Rapid Recovery Pathway After Spinal Fusion for Idiopathic ScoliosisWallis T. Muhly, MD, a, b Wudbhav N. Sankar, MD, a, b Kelly Ryan, CRNP, a Annette Norton, CRNP, a Lynne G. Maxwell, MD ,a, b Theresa DiMaggio, CRNP, a Sharon Farrell, CRNP, a Rachel Hughes, PharmD, a Alex Gornitzky, BS, b Ron Keren, MD, MPH, a, b John J. McCloskey, MD, a, b John M. Flynn, MDa, b
aThe Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania; and bPerelman School of Medicine at the
University of Pennsylvania, Philadelphia, Pennsylvania
Dr Muhly conceptualized and designed the quality
improvement pathway, led the development of
data acquisition and analysis, drafted the initial
manuscript, and approved the fi nal manuscript as
submitted; Mss. Ryan, Norton, Dimaggio, Farrell,
and Hughes made a substantial contribution to
the design and implementation of the quality
improvement pathway, reviewed and revised the
manuscript, and approved the fi nal manuscript
as submitted; Mr Gornitzky made a substantial
contribution in data acquisition and analysis,
reviewed and revised the manuscript, and approved
the fi nal manuscript as submitted; Dr Keren
made substantial contribution in the analysis
and interpretation of data, drafting of the initial
manuscript, and approved the fi nal manuscript as
submitted; and Drs Sankar, Maxwell, McCloskey,
and Flynn made substantial contributions to
the conceptualization and design of the quality
improvement pathway, reviewed and revised the
manuscript, and approved the fi nal manuscript as
submitted.
DOI: 10.1542/peds.2015-1568
Accepted for publication Oct 16, 2015
Address correspondence to Wallis T. Muhly, MD,
Department of Anesthesiology and Critical Care
Medicine, The Children's Hospital of Philadelphia,
Perelman School of Medicine at the University of
Pennsylvania, 34th St & Civic Center Blvd, Main
Building, 9th Floor, Suite 9329, Philadelphia, PA
19104. E-mail: [email protected].
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
Adolescent idiopathic scoliosis (AIS)
is the most common pediatric spinal
disorder in North America with an
average of 5000 AIS spine fusions
performed annually from 2001 to
2011.1 Surgical correction of AIS
presents a number of perioperative
challenges including effective pain
control, management of opioid
related side effects, and delay in
mobilization. This can result in
significant patient morbidity with the
potential for prolonged hospitalization
and delayed functional recovery at
home.2 Recent data suggests that the
average length of stay (LOS) for a
patient undergoing posterior spinal
fusion (PSF) for idiopathic scoliosis is
5 to 6 days.3–5 There is evidence that
nonopioid analgesics can improve
pain management in adolescents
undergoing PSF.6–8 Additionally,
early mobilization strategies and
dietary liberalization with early
discontinuation of intravenous opioids
can reduce LOS and costs without
abstractBACKGROUND: Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis
(AIS) is associated with significant pain and prolonged hospitalization.
There is evidence that early mobilization and multimodal analgesia can
accelerate functional recovery and reduced length of stay (LOS). Using
these principles, we implemented a quality improvement initiative to enable
earlier functional recovery in our AIS–PSF population.
METHODS: We designed and implemented a standardized rapid recovery
pathway (RRP) with evidence-based management recommendations
for children aged 10 to 21 years undergoing PSF for AIS. Our primary
outcome, functional recovery, was assessed using statistical process control
charts for LOS and average daily pain scores. Our process measures were
medication adherence and order set utilization. The balancing measure was
30-day readmission rate.
RESULTS: We included 322 patients from January 1, 2011 to June 30, 2015
with 134 (42%) serving as historical controls, 104 (32%) representing
our transition population, and 84 (26%) serving as our RRP population.
Baseline average LOS was 5.7 days and decreased to 4 days after
RRP implementation. Average daily pain scores remained stable with
improvement on postoperative day 0 (3.8 vs 4.9 days) and 1 (3.8 vs 5 days)
after RRP implementation. In the second quarter of 2015, gabapentin (91%)
and ketorolac (95%) use became routine and order set utilization was 100%.
Readmission rates did not increase as a result of this pathway.
CONCLUSIONS: Implementation of a standardized RRP with multimodal pain
management and early mobilization strategies resulted in reduced LOS
without an increase in reported pain scores or readmissions.
