Fast-Track Pathway for Non-Complicated Pediatric Appendicitis Utilizing a Single Dedicated Pre- and Postoperative Unit

General Information

Institution Name: Levine Children's Hospital

Submitter Name: Angela M. Kao, MD

Name of Case Study: Fast-Track Pathway for Non-Complicated Pediatric Appendicitis Utilizing a Single Dedicated Pre- and Postoperative Unit

What Was Done?

Global Problem Addressed

Acute appendicitis is the most common surgical indication in the pediatric population, yet there remains wide variability in its perioperative management.¹ Analysis of such variations in surgical management has introduced opportunities for quality improvement through standardization of care. Numerous studies have shown initiation of standardized protocols has led to more efficient resource utilization and decreased in-hospital costs, and compared with traditional practices, use of enhanced recovery after surgery (ERAS) has been shown to reduce recovery time by as much as 30 percent.^{2, 3}

Although enhanced recovery after surgery has been well-published in the adult literature, multidisciplinary fast-track protocols in pediatric surgery have been slow to generate the same enthusiasm. Recently, studies have demonstrated the feasibility of same day discharge ( <24 hours) following laparoscopic appendectomy in children with non-complicated appendicitis.^4-7 However, few pediatric studies have utilized a standardized protocol that is comprehensive and adopts components from ERAS bundle described in the adult population.⁸

This quality improvement initiative developed an enhanced recovery protocol for non-complicated 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.

Identification of Local Problem

Prior to implementation of our quality improvement initiative, there was no standardized perioperative management for appendicitis at our institution, leading to a wide range of hospital and postop length of stay (LOS). Preoperative antibiotics were based on provider preference while postoperative pain regimens, time to mobilization, and initiation of enteral nutrition were widely 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 and evidence-based practices, and ultimately reduce patients' length of stay.

How Was the Quality Improvement (QI) Activity Put in Place?

Context of the QI Activity

Levine Children's Hospital (LCH) is a 235-bed children's hospital in Charlotte, NC, that is affiliated with Atrium Health. As the largest pediatric hospital between Washington and Atlanta and the only pediatric Level 1 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. LCH participates in ACS NSQIP Pediatric.

Recent emphasis has been placed on the delivery of value-based care through quality improvement initiatives. At our institution, adult ERAS protocols have been implemented in the divisions of colorectal and HPB surgery, among others, serving as motivation to providers to initiate a similar protocol in the pediatric patient population. In an effort to respond to changing health care needs, we adopted the first pediatric surgery fast-track pathway at Levine Children's Hospital and introduced a multidisciplinary bundle of initiatives to streamline and standardize high-quality surgical care.

Planning and Development Process

A multidisciplinary team of physicians and nurses was formed, including members of the divisions of pediatric surgery, perioperative nursing, anesthesia, and emergency medicine. During 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, were also used during the planning process. A standard fast­ track pathway for non-complicated appendicitis was created with initiatives to standardize care in each perioperative phase, from diagnosis to discharge. The effectiveness and feasibility of implementing each initiative was discussed by the multidisciplinary team prior to reaching a consensus on fast-track pathway components. A preexisting physical unit adjacent to the operating room was newly designated as the dedicated preop and postop recovery unit. Additionally, 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 during the planning process.

An EMR-compatible order set (power plan) was created to facilitate identification of fast-track pathway patients and standardize preoperative and postoperative medications given. This order set was introduced to all surgery attending and resident physicians, who then entered the power plan for all pathway patients.

Initiating a culture change was critical to the implementation process and sustainability of the pathway. All staff, including nursing/nursing assistants, emergency department 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 non-complicated appendicitis fast-track pathway. A total of 14 sessions were held and were facilitated by the clinical nurse educator for preop/PACU. During the implementation process, resource tools were provided in the form of education folders and a Q&A board where staff members could easily reach out for additional clarification. Nursing supervisors were also readily available for questions during the implementation process. After the planning and carrying out phases of pathway implementation, the team met regularly to assess the effectiveness of the QI project and discuss changes to address current barriers (Plan-Do-Study-Act format).

