Implementation of an Enhanced Recovery After Surgery Pathway for Pediatric Surgical Oncology using Quality Improvement Methodology.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have demonstrated significant benefits, but often face challenges in implementation due to the scope of process measures and multidisciplinary buy-in required. This study aimed to standardize surgical care for children undergoing solid tumor resection by implementing an ERAS for Tumor (ERAST) pathway. PATIENTS AND METHODS: Our ERAST pathway consisted of 20 process measures. Plan-Do-Study-Act (PDSA) cycles were utilized, including implementing standardized pre- and postoperative orders, data-enabled electronic progress note templates, and multidisciplinary preoperative team huddles. Our primary outcome was 80% adherence to protocol process measures. Secondary outcomes included hospital length-of-stay (LOS) and opioid usage. Balancing measures included readmission and/or emergency room visits within 30 days post-procedure. RESULTS: Over 15 months, 57 patients (63 surgeries) were included. Median adherence to process measures was 89.5%. Intraoperative fluid administration decreased from 12.19 to 5.97 ml/kg/h (p < 0.001). Intraoperative opioid use in abdominal cases fell from 0.37 to 0.24 OME/kg (p = 0.0008); postoperative opioid use dropped from 0.16 to 0.04 OME/kg/day (p < 0.001). Thoracic cases saw post-operative opioid use decrease from 0.30 to 0.13 OME/kg/day (p = 0.0017). Median LOS decreased for laparotomy (4.48-2.87 days), thoracotomy (3.37-2.26 days), and thoracoscopy (1.60-1.15 days), all p < 0.001. There was no difference in readmission and/or emergency room visits pre/post ERAST for all cases. CONCLUSIONS: The ERAST pathway achieved high protocol adherence and led to significant reductions in opioid use and LOS, without worsening balancing measures. This demonstrates the effectiveness of multidisciplinary, protocol-driven recovery pathways in pediatric surgical oncology.