A median of 16 (range 12-19) of 24 institutional pathway elements were implemented for each patient. Balancing measures showed no significant increases in highest Clavien complication grade, readmission rate, or unplanned return to the operating room within 30 post-operative days.

Discussion: Implementation of ERP is feasible but requires commitment from multi-disciplinary stakeholders. While we were unable to consistently achieve 80% of the elements, we successfully implemented the pathway and improved our patients' recovery processes (indirectly reflected by a decreased post-operative LOS) with adherence to a median of 67% of elements. Our implementation and effectiveness results are specific to our center and may not be generalizable. However, our experience may offer some insight for others interested in ERP implementation and encourage initiation of their own institutional pathways.

Conclusion: Successful ERP implementation at our hospital for children undergoing bladder reconstruction was facilitated by open communication, early stakeholder involvement, and monitoring ERP adherence. ERP implementation significantly decreased LOS without increasing post-operative complications and readmissions (Summary figure).

Keywords: Bladder augmentation; Enhanced recovery pathways; Quality improvement.