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Feasibility of EnhancedRecovery Protocols in Children

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Lisa LPediatSurgerLaurieSurgicDivisioCenteThe auCorreSurgerStreet,E-mailDOI: 1

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Lisa L. Puett, BSN, RN and Laurie Smith, BSN, RN

Introduction: Enhanced recovery after surgery (ERAS) programshave been utilized among various adult populations, and suc-cessful outcomes are well described in the literature. However,similar programs are not well established for children. The aimsof this article were to explore the existing literature for currentknowledge of the feasibility of enhanced recovery protocolsin children, to explore patient and provider experiences withenhanced recovery programs, and to discuss implications fornursing.Methods: Two basic searches were conducted using PubMed/Medline, CINAHL, and EMBASE to identify pediatric ERAS studiesand studies discussing patient and nurse experiences with ERASprograms. Keywords included “pediatrics or children,” “enhancedrecovery after surgery,” “enhanced recovery,” “fast-track surgery,”“ERAS,” “perioperative,” and “experiences/perceptions/attitudes/views/opinions/feelings.”Results: The search for pediatric ERAS studies yielded ninestudies: five prospective implementations, one retrospectivecase-match, one retrospective review, one systematic review,one scoping review, and no randomized control studies. Therewere different combinations of ERAS principles among thestudies, ranging from 5 to 12. Outcomes included a decreasedhospital length of stay and reduced time to oral nutrition, re-turn of bowel function, and mobilization. The search for expe-riences with ERAS yielded three qualitative studies and onesystematic review: two patient experience and two healthcareprovider experience studies.Discussion: The literature suggests that ERAS protocols inpediatric surgery can be safely integrated into practice andare an effective method for standardizing care. However,additional high-quality experimental and quasi-experimentalstudies are needed to analyze the impact of ERAS on pediatricpatients.

. Puett, BSN, RNric Trauma & Burn Coordinator, Division of Pediatricy, The Johns Hopkins Children's Center, Baltimore, MD.Smith, BSN, RNal Clinical Nurse Reviewer, ACS NSQIP–Pediatric,n of Pediatric Surgery, The Johns Hopkins Children'sr, Baltimore, MD.thors have declared no conflict of interest.spondence: Lisa L. Puett, BSN, RN, Division of Pediatricy, The Johns Hopkins Children's Center, 1800 OrleansSuite 7329, Baltimore, MD 21287.: [email protected]/JPS.0000000000000159

l of Pediatric Surgical Nursing

ght © 2018 American Pediatric Surgical Nursing Associatio

KEY WORDS: enhanced recovery after surgery, ERAS,fast-track surgery, pediatric

Enhanced recovery after surgery (ERAS) was firstintroduced in 2001 by the ERAS Study Group, acollaboration of academic surgeons in Europe,

whose primary focus was to improve the overall qualityof postoperative recovery and reduce complicationsamong patients undergoing major abdominal surgery(Ljungqvist, Scott, & Fearon, 2017; Reismann, Arar,Hofmann, Schukfeh, & Ure, 2012; Reismann et al., 2007,2009; Schukfeh et al., 2014; Smart et al., 2012; Wilmore& Kehlet, 2001). On the basis of published evidence,the ERAS Study Group developed standardized proto-cols for the entire operative spectrum, including caremanagement in the preadmission, preoperative, in-traoperative, postoperative, and follow-up phases. Thefirst evidence-based protocol was published in 2005for adult patients undergoing colorectal surgery (ERASSociety, 2016). Currently, there are over 20 adult colo-rectal ERAS principles (Table 1)with the core includingperioperative counseling and education, limited fasting,early nutrition and mobilization, minimal use of nar-cotics, and nonroutine use of surgical drains and tubes(Gustafsson et al., 2012; Shinnick et al., 2016). Together,these principles aim to maintain physiologic homeo-stasis and reduce surgical stress, therefore facilitatinga quicker postoperative recovery and discharge tohome (Shinnick et al., 2016). ERAS is a multimodal ap-proach, and a single element alone has not been asso-ciated with improved surgical outcomes (Ljungqvistet al., 2017).

