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: muhlyw@email.chop.edu.

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

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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

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