QUALITY REPORTPEDIATRICS Volume 137 , number 4 , April 2016 :e 20151568
To cite: Muhly WT, Sankar WN, Ryan K, et al.
Rapid Recovery Pathway After Spinal Fusion for
Idiopathic Scoliosis. Pediatrics. 2016;137(4):
e20151568
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MUHLY et al
increasing early or late complications
in adolescents undergoing PSF.9
However, little is known about the
quality of recovery when using an
accelerated recovery pathway.
Within our institution, postoperative
management was variable. Some
surgeons adopted early mobilization
strategies with multimodal
analgesics, including ketorolac and
gabapentin, whereas others used
conventional recovery strategies
with 24 hours of bed rest and an
opioid-based analgesic platform. In
an effort to reduce this variability,
we convened a multidisciplinary
quality improvement (QI) team to
redesign, standardize, and implement
a recovery pathway for healthy
adolescents undergoing multilevel
PSF for idiopathic scoliosis. The
goals were to incorporate early
mobilization strategies to facilitate
earlier functional recovery while
maintaining effective analgesia
with an evidence-based multimodal
analgesic protocol.
METHODS
Ethics
Before initiation of this project,
multiple “standards” of care existed
for postoperative management
after PSF. We felt an obligation to
formalize a management protocol
for this population and design a
method for monitoring compliance
and effectiveness. As this protocol
represents QI work, it is not
considered human subjects research,
and we received exemption from our
Institutional Review Board.
Setting and Study Groups
This QI project was conducted
at a major tertiary care pediatric
hospital that performs 60 to 90
spinal fusions for idiopathic scoliosis
annually. All patients with scoliosis
who underwent PSF were identified
using a combination of diagnosis and
procedure codes (Current Procedural
Terminology codes 22802, 22804,
22843, 22844 and International
Classification of Diseases, Ninth
Revision code 737.30). Patients
with neuromuscular scoliosis, a
congenital/genetic/developmental
delay diagnosis, anterior
spinal fusion, or intraoperative
complications, including respiratory
depression, hemorrhage,
coagulopathy, or loss of motor
signals, were excluded. Because
our postoperative standard of care
was surgical floor admission, we
excluded patients who were admitted
to the ICU or a nonsurgical recovery
floor for >24 hours because initial
recovery may have been delayed
due to surgical complications or
inconsistent care provided on
nonsurgical floors. Finally, the study
group was divided into three time
periods: conventional management
(January 1, 2011 to December 31,
2012), transitional management
(January 1, 2013 to June 30,
2014) and standardized pathway
implementation (July 1 2014 to June
30, 2015).
QI Development
Conventional Management
Historically, postoperative care for
PSF patients consisted of limited
movement for the first 24 hours,
initiation of physical therapy (PT)
on postoperative day (POD) 2, nil
per os for the first 24 hours with
diet advancement beginning on POD
2, and eventual discharge after PT
clearance, first bowel movement, and
surgical drain removal. Analgesic
management consisted of an
intraoperative dose of methadone
(0.1–0.2 mg/kg) and postoperative
morphine or hydromorphone
intravenous patient controlled
analgesia (IVPCA) for 3 to 4 days with
eventual transition to oral oxycodone
and acetaminophen. Oral diazepam
was used throughout recovery for
muscle spasm.
Transition Period
Conventional pain management after
PSF was dictated by the orthopedic
surgeons and facilitated by the
acute pain service. Incorporation
of nonopioid agents other than
benzodiazepines or acetaminophen
was uncommon and interdisciplinary
management discussions were
rare. Starting in 2013, members of
the orthopedic and pain services
began to collaborate to reassess our
standard management. Informal
plan-do-study-act (PDSA) cycles
with medication (ketorolac and
gabapentin) pilots and physical
activity acceleration were
conducted. These efforts aimed to
improve the quality of recovery by
reducing opioid dependence for
pain management and enabling
earlier rehabilitation. All patients
were monitored by a small group
of physicians, nurse practitioners,
nurses, and physical therapists.
Patients were noted to be more
comfortable with a trend toward
earlier discharge readiness.
A number of challenges to
widespread implementation of our
management strategies existed.
