The how and why of ERAS protocol adoption in pediatric urology

Sarah Hecht, MD

Emerging data support the use of Enhanced Recovery After Surgery (ERAS) protocols in pediatric urology. In this interview, Sarah Hecht, MD, discusses the reasons for using ERAS protocols in pediatric urology and how to overcome barriers to their adoption. Hecht is an assistant professor of urology at Oregon Health & Science University, Portland.

What are some procedures that would benefit most from pediatric ERAS protocols?

Major bladder reconstructive surgeries have the most room for improvement, particularly surgeries involving a bowel anastomosis; also our major oncologic surgeries—Wilm's tumor resections, those types of surgeries. So many of our patients in pediatric urology do so well that we might feel that there's little room for improvement. Many of our surgeries are outpatient; many of our kids stay just 1 night in the hospital. But even with these patients, multimodal analgesia, opioid-free protocols are becoming the norm. We're doing most outpatient urologic surgeries without any opioids; there's no reason not to apply ERAS principles to all surgeries within pediatric urology.

What are the outcomes that are important to track?

What gets measured gets managed, so if you're implementing an ERAS protocol, you want to track your implementation metrics and know how well you're doing at implementing the protocol. Standard perioperative metrics are good to track: pain scores, opioid use, length of stay, cost, time to return of bowel function, and complications—particularly bowel-related complications. The reality is the data are so convincing that we know what to expect with these outcomes. As with any surgery, you want to make sure that your outcomes are in line with the published data.

I'm hopeful that our field moves toward looking into patient-centered outcomes, because I think next steps with ERAS implementation will really be listening to our patients. They can help us improve our protocols.

How do you ensure buy-in from all the collaborative parties involved?

Change is hard, and organizational change is very hard. Whenever you're implementing a new program, system, or protocol, I recommend approaching it with humility and expecting challenges. There may be logistical and enthusiasm barriers, as well as skepticism regarding the mission. Create short-term wins along the way. Be quick to praise people. Be clear in your communication. It's important to start by identifying all of your stakeholders and including everybody. That's not just surgeons and anesthesiologists, it's outpatient clinic staff, schedulers, perioperative staff, floor nursing, child life specialists, even hospital administration. It's important to make everyone feel like they have a say and that they can ask their questions. It's important to have a clear mission, almost like an elevator pitch. This is new for a lot of people.

Our mission with ERAS is not just cost and length of stay improvements—which these days doesn't move many of us in clinical medicine—but it really is enhanced recovery. It's better patient care, so our patients have decreased pain, decreased complications, and easier recovery. Most people can get behind that, and we have a mountain of data to back it up.

I will say one major barrier to ERAS adoption is often surgeon skepticism. It's something different from how we were trained; it's something different from how we've always liked to do things. Common comments from surgeons who are resistant to ERAS protocols are things like, "My patients are different. This patient is too complicated for ERAS." And here, I think it's important to rest on the data and really frame ERAS as mitigation of risk or a shift in mindset. We are trained to think that we’re doing the conservative thing when we’re placing a nasogastric tube, pre-admitting, hydrating, doing a bowel prep, and leaving drains, and it almost seems “cowboy-ish” to forego these interventions. But if you follow the data, you realize that these aren't conservative interventions, they're actually potentially harm-causing interventions, and we can return to our Hippocratic oath to first do no harm and reframe our mindset.

How can pediatric urology evolve to incorporate more principles of ERAS?

The evidence is going to lead us there. In pediatrics we're late adopters and get to sit back and see what the adult world has done before we're willing to try new things on our children. But we have a mountain of data from the adult literature and emerging data in the pediatric literature that ERAS is really helping our patients. I expect the PURSUE [Pediatric Urology Recovery After Surgery Endeavor] study from Kyle Rove, MD, is going to produce data that will be hard to argue with. The Children's Surgery Verification Program is moving toward adopting ERAS pathways as a measure of quality. The data are strong enough now that ERAS will probably just become standard of care. It may be incorporated into guidelines in the near future, and surgeons who don’t adopt ERAS may be left behind as their patients seek care elsewhere. I hope that the data are what's going to take us there.