Colorectal surgery is common in children and isassociated with a high rate of postoperative mor-bidity. Colorectal procedures are responsible for adisproportionate burden of surgical site infection rela-tive to other surgical procedures in children (Feng,Sidhwa, Cameron, Glass, & Rangel, 2016). Presently,there is high variability in the perioperative manage-ment and surgical outcomes of pediatric colorectalpatients (Leeds et al., 2016; Mattioli et al., 2009; Pearson

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Table 1: ERAS Guidelines for Perioperative Care in Colorectal Surgery

ERAS Society Recommendations (Gustafsson et al., 2012)

Johns Hopkins Children's Center PilotERAS for Patients ≥ 12 Years Old

(Leeds et al., 2016)

Item Guideline Modified Guidelines

Preoperative information, education, and counseling Routine for all patients Included

Preoperative medical optimization Cessation of smoking and alcohol consumption atleast 4 weeks before surgery

Omitted

Preoperative standardized bowel preparation Routine mechanical prep not recommended Antibiotic and mechanical

Preoperative fasting and fluid Carbohydrate treatment Before anesthesia: Solids allowed up to 6 hoursprior. Clears allowed up to 4 hours prior. Routinecarbohydrate treatment, including diabetic.

Gatorade/Pedialyte up to 2 hours before anesthesia

Preanesthesia medication Avoid routine sedatives before anesthesia. Included

Thromboembolism prophylaxis Compression stockings, intermittent pneumaticcompression device, and low-molecular-weightheparin

For patients > 14 years old

Antibiotic prophylaxis and skin preparation Intravenous (IV) antibiotics 30–60 minutes beforesurgery and subsequent doses for prolongedoperations.

Included chlorhexidine baths night before andmorning of surgery

Perioperative fluid management Administration of crystalloids and colloids, guidedby clinical measurements to optimize cardiac output.IV fluids should be transitioned to enteral as soon aspossible.

Internal anesthesia/surgical consensus

Perioperative nutrition Early nutrition screening and support Minimalperioperative fasting Early postoperativeenteral nutrition

Included

Standardized anesthesia protocol Short-acting anesthetics Midthoracic epidural analgesia Internal anesthesia consensus group

Laparoscopic approach Recommended Omitted

Intraoperative normothermia Maintain core body temperature > 36 °C usingwarming devices and warmed IV fluids.

Included

Nasogastric tube Early removal Included

Drains Discouraged Excluded

Urinary catheter Early removal; epidural analgesia is not an indicationfor maintaining a Foley catheter.

Included

Postoperative glucose control Prevent hyperglycemia without causing hypoglycemia Omitted

Postoperative nausea and vomiting Multimodal approach to prevention Included

Postoperative ileus prevention Midthoracic epidural analgesia and laparoscopicapproach recommended. Avoid fluid overloadand nasogastric decompression. Chewing gummay be recommended.

Omitted

Postoperative analgesia Nonopioid Included

Early mobilization Routine for all patients Included

Outcomes and compliance monitoring Standardized routine audits Included

Note. ERAS = enhanced recovery after surgery.

&Hall, 2017; Reismann et al., 2007, 2009, 2012; Schukfehet al., 2014; Shinnick et al., 2016; Vrecenak & Mattei,2014; West et al., 2013). In the last two decades, stan-dardization in perioperative care has become increas-ingly popular due to associated improvements in clinical

Journal of Pediatric Surgical Nursing

Copyright © 2018 American Pediatric Surgical Nursing Associatio

outcomes and reduced healthcare costs (Huang, 2016).ERAS programs, also referred to as fast-track surgery, areclinical pathways designed to standardize perioperativecare and improve surgical outcomes by reducing institu-tional and provider level variation in care.



ERAS programs have been utilized among vari-ous adult populations, and successful outcomes arewell described in the literature. However, similarprograms are not well established for children, per-haps because of the physiological, psychosocial,and developmental factors unique to the pediatricpopulation. The aims of this article were to explorethe existing literature for current knowledge of thefeasibility of enhanced recovery protocols in children,to explore patient and provider experiences with en-hanced recovery programs, and to discuss implicationsfor nursing.