Date when the QI activity was first implemented: June 1, 2017

Resources Used and Skills Needed

Staff

Involvement of pediatric surgeons, emergency department 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 prior to and during the implementation process to address feedback and troubleshoot obstacles. A clinical nurse educator for pre-op/PACU was instrumental in holding education sessions for approximately perioperative staff, and participating in monthly ED staff meetings and daily huddles prior to implementation.

Costs

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 did not receive any funding prior to implementation, grants to offset cost of recovery recliners are currently pending.

What Were the Results

The fast-track pathway was implemented in June 2017. Patients who were found to have ruptured appendicitis intraoperatively were excluded from the pathway. ACS NSQIP Pediatric data and electronic medical records were used to track results and adherence to the protocol, and fast-track patients were compared with a historical cohort of patients prior to implementation.

The reduction in median total hospital LOS and postoperative LOS are illustrated in Figure 1. Following implementation of the protocol, there was a 59 percent reduction in postoperative LOS and a 39 percent reduction in total hospital LOS, without an accompanying increase in postoperative readmissions or complications. Compared with the median average length of stay of two (1.4-3.1) reported by a study looking at practices in more than 30 pediatric hospitals, our results showed a median hospital LOS of 14.7 hours following protocol implementation.1 More than 67 percent (67.2%) of fast-track protocol patients were discharged home within eight hours of surgery. An additional 23 percent of patients who had surgery performed after 10:00 pm were discharged home immediately following morning rounds.

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 intraoperative urinary catheter was also significantly decreased by more than 30 percent after protocol 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 also led to a significant reduction in postoperative nausea and vomiting indicated by number of patients requiring PRN antiemetics in the designated postoperative unit. Use of a stepwise multimodal analgesia regimen resulted in a 37 percent reduction in PRN IV narcotics given postoperatively.

Following discharge, 91.8 percent of patients were followed up with nursing phone calls at 24 hours and seven to 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, or a 4.3 percent decrease in patient cost. Over the monitored period, this yielded a net cost savings of $8,174.

Setbacks

During QI implementation, barriers encountered during the initial phase included ensuring patients were admitted to the designated unit. Patients admitted to other inpatient floors where nurses were not familiar with the fast-track pathway were less likely to be compliant with fast-track initiatives. After identification of the problem, numerous changes, including direct communication with bed management, were taken 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 non-complicated appendicitis were started on the fast­ track pathway. Team members were also 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 the goals of enhanced recovery and set patient expectations for postoperative care.
• Make simple, sustainable changes. In order 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 also minimized interprovider variability at our teaching hospital with different residents rotating on pediatric surgery each month.
• 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.
• Nursing-driven discharge. Shifting the culture to a nursing-driven recovery and discharge process was critical. 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.

References

1. 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;38:372-379. https://doi.org/10.1053/jpsu.2003.50111.
2. 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;100:1108-1114. https://doi.org/10.1002/bjs.9184.
3. Feldman LS, Lee L, Fiore J. What outcomes are important in the assessment of Enhanced Recovery after Surgery (ERAS) pathways? Can J Anesth. 2015;62120-130. https://doi.org/10.1007/s12630-014-0263-1.
4. Bensard D, Hendrickson R, Fyffe CJ, et al. Early discharge following laparoscopic appendectomy in children utilizing an evidence-based clinical pathway. PubMed NCBI. J Laparoendosc Adv Surg Tech A. 2009. https://doi.org/doi:10.1089/ lap 2008 0165
5. Farach SM, Danielson PD, Walford NE, et al. Same-day discharge after appendectomy results in cost savings and improved efficiency. Am Surg. 2014;80:787-791.
6. Putnam LR, Levy SM, Johnson E, et al. Impact of a 24-hour discharge pathway on outcomes of pediatric appendectomy. Surgery. 2014;156:455-461. https://doi.org/10.1016/j.surg.2014.03.030.
7. Aguayo P, Alemayehu H, Desai AA, et al. Initial experience with same day discharge after laparoscopic appendectomy for nonperforated appendicitis. J Surg Res. 2014;190:93-97. https://doi.org/10.1016/j.jss.2014.03.012
8. Shinnick JK, Short HL, Heiss KF, et al. Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res. 2016;202165-176. https://doi org/10.1016/j jss.2015.12 051.