These included patient identification
and preoperative medication
ordering in the outpatient clinic, pain
service implementation of analgesic
protocols, ensuring consistent PT
availability for early rehabilitation
efforts, and spreading awareness
of these strategies to a number of
clinical departments.
Rapid Recovery Pathway
Building on transitional period
efforts, a larger multidisciplinary
team was assembled including
anesthesiologists, orthopedic
surgeons, inpatient and outpatient
orthopedic nurse practitioners,
physicians and a nurse practitioner
from the acute pain service, a
pharmacist, a physical therapist,
and surgical recovery unit nurses.
We received institutional support
in the form of a clinical quality
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PEDIATRICS Volume 137 , number 4 , April 2016
improvement advisor and data
analyst who facilitated the QI project.
The overall aim was to develop,
implement, and demonstrate efficacy
and safety of the pathway. Using the
PDSA cycles and lessons from the
transition period, we developed a
standardized clinical care pathway
outlining nursing, PT, and pain
management recovery goals for each
postoperative day. This pathway
was published as a Web-based
algorithm (Fig 1; http:// www. chop.
edu/ clinical- pathway/ spinal- fusion-
post- op- adolescent- idiopathic-
scoliosis- ais- clinical- pathway) on
our institutional Web site to codify
the recovery process and provide a
clinical education resource. The full
details of the rapid recovery pathway
(RRP) are outlined in Supplemental
Fig 5. In addition, we built computer-
based order entry order sets within
our electronic health record (EPIC)
for all phases of the patient’s care:
the outpatient orthopedic surgery
clinic visit, the inpatient postsurgical
encounter, and the acute pain
service. These order sets simplify
compliance among front-line
clinicians by embedding the pathway
recommendations into their daily
workflow.
Pathway Implementation and Early Challenges
Members of our QI team organized
the pathway roll out using
divisional educational sessions
for messaging. An early challenge
was the inconsistent application
of PT and pain service goals on
the weekends when staffing is
limited. Patients were not receiving
PT consistently on POD 1, and
IVPCA’s were maintained through
POD 3. Based on these findings,
QI participants from PT and pain
service went back to their divisions
and reinforced the need to maintain
consistent application of pathway
goals with respect to scheduled
PT sessions and transitioning off
the IVPCA, if appropriate, on the
weekends. Additionally, some
surgeons hesitated using ketorolac
in their patients. We reviewed these
concerns and discussed the evidence
supporting the efficacy and safety of
ketorolac. Ultimately, all surgeons
performing spinal fusions agreed to
use ketorolac in AIS patients while
use of ketorolac in patients with
neuromuscular scoliosis would be
reviewed on a case-by-case basis.
Process, Outcome, and Balancing Measures
To monitor the QI initiative, process,
outcome, and balancing measures
were displayed using the data
visualization tool QlikView (Radnor,
PA). Development of this tracking
tool involved defining the patient
population of interest, tolerating
some noise in the data, and picking
extractable and measurable metrics.
Our initial process measures were
use of multimodal agents (gabapentin
and ketorolac) and discontinuation of
IVPCA before POD 3. Once the order
set was completed and activated in
January 2015, use of the order set
was included as a process measure to
track compliance.
Our primary outcome was functional
recovery or discharge readiness.
We tracked this outcome using the
surrogate measures average LOS and
pain scores on POD 0 (end of surgery
to 6 AM) and POD 1, 2, and 3 (6 AM to
6 AM). Both LOS and pain scores were
thought to be appropriate markers of
functional recovery because patients
cannot be discharged until they
are cleared by PT and their pain is
adequately controlled. As a balancing
measure, we collected information
regarding 30-day emergency
department (ED) visits and/or
readmission.
Analysis
We tracked our outcomes using
statistical process control (SPC)
charts for mean LOS and average
daily pain scores on POD 0 to 3.
Because of variability in the number
of patients each month, we grouped
patients in quarterly blocks to have
sufficient patient numbers to use
X-bar and S-chart methodology. X-bar
charts express the averages with
control limits for each subgroup over
time whereas S-charts characterize
the spread between measurements
within each subgroup.10
Charts were created with SPC
for Excel (BPI Consulting, LLC,
Cypress, TX), and the conventional
management time period (January
1, 2011 to December 31, 2012)
was used to generate an historical
average as well as trial control
limits for LOS and daily pain scores.