METHODSTwo basic searches were conducted using PubMed/Medline, CINAHL, and EMBASE. Filters for both searcheswere set to include full-text articles with an abstract,available in English, and published in an academicjournal between 2007 and 2017. The first search wasconducted to identify pediatric ERAS studies. Thekey search terms included “pediatrics” or “children,”“enhanced recovery after surgery,” “enhanced recov-ery,” “fast-track surgery,” “ERAS,” and “perioperative.”Titles were reviewed for pediatric ERAS studies, andpediatric was defined as less than 18 years old. Abstractsand articles were then reviewed for the inclusionof multimodal ERAS programs for the perioperativemanagement of colorectal and abdominal surgicalpatients. Articles that were adult-only, were not re-search oriented, and/or studied a population not in-clusive of colorectal or abdominal surgical patientswere excluded.

The second search was conducted to identifyarticles discussing nurse and patient experienceswith ERAS. The key search terms included “enhancedrecovery after surgery,” “enhanced recovery,” “fast-tracksurgery,” “ERAS,” and “experiences” or “perceptions” or“attitudes” or “views” or “opinions” or “feelings.” Thesearch was not limited to pediatrics or colorectal orabdominal surgical patients, and there were no addi-tional exclusions. Titles and abstracts were reviewedfor relevant qualitative studies.

RESULTSPediatric ERAS Studies

The search for pediatric ERAS yielded nine stud-ies (Table 2) that originated from Germany (n = 4),Italy (n = 1), the United Kingdom (n = 2), and theUnited States (n = 2). There were no randomized controlstudies. Four studies were prospective implementations



of ERAS programs, using data from the German di-agnosis-related groups as the comparison group(Reismann et al., 2007, 2009, 2012; Schukfeh et al.,2014). Three of these prospective studies investi-gated the feasibility of ERAS in pediatric surgery(Reismann et al., 2007, 2009; Schukfeh et al., 2014),and the fourth investigated the impact of individ-ual elements of an ERAS protocol on outcomes(Reismann et al., 2012). Of note, these four studieswere conducted by the same research group but atdifferent periods and with different samples. Therewas a fifth prospective study that described the expe-rience with ERAS protocol implementation and out-comes; however, this study did not have a control orcomparison group (Mattioli et al., 2009). A retro-spective case-match study compared outcomes amonga pediatric cohort, managed by traditional periopera-tive methods, with the outcomes of an adult cohort(18–25 years old) that was managed by an establishedERAS program; patients were matched by diagnosisand surgical procedure (West et al., 2013). There wasone retrospective review that investigated ERAS out-comes in pediatrics (Vrecenak & Mattei, 2014). Onesystematic review synthesized evidence from five pe-diatric ERAS studies, all of which are also included inthis review (Shinnick et al., 2016). One scoping re-view discussed nine studies, seven of which are also in-cluded in this review (Pearson & Hall, 2017); the twostudies excluded focused exclusively on nutrition orsurgical technique.

Sample sizes among the prospective and retro-spective studies were small, ranging from 46 to 203participants. Males accounted for greater than 50%of the sample in six of seven studies (Reismann et al.,2007, 2009, 2012; Schukfeh et al., 2014; Vrecenak &Mattei, 2014; West et al., 2013), ranging from 53%to 78%. Gender was not included in the seventh study(Mattioli et al., 2009). The mean ages are describedin Table 2. In three studies, the surgeries were colo-rectal procedures only (Mattioli et al., 2009; Vrecenak& Mattei, 2014; West et al., 2013). One study includedabdominal and urological procedures (Reismann et al.,2007), and three studies included abdominal, urologi-cal, and thoracic procedures (Reismann et al., 2009,2012; Schukfeh et al., 2014). There were differentcombinations of ERAS principles among the studies,ranging from 5 to 12. Principles utilized in all six pedi-atric ERAS studies were perioperative counseling andeducation, early nutrition, early mobilization, limiteduse of opioids, nonroutine use of surgical drains, andlimited use/early removal of nasogastric (NG) tubeand Foley (Figure 1).



Table

2:Cha

racteristics

ofInclud

edPe

diatricER

ASStud

ies

Reference,Journa

l,an

dLo

cation

Aim

oftheStud

yStud

yTypean

dDates

Num

ber

ofPa

rticipan

tsMeanAge

(Years)

Surgical

Proced

ures

Outcomes

Con

clusions

Reisman

net

al.(2007),

JournalofPediatricSurgery,

Germany

Toassess

feasibility

ofFT

concep

tsforpe

diatric

surgicalproced

ures.

Prospe

ctivecoho

rt,

June

2004–Jun

e2005

113,65

%male

5.8±5.3

Abdo

minalandurolog

ical

procedures.

