High-fidelity implementation of enhanced recovery protocols improves outcomes in pediatric gastrointestinal surgery

1. High-fidelity adherence to an enhanced recovery protocol was associated with a significantly shorter length of stay and fewer complications compared to low-fidelity care in pediatric patients undergoing elective gastrointestinal surgery.

2. Protocol adherence improved across study phases, and electronic health record order set integration and favorable site culture were the institutional factors most strongly linked to higher adherence.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Enhanced recovery protocols (ERPs) are evidence-based surgical care bundles designed to reduce complications, expedite recovery, and lower costs through strategies such as minimally invasive surgery, nutritional optimization, and multimodal pain management. Although ERPs are well-established in adult surgery, their adoption in pediatric populations has been slower and largely limited to single-center studies. The ENRICH-US trial tested a 21-element, consensus-built ERP across U.S. surgery centers in pediatric patients undergoing elective gastrointestinal (GI) surgery. The protocol did not significantly shorten hospital length of stay or improve most secondary outcomes when analyzed by study phase alone. However, when ERP fidelity was considered, patients who received more ERP elements had shorter hospital stays and fewer complications with reduced opioid use and time to regular diet across phases. These findings suggest that mere ERP introduction is insufficient, but high-fidelity ERP implementation yields measurable benefits for patients. Strengths of this study included its multicenter, randomized design and rigorous implementation science framework. Limitations included COVID-19-related enrollment concerns and limited generalizability, as the study excluded newborns, infants, and patients requiring urgent surgery.

Click to read the study in JAMA Surgery

Relevant Reading: Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System

In-Depth [randomized controlled trial]: In this prospective type 2 hybrid implementation-effectiveness, stepped-wedge cluster-randomized controlled trial, 597 patients aged 10-18 years undergoing elective GI surgery were enrolled across 18 U.S. sites between September 2019 and June 2024. The most common surgical indication was inflammatory bowel disease (n = 433, 72.5%). Sites were randomized into three groups, each completing a minimum 9-month control period (n = 248), followed by a 12-month implementation phase (n = 156), and then a one- to two-year sustainability phase (n = 193). During the implementation phase, sites received a structured implementation toolkit guided by the five Active Implementation Frameworks (5AIFs), monthly learning collaborative sessions, and quarterly feedback reports with ERP adherence data. Patient-level ERP fidelity was scored from 0 to 17, with patients categorized as high fidelity (≥13 elements) or low fidelity (<13 elements) based on the empirical distribution. Overall, there was no significant change in postoperative length of stay across the three study phases (adjusted change for implementation vs. baseline, -1.10; 95% CI -3.23 to 1.03; adjusted change for sustainability vs. baseline, 0.24; 95% CI -2.51 to 2.99). However, fidelity improved significantly across phases (median [IQR]: 11 [10-13] at baseline vs. 14 [12-15] during implementation vs. 14 [13-15] during sustainability; P < .001). Site-level EHR order set integration (Kendall correlation coefficient = 0.46; 95% CI, 0.15-0.69, P = .02) and site culture (Kendall correlation coefficient = 0.41; 95% CI, 0.09-0.65; P = .03) were the two 5AIF domains significantly correlated with higher fidelity. In the fidelity-stratified sensitivity analysis, patients with high-fidelity care had a 1.14-day shorter hospital stay (95% CI -2.01 to -0.27) and significantly lower odds of any postoperative complication (OR 0.48, 95% CI 0.28-0.82) compared to those receiving low-fidelity care. Among secondary outcomes, only time to regular diet (36.1% decrease, 95% CI 5.91%-56.61%) and average daily opioid use during hospitalization (55.9% decrease, 95% CI 11.4%-78.0%, P = .02) improved significantly. Overall, these results indicate that the clinical benefit of ERPs in pediatric GI surgery depends more on the thoroughness of protocol delivery than on institutional rollout alone.

Image: PD

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