Control limits were set at 3 SDs
from the mean. Although 20 to 30
subgroups are needed to establish
process stability, we elected to
present the historical control in
8 quarterly subgroups. Analysis
using 24 monthly subgroups was
inappropriate due to variability
in monthly surgical volume and
subgroup data before 2011 could not
be extracted because we were using
a different electronic medical record.
We feel the use of the conventional
management population for our
trial limits is justified because it
represents a large patient population
over 2 years with a stable recovery
process.
For simplicity, presence of a single
point outside control limits was used
to determine if the observed changes
were due to our interventions
(special cause variation) or random
variation (common cause variation)
with an acknowledgment that a
number of rules could be considered
to signify special cause variation.10
Because we only have 1 year of data
after pathway implementation, we
did not revise our charts in the event
of an indication of special cause
variation. S-charts generated for
LOS and pain scores demonstrated
common cause variation (charts not
presented), thus validating the X-bar
chart.
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RESULTS
A total of 328 adolescent PSF
patients managed by 6 different
surgeons from January 1, 2011
through June 30, 2015 were
identified. Of those patients, 322
had complete pain scores recorded
from POD 0 through POD 2 and
were included for analysis. Patient
characteristics were similar among
the historical, transitional, and
pathway periods (Table 1).
Process Compliance
As multimodal medication
administration is a hallmark of
this pathway, gabapentin and
ketorolac administration was
selected as an early process
measure. Figure 2 highlights
the evolving nature of our QI
project. Beginning in the second
quarter of 2013, ketorolac was
initiated on POD 1 for the first
time. Gabapentin was introduced
in the first quarter of 2014,
e4
FIGURE 1General pathway for recovery after PSF for AIS. Hyperlinks are available in the Web version that link to a more detailed explanation of the specifi c population included, treatment, and management goals for this group of patients (http:// www. chop. edu/ clinical- pathway/ spinal- fusion- post- op- adolescent- idiopathic- scoliosis- ais- clinical- pathway).
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PEDIATRICS Volume 137 , number 4 , April 2016
which coincided with a consistent
pattern of IVPCA discontinuation
on POD 2. Overall adherence to
the multimodal analgesic regimen
continued to improve after full
pathway implementation in
July 2014 with 89% of patients
receiving ketorolac on POD 1, 100%
of patients receiving gabapentin
on the night of surgery, and 86% of
patients off of their IVPCA by POD
3 in the second quarter of 2015.
Additionally, adherence to order set
use, which began mid–first quarter
of 2015 was 100% by the second
quarter of 2015.
Outcomes
SPC charts for mean LOS is presented
in Fig 3. There is strong evidence of
a special cause reduction in LOS with
4 consecutive data points outside
the lower control limit with RRP
implementation. Average LOS during
the conventional management period
from January 1, 2011 to December
31, 2012 was 5.7 days and fell to 4
days after institution of the RRP from
July 1, 2014 to June 30, 2015.
e5
TABLE 1 Characteristics of Patients Undergoing PSF for AIS From January 1, 2011 to June 30, 2015
Baseline Period Transition Period Pathway Period
No. of patients 134 104 84
Agea (years) 15 (13–16) 14 (13–16) 14 (13–16)
Weighta (kg) 55 (48–65) 58 (4–66) 53 (47–63)
Female genderb (%) 105 (78) 78 (75) 65 (76)
a Median value (interquartile ranges).b Total number (percentage).
FIGURE 2Adherence to process measures.
FIGURE 3Statistical process control chart showing length of stay over time with control limits (3 SDs).
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SPC charts for pain scores are
presented in Fig 4 and indicate a
special cause pain reduction after
RRP implementation. This is seen on
POD 0 (average pain score 3.8 vs 4.9),
where there was 1 point outside the
lower control limit in the third quarter
of 2014, and on POD 1 (average pain
score 3.8 vs 5), with 2 points below
the lower control limit. Pain scores
for POD 2 and POD 3 (not shown)
revealed common cause variation
and average pain scores were
similar between the conventional
management and RRP time periods.
Balancing Measures
The incidence of 30-day readmissions
or ED visits after discharge was 2.9%
(7/238 patients) for the first quarter
of 2011 through the second quarter
of 2014. From the third quarter of
2014 through the second quarter of
2015, 3.6% (3/84) of patients were
seen in the ED and/or admitted for
postoperative issues. One patient,
readmitted for nausea and vomiting
related to oxycodone, improved with
rehydration and a change to enteral
hydromorphone. The other 2 patients
were evaluated for possible wound
infections.