Redu

cedLO

SPatie

nts“highly”

satisfied

Threeread

mission

s:tw

orequ

iredadditionalsurgery

Implem

entatio

nof

all

elem

entsof

FTprotocols

isrequ

iredto

achieve

optim

alresults.

Mattioliet

al.(20

09),

Journa

lofLapa

roen

doscop

ican

dAdvan

ced

Surgical

Techniqu

es,Italy

Topresen

tFTexpe

rience.

Prospectivecohortwithout

acomparison

group,

2000–2007

46Co

loninne

rvation=

7.9mon

ths

IBD=8mon

ths

Lapa

roscop

iccolon

resectionsurgeryfor

anom

aliesof

colon

inne

rvationandIBD.

Oraln

utritionan

dfirst

bowelmovem

ent

achieved

with

in1da

yDischarge

byDay

5in

96%

Tworead

mission

s,bo

threqu

iredad

ditio

nal

surgery

FTprincip

lesshouldalways

beimplem

entedunless

thereisearly

detectionof

postoperativecomplications.

Reisman

net

al.(2009),

Lang

enbeck'sArchives

ofSurgery,Germany

ToinvestigateFT

concepts

inroutinepediatric

surgery.

Prospe

ctivecoho

rt,

June

2006–Jun

e2007

155,65

%male

7.3±6.4

Electiveab

dominal,

thoracic,orurolog

ical

surgerywith

requ

ired

hospitalization.

Redu

cedLO

S90%achieved

oralnu

trition

bytheen

dof

POD1

Patie

nts“gen

erally”

satisfied

Threeread

mission

s

Inthispo

pulation,FT

principles

canbe

applied

safelyandbe

effectivein

redu

cing

hospitallength

ofstay.

Reisman

net

al.(2012),

European

JournalofPediatric

Surgery,Germany

Toinvestigatethe

applicab

ility

ofsing

leFT

elem

entsan

dtheir

impa

cton

thequ

ality

ofpa

tient

care.

Prospe

ctivecoho

rt,

April20

09–A

pril2010

203,66

.5%

male

8.3±6.7

Electiveab

dominal,

thoracic,orurolog

ical

surgerywith

requ

ired

hospitalization.

Redu

cedLO

S95%

ofpa

tientswere

“verysatisfied”

Four

read

mission

s:on

erequ

iredad

ditio

nal

surgery

FTelem

entsin

pediatric

surgeryhave

thepotential

toim

prov

eou

tcom

esirrespective

ofthe

applicab

ility

ofawho

leFT

protoc

ol.

Westet

al.(2013),Journa

lof

Pediatric

Surgery,

UnitedKing

dom

Tocompa

reacoho

rtof

pediatric

patientsmanaged

with

traditionalperioperative

metho

dswith

amatched

coho

rtof

adultpa

tients

(<25

yearsold)

man

aged

with

anestablishe

dERAS

protocol.

Retrospe

ctivereview

,January2005–January2011

Pediatrics=34,53%

male

Adu

lts=34,53%

male

Pediatrics=15

Adults=22

Electivecolorectalsurgery

forIBD

.Th

ead

ultcoho

rtexpe

rienced

redu

ced

LOSan

dredu

cedtim

eto

oralnu

trition

and

mob

ilizatio

n.Nodiffe

rencebe

tween

pediatric

andadultcoh

orts

intim

eto

return

ofbo

wel

functio

n,morbiditie

s,or

read

mission

s.One

read

mission

inERAS

coho

rtan

drequ

ired

additio

nalsurge

ryTh

reeread

mission

sin

pediatric

coho

rt:one

requ

iredad

ditio

nal

surgery.

App

licationof

ERASin

pediatric

surgerycould

accelerate

recovery

and

redu

celeng

thof

postop

erativestay,

improvingtheoverall

quality

andefficiency

ofcare.

Journal of Pediatric Surgical Nursing Volume 7 • Issue 1 12

(continues)

Copyright © 2018 American Pediatric Surgical Nursing Association, Inc. Unauthorized reproduction of this article is prohibited.

