Enhanced Recovery after Surgery for Cesarean Delivery: A Quality Improvement Initiative

Abstract

Objective Enhanced recovery after surgery (ERAS) was developed as a way to standardize clinical care pathways and communication across multidisciplinary teams to improve patient recovery and reduce hospital length of stay (LOS). Our objective was to implement an ERAS protocol for cesarean delivery (ERAS-CD) and evaluate its efficacy in reducing LOS. Study Design An ERAS-CD program was implemented at our institution in October 2018. Patients undergoing scheduled and unscheduled CD were maintained on an ERAS pathway of care, which included preoperative hydration, standardized intraoperative protocols, and postoperative analgesic regimens as well as early feeding, urinary catheter removal, and ambulation. We compared LOS after delivery (calculated from time of delivery to discharge), readmission rates, health care disparities and postoperative opioid prescribing practices before (October 2017–September 2018) and after (November 2018–October 2019) ERAS implementation. We excluded any outliers, defined as a LOS >25 days. Continuous data are expressed as mean ± standard deviation. Student's t-test and Chi-square were used for statistical comparison with p <0.05 considered statistically significant. Results There were 1,729 patients who had a CD in the pre-ERAS group with a mean LOS after delivery of 3.32 ± 6.19 days. In the post-ERAS group, 1,753 women underwent CD with a mean LOS after delivery of 2.85 ± 5.79 days, a statistically significant difference from the pre-ERAS group (p <0.001). There was no difference in readmission rates between pre- and post-ERAS implementation groups (1.9 vs. 2.2%, p = 0.53). There was a reduction in health care disparities in postoperative LOS, when stratifying by race-ethnicity, and a reduction in opioid prescribing practices after the implementation of the program. Conclusion With the implementation of an ERAS-CD program, we achieved a reduced LOS, without increasing readmission rates, and saw a reduction in health care disparities and opioid dispensing. A shorter LOS could offer an enhanced patient experience, as well as improved and equitable perioperative outcomes. Key Points

Closing the gap: Perioperative health care disparities and patient safety interventions

“…Since obstetric hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality, the Society of Obstetric Anesthesiology and Perinatology expanded ERAS pathways to improve perioperative maternal and fetal outcomes after cesarean delivery, including recommendations to provide neuraxial anesthesia whenever possible. [56][57][58] The Perioperative Surgical Home, a patient-centered, innovative model of delivering health care during the perioperative period that emphasizes proactive and collaborative evidenceinformed decision-making, offers another opportunity to improve patient safety. 59 Perioperative optimization performed by anesthesiologists through the perioperative surgical home has helped decrease patient length of stay, improve quality, and lower the cost of care.…”

“…Compared with vaginal births, cesarean delivery is associated with higher postoperative infections and maternal morbidity. Since obstetric hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality, the Society of Obstetric Anesthesiology and Perinatology expanded ERAS pathways to improve perioperative maternal and fetal outcomes after cesarean delivery, including recommendations to provide neuraxial anesthesia whenever possible 56–58 …”

“…Evidence-based ERAS elements 10,[45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62]. …”

“…Common recommendations for anesthesiologists found in ERAS protocols 10,[45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62]. …”

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

“…9 Moreover, most of the studies have not extended ERAC pathways to specific populations such as opioid-naive patients, patients with postpartum depression, or patients receiving magnesium sulfate, allowing aforementioned confounders to affect the magnitude of the measured outcome. 6,[10][11][12] Persistent opioid use in opioid-naive women after cesarean has become an alarming trend, where 1:50 to 1:300 women are at risk of chronic opioid use. 13,14 Substance abuse has been cited as a major risk factor for pregnancy-associated deaths.…”