DISCUSSION
We present our experience using
an early mobilization RRP with
multimodal analgesic strategies
to improve the quality of recovery
for pediatric patients undergoing
PSF for AIS. Our clinical pathway
reduced time to functional recovery,
as reflected by shorter LOS, while
maintaining effective analgesia and
potentially improving pain scores on
e6
FIGURE 4Statistical process control chart showing numeric pain score over time with control limits (3 SDs) for postoperative day 0 to 2.
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PEDIATRICS Volume 137 , number 4 , April 2016
POD 0 and 1 without an increase in
the rate of readmission.
Interpretation
The pain after PSF is often severe
and difficult to control without
significant side effects. Traditional
management using bed rest and slow
return to activity after surgery is
likely unnecessary and may actually
contribute to patient morbidity.
In adults, early mobilization
strategies with multimodal analgesia
techniques are routinely used after
major orthopedic surgery from total
hip replacements to spine fusion.11, 12
Our traditional approach included
the use of intraoperative methadone,
which acts as a μ-opioid agonist
and N-methyl-D-aspartate (NMDA)
receptor antagonist and has been
shown to be helpful in reducing
opioid consumption after spinal
fusion in adults.13 However, with the
exception of oral acetaminophen and
oral diazepam for muscle spasms,
postoperative analgesia was almost
entirely dependent on opioids.
Patients were often somnolent and/
or nauseated, and we sought to
improve the quality of the recovery
by focusing on early mobilization
and reducing reliance on intravenous
opioids for pain control.
There is growing evidence to
support the use of several nonopioid
pharmacological analgesic
classes including gabapentinoids,
acetaminophen (paracetamol), and
nonsteroidal antiinflammatory
drugs14 after major orthopedic
surgery. Gabapentin has been studied
for pediatric PSF with conflicting
results. One study reported improved
early pain scores and reduced opioid
consumption in the first 48 hours
after surgery with preoperative
and postoperative gabapentin
administration, 7 whereas another
study found no difference in pain
scores after a single preoperative
dose.15 Intravenous acetaminophen
has been proposed as a useful
adjuvant in pain management
after major orthopedic surgery8
and, within pediatric PSF patients,
intravenous acetaminophen has
been shown to improve early pain
scores but has no effect on opioid
consumption.16 Ketorolac has
been shown to improve analgesia
and reduce opioid consumption
while reducing both opioid-related
gastrointestinal side effects and
LOS in general pediatric orthopedic
populations17, 18 and pediatric spinal
fusion populations.6 Although some
have cautioned against the use
of ketorolac in major orthopedic
surgery because of concerns about
platelet dysfunction and impaired
bone healing, 19, 20 there is growing
evidence that ketorolac is safe in
pediatric orthopedic populations21–23
and spinal fusion populations.24, 25
We found that our pairing of a
multimodal pain protocol with early
rehabilitation was not associated
with an increase in self-reported pain
scores, and there is early suggestion
that the pain improved on POD 0
and 1. We used self-reported pain
scores as both an outcome and
a balancing measure. With early
mobilization, we were concerned
that patients would have increased
pain, and we preemptively altered
our analgesic pathway to optimize
pain relief. Anecdotally, all providers
felt that the patients appeared more
awake and comfortable on POD 0, 1,
and 2 compared with traditionally
managed patients. Based on our
previous experience with this
population, it seems unlikely that we
would have been able to make this
early transition to PT without the
successful implementation of our
multimodal analgesic regimen.
Strengths and Limitations
Strengths of this QI project include
the relatively large sample of 322
patients with an intervention group
consisting of 84 patients managed
over the course of 1 year. Formal
facilitation by QI advisors allowed
for multidisciplinary team meetings
over 6 months and the creation of
a real-time and transparent data
visualization tool to monitor patient
outcomes. This aided the spread
of early mobilization strategies
and medication protocols to all
surgeons caring for these patients.
Future PDSA cycles may involve the
introduction of surveys to monitor
patient reported quality of recovery
in both the inpatient and outpatient
setting.