Table

2:Cha

racteristics

ofInclud

edPe

diatricER

ASStud

ies,Con

tinu

ed

Reference,Journa

l,an

dLo

cation

Aim

oftheStud

yStud

yTy

pean

dDates

Num

ber

ofPa

rticipan

tsMeanAge

(Years)

Surgical

Proced

ures

Outcomes

Con

clusions

Schu

kfeh

etal.(20

14),

European

Journa

lof

PediatricSurgery,Germany

Toassesstheap

plicab

ility

ofestablishedFT

concep

tsin

ano

nacade

mic

departmentof

pediatric

surgery.

Prospe

ctivecoho

rt,

February2011–January2012

143,78%

male

7.9±5.0

Abd

ominal,tho

racic,an

durolog

icalproced

ures

Noredu

ctionin

hospital

LOS

Meanpa

tient

satisfaction=8.6/10

Sixread

mission

s

FTconceptscanbe

safely

andeffectivelyappliedto

pediatricsinanonacademic

hospitalw

ithou

tpreviou

sFT

expe

rience.

Vrecen

ak&Mattei(2014),

Journa

lofP

ediatric

Surgery,UnitedStates

Toassess

FTou

tcom

esRe

trospe

ctivereview

,Decem

ber2000–

Decem

ber2010

71,60%

male

14.6

Lapa

roscop

icileocecectomyfor

Croh

n'sdisease.

Redu

cedLO

SRedu

cedtim

eto

oral

nutrition

andreturn

ofbo

welfunctio

nTw

oread

mission

sIncrease

inSB

Oin

ERAScoho

rt(p

=.15)

FTprinciples

aresafe

andeffectivein

redu

cing

hospitallen

gthofstay

and

return

ofbo

welfunctio

n.

Shinnick

etal.(2016),

Journa

lofSurgical

Research,U

nitedStates

Toexploretheexistin

geviden

ceof

multim

odal

ERASprog

ramsthat

integrategu

idelines

from

theERASSociety.

System

aticreview

,2000–2012

––

––

ERAS

inpediatricsappears

prom

ising;how

ever,there

isaneed

foradd

itional

prospectivestudiesto

defineandvalidateadult

ERAS

principles

adaptedto

pediatrics.

Pearson&Hall(2017),

Pediatric

Surgery

Internationa

l,UnitedKing

dom

Toiden

tifygaps

inthe

existin

gliteratureon

pediatric

ERASto

offer

guidan

ceforfuture

clinicalworkandresearch.

Scop

ingreview

––

––

ERASin

pediatricshas

bene

fits.How

ever,the

literatureislim

ited,

and

additio

nalp

rospective

stud

iesarene

eded

.

Note.ERAS=enhancedrecovery

aftersurgery;FT=fast-track;IBD

=inflam

matorybow

eldisease;POD

=postoperativeday;SB

O=sm

allbow

elobstruction.



Five of seven studies reported a decreased hospitallength of stay among ERAS cohorts (Reismann et al.,2007, 2009, 2012; West et al., 2013; Vrecenak &Mattei,2014). Mattioli et al. (2009) reported that 96% of pa-tients were discharged by postoperative day (POD) 5.West et al. (2013) reported a reduced time to oral nu-trition and return of bowel function. Vrecenak andMattei (2014) also reported these outcomes, plusreduced time to mobilization. Mattioli et al. reportedthat oral nutrition and first bowel movement wereachieved by 100% of patients by the end of POD 1.Vrecenak and Mattei reported that 90% of patientsachieved oral nutrition by the end of POD 1. All stud-ies reported readmissions, and four studies reportedreadmissions for surgical management of a complica-tion (Mattioli et al., 2009; Reismann et al., 2007, 2012;West et al., 2013). Three studies reported that compli-cations were not associated with the ERAS interven-tions (Reismann et al., 2007, 2012; Schukfeh et al.,2014). Four studies reported patient satisfaction out-comes, which range from “generally satisfied” to “verysatisfied” (Reismann et al., 2007, 2009, 2012; Schukfehet al., 2014).

All seven pediatric ERAS studies concluded thatimplementation of ERAS is feasible and safe for pedi-atric surgical patients. Schukfeh et al. (2014) suggestthat pediatric ERAS may be implemented in nonaca-demic hospital settings. Reismann et al. (2007) con-cluded that implementation of all elements of ERASprograms is required to achieve optimal results; how-ever, Reismann et al. (2012) suggest that individual ele-ments of ERAS in pediatric surgery have the potential

FIGURE 1. ERAS principles utilized in the pediatric studies.



to improve outcomes “irrespective of the applicabilityof awhole [ERAS] protocol” (p. 44). Although outcomesand conclusions were positive, all studies implied thatthe literature is limited and additional research is needed.Shinnick et al. (2016) and Pearson and Hall (2017) dis-cussed the need for future prospective cohort studieswith strong controls, large samples, and models thatimplement multifaceted ERAS.

