Paediatric anaesthesia & critical care
Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial
Authors' conclusion
This stepped-wedge cluster-randomized trial found that despite multifaceted implementation strategies, a pediatric GI surgery ERP did not significantly reduce LOS. However, when accounting for implementation fidelity at the patient level, it resulted in significantly lower LOS and complications.
Study context
- Population
- Pediatric patients aged 10 to 18 years undergoing elective gastrointestinal (GI) surgery at 18 US sites, 2019–2024
- Participants
- 597 patients · 18 US sites
- Comparison
- 21-element ERP with structured implementation toolkit vs usual care
- Primary endpoint
- Postoperative LOS
Methodological detailsprospective, type 2 hybrid implementation-effectiveness, stepped-wedge, cluster-randomised, multicentre, Implementation facilitated by 1-year group-based Learning Collaborative, tool repository, adherence feedback and report cards
- Prospective
- Type 2 hybrid implementation-effectiveness
- Stepped-wedge
- Cluster-randomised
- Multicentre
- Implementation facilitated by 1-year group-based Learning Collaborative, tool repository, adherence feedback and report cards
Primary result
As reported in the abstract
Postoperative LOS by study phase
- No significant differences by study phase in length of stay (LOS)
Secondary outcomes
Postoperative LOS, patients receiving ≥13 ERP elements
| Median LOS difference (days) (95% CI) | ||
|---|---|---|
| At least 13 ERP elementsShorter median LOS | −1.14 (−2.01 to −0.27) | |
| −3−2−101Difference, days (linear scale) |
Complications, patients receiving ≥13 ERP elements
| aOR (95% CI) | ||
|---|---|---|
| At least 13 ERP elementsFewer complications | 0.48 (0.28–0.82) | |
| 0.20.5125Adjusted odds ratio (log scale) |
Secondary outcomes by study phase
- No significant differences by study phase, except shorter time to regular diet and decreased opioid use during hospitalization
Patient-level ERP adherence (number of ERP elements) by study phase
- Adherence increased by study phase (number of enhanced recovery protocols (ERPs) across phases)
- 11 [10-13], 14 [12-15], and 14 [13-15]
- P < .001
Correlation of implementation scores with fidelity
- ERP integration into order sets and site culture moderately correlated with fidelity
Original publication
Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial. JAMA Surg. Published 1 July 2026. doi:10.
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