Despite the majority buy-in,
the interventions were not
entirely standardized among the
improvement intervention group
because some surgeons initially
resisted using ketorolac. We
elected to present the results of our
interventions as all cases of PSF
for AIS rather than focusing on the
outcomes of the surgeons involved
in early PDSA cycles because this is a
more accurate representation of the
realities of implementing QI projects
in clinical settings where “best
practices” remain subject to debate.
Caution must be used in drawing
conclusions about the effect of
our pathway on postoperative
pain. Frontline clinicians were not
blinded to treatment strategies,
and they may have influenced the
patients’ responses. This work does
not identify which analgesic agent
within the multimodal bundle is most
effective. However, we assume that
the noxious stimuli from this surgery
are so great that it is unlikely that
any 1 agent can produce a profound
analgesic benefit in isolation; it is
the combination of medications
that enable early mobilization while
maintaining effective analgesia
and minimizing adverse effects.
Earlier research demonstrating that
individual nonopioid analgesics
can provide modest but limited
improvement in pain after PSF
supports this assumption. We have
not reported on opioid related side
effects such as nausea and vomiting
because these outcomes were
difficult to reliably extract from the
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MUHLY et al
medical records. Finally, although
we report the rate of ED visits/
readmissions after discharge, we
only present data on return visits
to our hospital and cannot account
for return visits/hospitalizations
elsewhere. The incidence of this
is likely low because patients are
typically directed to our hospital
for postoperative complication
management.
Implications for Practice
The results of this QI project
reinforce findings that pediatric
patients can be mobilized and
discharged earlier after PSF9 and
add to this work by demonstrating
how multimodal analgesic strategy
can facilitate early discontinuation
of intravenous opioids while
maintaining effective analgesia.
Standardization of care reduces
practice variability and allows for
meaningful assessment of outcomes
in specific patient populations by
creating shared baseline process,
outcome, and balancing metrics.
This multidisciplinary improvement
approach to perioperative care
can be applied to other pediatric
surgical populations in which
significant postoperative pain and
morbidity is expected, such as PSF
for neuromuscular scoliosis or
adolescents undergoing correction of
pectus excavatum.
ACKNOWLEDGMENTS
We thank the many people
who helped make this quality
improvement project possible.
Specifically, Blair Kraus, our
improvement advisor, and Ethan
Jacobi, our data analyst, were
instrumental in the coordination
and execution of this improvement
project. Additionally, we thank the
nurses and PT team on the surgical
floor who made the implementation
of our protocol possible.
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e8
ABBREVIATIONS
AIS: adolescent idiopathic
scoliosis
ED: emergency department
IVPCA: intravenous patient
controlled analgesia
LOS: length of stay
POD: postoperative day
PDSA: plan-do-study-act
PSF: posterior spinal fusion
PT: physical therapy
QI: quality improvement
RRP: rapid recovery pathway
SPC: statistical process control
FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.
FUNDING: This research was supported through internal funds from the Children’s Hospital of Pennsylvania Department of Anesthesiology and Critical Medicine
as well as the Division of Orthopedic Surgery. In addition, we applied for and received support from The Children’s Hospital of Pennsylvania Offi ce of Clinical
Quality Improvement, which provided an improvement advisor and a data analyst to facilitate this improvement project.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no confl icts of interest to disclose.
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PEDIATRICS Volume 137 , number 4 , April 2016
12. Raphael M, Jaeger M, van Vlymen
J. Easily adoptable total joint
arthroplasty program allows
discharge home in two days. Can J
Anaesth. 2011;58(10):902–910
13. Gottschalk A, Durieux ME, Nemergut EC.
Intraoperative methadone improves
postoperative pain control in patients
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DOI: 10.1542/peds.2015-1568 originally published online March 23, 2016; 2016;137;Pediatrics
Keren, John J. McCloskey and John M. FlynnMaxwell, Theresa DiMaggio, Sharon Farrell, Rachel Hughes, Alex Gornitzky, Ron
Wallis T. Muhly, Wudbhav N. Sankar, Kelly Ryan, Annette Norton, Lynne G.Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis
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DOI: 10.1542/peds.2015-1568 originally published online March 23, 2016; 2016;137;Pediatrics
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Wallis T. Muhly, Wudbhav N. Sankar, Kelly Ryan, Annette Norton, Lynne G.Rapid Recovery Pathway After Spinal Fusion for Idiopathic Scoliosis
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