ERAS Experience StudiesThe search for experiences with ERAS yielded three

qualitative studies (Bernard & Foss, 2014; Gotlib Connet al., 2015; Jeff & Taylor, 2014) and one system-atic review (Sibbern et al., 2017). Two studies dis-cussed patient experiences (Table 3; Bernard & Foss,2014; Sibbern et al., 2017), and two studies discussedprovider experiences (Table 4). Of the provider expe-riences, one Gotlib Conn et al., 2015) and one studydiscussed experiences of ward nurses with varyingyears of nursing experience (Jeff & Taylor, 2014). Sam-ple sizes for the three qualitative studies were small.Two studies enrolled less than 10 participants (Bernard& Foss, 2014; Jeff & Taylor, 2014). Gotlib Conn et al.(2015) enrolled 48 participants, including nurses, anes-thesiologists, and surgeons from each of 15 participat-ing ERAS centers. Sibbern et al. (2017) synthesizedfindings from11 qualitative studies, one ofwhich is alsoincluded in this review (Bernard & Foss, 2014). Thequalitative studies utilized semistructured interviews,and all four studies utilized thematic analysis, whichproduced four final themes. These are described inTable 4.



Table

3:Pa

tien

tExperiences

WithER

ASProtocols

Reference,Journa

l,an

dLo

cation

Aim

oftheStud

yStud

yCha

racteristics

NFind

ings

Con

clusions

Bernard&Foss

(2014),

British

Journa

lofN

ursin

g,En

glan

d

Toexploreexpe

riences

ofpa

tients

who

received

care

with

inan

ERAS

prog

ram

byun

derstand

ingho

wpa

tientsview

,cop

ewith

,and

expe

riencesurgery.

Qualitative

Groun

dedtheo

rySemistructuredinterviews

Them

atican

alysis

Constant

compa

rativean

alysis

6Th

eme1:inform

ationprovision.

Variatio

nin

theam

ount

andqu

ality

ofpe

riope

rativeinform

ationan

ded

ucation.

Them

e2:inpa

tient

expe

riences

Expe

ctations

forrecovery

anddischa

rgewere

cleara

ndade

creasedho

spitalLOSwas

preferred.

Them

e3:ho

merecovery

expe

riences.

Hom

erecovery

was

preferred,althou

ghcomplicated

byph

ysicalchalleng

es/limitatio

nsandconfusionregardingou

tpatient

resourcesand

follow-up.

Them

e4:psycho

logical/emotionalexperiences

Increasedanxietyandisolation,espe

ciallydu

ring

homerecovery,attrib

uted

toan

increased

emph

asison

patient

self-care

andade

creased

hospitalLOS.

Hom

erecovery

elicite

dhigh

levelsof

anxiety

amon

gERASpa

tients,which

was

exacerba

tedby

alack

ofinform

ationandpo

orcommun

icationwith

theirERA

Steam

.Con

sistent,high-qu

ality

inform

ation

forp

atientsisneeded

tosupp

ortand

achieve

successfulho

merecovery.

ERASisexpand

ingam

ongspecialties,and

nursingwill

beexpected

tobe

know

ledg

eableoftheERAS

process.

Commun

itynu

rses

need

additionalresources

tosupp

ortp

atientsdu

ringho

merecovery.

Sibb

ernet

al.(2017),

Journa

lofC

linicalNursin

gTo

furthe

rknow

ledg

eon

patie

nts'

perio

perativeexpe

riences

unde

rERASprog

ram

man

agem

ent.

System

aticreview

ofqualitativestudies

11Th

eme1:inform

ationtran

sfer

Preo

perativeinform

ationwas

helpful,bu

tsome

patie

ntspreferredad

ditio

naltim

eto

ask

questio

nsan

dconsider

theinform

ationbe

fore

surgery.Inconsistent

inform

ationwas

trou

blesom

e.Th

eme2:ba

lancingbu

rden

somesymptom

san

dexpe

ctations

forrapidrecovery

Patie

ntsweremotivated

topa

rticipatein

their

care

planning

.Patie

ntsfoun

ditchalleng

ingto

meetthe

prov

iders'expe

ctations

forrecovery

whe

nthey

werein

pain

orph

ysicallylim

ited.

