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Changes in care improve recovery for surgery patients

Jul. 28, 2016, 10:55 AM

Hip surgery patient Shelbey Mitchell, center, with Andrew Franklin, M.D., MBA, and Jenna Scobey, M.D., part of the Pediatric Perioperative Interdisciplinary Surgery Home team that devised new strategies to improve the surgical recovery process. (photo by Susan Urmy)
Hip surgery patient Shelbey Mitchell, center, with Andrew Franklin, M.D., MBA, and Jenna Sobey, M.D., part of the Pediatric Perioperative Interdisciplinary Surgery Home team that devised new strategies to improve the surgical recovery process. (photo by Susan Urmy)

Many patients having surgeries at Monroe Carrell Jr. Children’s Hospital at Vanderbilt are experiencing better recoveries, with less opioids for pain, fewer post-surgery complications and shorter hospital stays due to the work of a medical team that has transformed the way surgeries are handled.

“When we looked at various surgical populations and we examined the data over a 10-year period, we found that some patients were having the same trends of less-than-ideal issues that lead to complications or to increased lengths of stay after surgery,” said pediatric anesthesiologist Andrew Franklin, M.D., MBA, director of Pediatric Pain Management Services.

“We found that if we were able to optimize just a few things we could have a large, positive impact, reduce many of the complications and enhance the surgical experience of the child overall.”

Excessive pain, extreme drowsiness, nausea and vomiting, poor mobility and severe constipation are the chief culprits that lead to poor recoveries after surgery and increased time in the hospital.

Franklin teamed up with other pediatric anesthesiologists, surgeons and nurses to identify ways to combat these issues. The team created a pilot program, launched in 2015, called Pediatric Perioperative Interdisciplinary Surgery Home (PRISM) that has modified how patients are cared for before, during and after surgery — a time known as the perioperative period.

Care of PRISM patients is an interdisciplinary team effort led by the Pediatric Pain Management Services, and the team follows the patient from the moment they have their pre-surgery evaluation to the point after surgery when they are released from care. They also have the ability to follow-up with patients in the Pediatric Pain Management Clinic post-operatively, if there is a need.

The PRISM protocol includes giving patients medications before surgery to reduce the incidence and severity of pain during and after surgery and to reduce the need for opioids. During surgery, spinal anesthesia and intravenous anesthesia are used rather than inhaled anesthesia. Inhaled anesthesia can often cause nausea and vomiting, as well as extreme drowsiness following surgery.

More than 50 patients undergoing hip surgeries at Children’s Hospital have been part of the PRISM pilot, providing enough data to demonstrate the effectiveness of the changes. Not all hip surgery patients are candidates for the PRISM protocol, as other existing medical conditions or concerns can rule out their participation.

“We’ve had statistically significant reductions in perioperative opioid consumption,” said Franklin. “We have reduced post-operative nausea and vomiting from 14 percent down to zero. So, we’ve nearly eliminated these issues as a result of using regional anesthesia techniques and opioid-sparing, multimodal regimens. We were also able to reduce the median length of stay after starting our protocol from 3.3 days to 2.3 days. Because of these improvements, we’re able to get our patients mobile more quickly and get them home sooner.”

Shelbey Mitchell of Chapel Hill, Tennessee, was born with severe hip dysplasia, a condition that involves hip joint deformities that can lead to arthritis. Her pain had become so bad that she soaked in a tub of ice water nightly just so she could sleep, and she had given up on one of her favorite activities, cheerleading. She was 17 in 2014 when she had a surgery at Children’s Hospital called periacetabular osteotomy, in which the pelvis is cut to realign the hip.

After her first surgery, she had significant pain, difficulty staying alert and was extremely nauseous. While her recovery was challenging, at the time this was fairly routine for such a complex surgery, said her orthopedic surgeon, Jonathan Schoenecker, M.D. When Schoenecker performed the same surgery on her second hip in May 2016, the improvement in her recovery was remarkable. Her care team and family credit this change to PRISM.

“Just seven weeks after her surgery we had to remind Shelbey to use her crutches,” said her mother, Lora Mitchell. “She’s getting around great, and her physical therapy has been a breeze. This recovery has been like night and day.”

Shelbey was thrilled to have a better recovery after the second surgery, and she quickly tackled the challenges of physical therapy so she could go to cheerleading camp at the end of July. She’s cheering for Tusculum College in East Tennessee, and she’s ready to get back to doing back flips.

“The first time I was in the hospital, I couldn’t eat at all,” she said. “I either felt sick or my leg was hurting too much. With the second surgery, there was not as much pain, and I was more ‘with it’ because I wasn’t on a pain pump. I could actually talk to my friends and family and not feel loopy. And, I wanted food right after I woke up.”

In April, the PRISM protocol was expanded to include patients undergoing pectus excavatum surgery (to correct chest wall deformity) and those with post-dural puncture headaches, and there are plans to expand to surgical areas where it’s felt patients can benefit. Schoenecker was a part of the PRISM team, and is eager to add the protocol to his other orthopedic surgeries.

“Usually by the third day after one of these big surgeries the intense inflammatory response goes away, and the patient starts to look a lot better,” Schoenecker said. “On our old pain protocols, that’s when we would start physical therapy because the patient could not really do anything worthwhile up until that point. Now, you’ll go by a patient’s room the first day after surgery, and they’re wide awake and can talk to you. They have discomfort, but they can start physical therapy. Typically by two or three days after surgery, they are really, really wanting to go home.”

The PRISM team has begun sharing study results at national medical conferences and writing articles for medical journals so other pediatric medical centers can learn from their success.

They also meet regularly to review their cases and continue to make improvements to the process.

“We hope to be the ones who generate the data that validates the use of pediatric enhanced recovery protocols following surgery,” said Franklin. “Vanderbilt can really make a mark as being the institution that led the charge with this type of initiative in the pediatric population.”

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