A Prospective Cohort Study Towards Improving Enhanced Recovery After Cesarean (ERAC) Pathways

Abstract

ObjectiveTo evaluate whether Enhanced Recovery After Cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery.Study designThis is a prospective cohort study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English and non-Spanish speaking patients. Our study compared the outcomes in patients before (pre-ERAC) and after (post-ERAC) implementation of an ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient’s delta pain scores. Secondary outcomes were outpatient MME prescriptions as well as indicators of postoperative recovery.ResultsOf 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the post-ERAC cohort were less likely to require opioids in the postoperative period compared to the pre-ERAC cohort (35.7% vs. 18.4%, p<0.001). In addition, there was a significant reduction in the MME per stay in this cohort [16.8 MME (11.2-33.9) vs. 30 MME (20-49), p<0.001]. In the post-ERAC cohort, there was also a reduction in the number of patients who required prescribed opioids at the time of discharge (86.6 vs. 98%, p<0.001) as well as in the amount of MMEs prescribed [150 MME (112-150) vs. 150 MME (150-225), p<0.001; different shape of distribution]. Patients in the post-ERAC cohort had lower delta pain scores [2.2 (1.3-3.7) vs. 3.3 (2.3-4.7), p<0.001].ConclusionOur study has illustrated that our ERAC pathways reduced inpatient and outpatient opioid use as well as patient-reported pain scores while improving indicators of postoperative recovery.

Enhanced recovery after cesarean from the patient perspective: a prospective study of the ERAC Questionnaire (ERAC-Q)

“…Further, delivery complications and peripartum treatments that are unique to obstetrics, such as magnesium for seizure prophylaxis in preeclamptic patients, can also influence outcomes and patient perceptions of recovery. In our prior work, we found that the objective time to ambulation postpartum was more than twice as long for patients receiving eclampsia prophylaxis with magnesium, and the beneficial effect of ERAC on time to achieve this milestone was dulled [22]. In the current study, we found that patients' perceptions of mobility likewise were negatively impacted by magnesium therapy, despite the benefits of ERAC protocol implementation shown in the cohorts not treated with magnesium.…”

“…Patients 18 years of age or older with a singleton gestation undergoing CD were considered for enrollment. Exclusion criteria were chosen to minimize factors that might significantly prolong recovery and/or increase postoperative opiate use [22]. Study population data were collected from electronic medical records and entered into a secure Research Electronic Data Capture (REDCap) database.…”

“…ERAC interventions focused on four major areas: expansion of multimodal analgesia, reduction in perioperative fasting times, a standardized approach to early ambulation, and provision of patient educational visual aids on ERACbased recovery (http://umm.edu/ERAC). Full details of our ERAC protocol and compliance with it are described in our prior published work [22].…”

“…Visual analog was strengthened by the addition of emojis, which have a high level of agreement with the numeric rating scale [27]. The content and construct validity of the ERAC-Q were evaluated by the ERAC team [22,28]. The questionnaire was made available in two languages (English and Spanish), with Spanish translation performed using professional services to ensure equivalence to the English version.…”

A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways

“…Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49).9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of , p < 0.001; different shape of distribution).…”