Positiv

ereinforcem

entfrom

thetreatm

entteam

motvatedpa

tients.

Them

e3:individu

alized

treatm

entv

s.stan

dardized

regimen

Patie

ntsexpe

rienced

variablerespon

sesto

ERAS

protocols.

Patie

ntsexpressedthene

edto

besupp

ortedas

individu

als.

Them

e4:senseof

securityat

discha

rge

Patie

ntsweremotivated

bythepo

ssibility

ofearly

discharge.Levelo

fcom

fortat

discha

rge

correlated

with

theam

ount

andqu

ality

ofinform

ationgiven.

Patie

ntsaremotivated

topa

rticipatein

theircare

plan.U

nderstanding

ofprog

ram

expectations

eases

patient

anxiety.Therefore,sufficientpatient

education

andcoun

selingareessential.


aftersurgery;LOS=lengthof

stay.



Table

4:Nurse/HealthcareProfession

alExperiences

Reference,Journa

l,an

dLo

cation

Aim

oftheStud

yStud

yCha

racteristics

NFind

ings

Con

clusions

Gotlib

Conn

,McKen

zie,

Pearsall,&McLeo

d(2015);Implem

entatio

nScience;Ca

nada

Toun

derstand

thecham

pion

s'pe

rcep

tions

ofprocessen

ablers

andba

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aftersurgery.



PATIENT EXPERIENCESPatients are motivated to participate in their own careplanning (Sibbern et al., 2017). At the same time, patientsexperience high levels of anxiety when discussing earlydischarge and home recovery. This anxiety is exacerbatedby inadequate or inconsistent information providedby the healthcare team and unclear expectations ofthe patient during the postoperative recovery phase.Therefore, consistent and high-quality information forpatients and individualized supportive measures areessential for easing patient anxiety and promotingsuccessful outcomes (Bernard & Foss, 2014; Mitchell,2011; Sibbern et al., 2017).

PROVIDER EXPERIENCESAccording to Gotlib Conn et al. (2015), “successful ERASimplementation is achieved by a complex series ofcognitive and social processes” (p. 10). The multidis-ciplinary team “championing” an ERAS programmustbe committed and engaged, as they are responsiblefor the program implementation; the ongoing monitoringof quality, compliance, and outcomes; and the problem-solving and team-building activities necessary to achievesustainability. For bedside nurses, Jeff and Taylor (2014)found that level of experience was influential on nurseperceptions of ERAS. Experienced nurses reported nega-tive feelings toward ERAS and deviated from the protocolif certain elements conflicted with the care they providedin the past. Newer nurses felt that they were more posi-tive than the experienced nurses in regard to program im-plementation and, as a result, adjusted to ERAS programswith more ease. Both experienced and newer nurseswanted to feel confident in the care they provide. How-ever, nurses felt confused about their role in the ERASprotocol, when to advance a patient's recovery, andwhen to deviate from the ERAS protocol if a patient isnot meeting treatment goals. Nurses felt that theyneeded more clarity and guidance. Jeff and Taylor con-cluded that nurses must have the “autonomy to adaptstandardized protocols to individualize patient care”(p. 31) based on patient recovery trajectory.

DISCUSSIONFeasibility of ERAS Programs in Children

There is a notable gap in the literature regardingpediatric-specific enhanced recovery protocols. Thisreview identified only six studies that exclusively inves-tigated multimodal pediatric ERAS programs. Althougheach of the six studies concluded that implementationof ERAS is feasible and safe for pediatric surgical pa-tients, additional research is needed. The comparability



between studies and the generalizability beyond studiesare impaired by multiple factors. Most of these studieswere small populations housed within a single institu-tion. It is difficult to evaluate if these early adopters mayhave also been disproportionately suited to benefit fromsuch a pathway comparedwith other care environments.In addition, different combinations of ERAS principleswere utilized within each study leading to limited hy-pothesizing of which of the many time-consumingand often resource-intensive ERAS interventions arecritical and drive the observed benefits. We also worrythat the lack of rigorous criteria for selecting includedERAS components suggests that improvements maynot have been directly linked to an ERAS implementa-tion at all. Of note, not one study included all elementsof an adult ERAS program as defined by the ERAS Soci-ety (Table 1; Gustafsson et al., 2012).

Furthermore, there are important considerationswhen transposing adult ERAS principles to children,and many of the best practices in the latter patientpopulation are yet to be determined. It cannot be con-cluded whether all adult principles are meaningful andapplicable to the pediatric population. Furthermore,it cannot be concluded that all principles deemed ap-propriate for pediatric ERAS programs are actuallyclinically relevant to all children aged 0–18 years. Age-related implications are not well described, making itdifficult to ascertain whether, for example, neonatesexperienced the same benefits from a colorectal ERASprogram compared with school agers and adolescents.No current society recommendations exist for how tomodify ERAS principles for a pediatric population. Rec-ognizing the potential need for further age stratifica-tion, Leeds et al. (2016) have initiated a pilot study toinvestigate the outcomes of a modified ERAS programamong pediatric colorectal patients greater than 12 yearsold. Modificationswere based on age-related physiologicand psychosocial factors. This modified ERAS programis compared with the ERAS Society adult principles inTable 1.

Implications for NursesAs ERAS programs are growing in popularity among

pediatric surgical specialties, it is imperative for nursesto have a fundamental understanding of what an ERASprogram is, why the program is important, and the ex-pectations for nurses in practice. As active and integralmembers of the ERAS team, nurses facilitate the patients'transitions through the perioperative process, beginningwith the preoperative counseling and assessments,patient and caregiver education, hospital and procedurecoordination, and overall expectation setting for the



duration of the ERAS protocol. In the outpatient setting,a small group of nursesmay be responsible for the ERASpatients. However, once admitted to the hospital, patientsmay encounter a number of nurses, from preoperative tothe inpatient unit. A reliable method for identifyingERAS patients should be established as well as a con-sistent and reliable method for communicating thepatient's protocol and clinical progress.

Although standardization is the fundamental intentof ERAS programs, it is important for nurses to under-stand that not every patient will be a “perfect fit.” Ele-ments of the protocol may need to be individualizedto meet the patients' needs. We suspect that individual-ization will be needed more for the pediatric popula-tion as compared with adults because of the uniquedevelopmental and psychosocial factors associated withchildren. In such cases, communication of individual-ized protocols will be crucial to ensure consistent careand to prevent frustration among the ERAS team, patient,and caregiver(s).

Resistance to ERAS programs may arise when thenursing interventions outlined in a protocol conflictwith traditional nursing cares. For instance, Jeff andTaylor (2014) found that experienced nurses tendedto deviate from the protocol when it differed fromtheir prior experiences. Because the success of anERAS program relies heavily on protocol compliance,it is imperative for nursing leadership to identify waysto engage the nursing staff while fostering an envi-ronment that supports change and the advancementof evidence-based practice. It is important for ERASteams and clinical nursing units to establish an orga-nized ongoing process for identifying and monitoringissues related to compliance and educational needs. TheComprehensive Unit-Based Safety Program could be aviable option for this task.

CONCLUSIONThe literature suggests that ERAS protocols in pediatricsurgery can be safely integrated into practice and are aneffectivemethod for standardizing care. However, addi-tional high-quality experimental and quasi-experimentalstudies are needed to analyze the impact of ERAS on pe-diatric patients. Researchers may consider investigatingwhich ERAS interventions are most effective in ensur-ing optimal pediatric outcomes. This specificity wouldbe beneficial when designing education for the multi-disciplinary healthcare team, patients, and caregivers.Further observation and management of the bedsidecaregiver experience is also an important area forfurther research. Nurses play an integral role in successful



ERAS programs; thus, it is imperative for nurses to have afundamental understanding of what an ERAS program is,why the program is important, and the expectationsfor nurses in practice.

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of enhanced recovery after surgery: A systematic re-view of qualitative studies. Journal of Clinical Nursing,26(9), 1172–1188. doi:10.1111/jocn.13456

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Vrecenak, J. D., & Mattei, P. (2014). Fast-track management issafe and effective after bowel resection in children withCrohn's disease. Journal of Pediatric Surgery, 49(1), 99–103.doi:10.1016/j.jpedsurg.2013.09.038

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