Enhanced Recovery after Surgery Implementation in a Cesarean Section Population in an Integrated Healthcare System [35B]

Abstract

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) programs are evidence-based care pathways that focus on optimizing pain control, nutrition, fluids, and mobility. We evaluated implementation of a multi-faceted ERAS program among a cesarean section surgical population within Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system. We compared process measures before and after ERAS implementation at two pilot hospitals. METHODS: We evaluated changes in perioperative pain management (morphine equivalents and multimodal analgesics), mobility (early ambulation within 12 hours) and nutrition (early feeding within 12 hours), from pre-Implementation (March 2015-August 2015, n=1390 cesarean patients) to post-Implementation (March 2016-August 2016, n=1471 cesarean patients) of the multifaceted ERAS program. All urgent and elective cases were included. We quantified these metrics based on medication administration records, preoperative checklists, and/or nursing shift assessments recorded in the EMR. RESULTS: Process metrics among ERAS patients demonstrated significant changes between pre- and post-Implementation phases. The rate of early ambulation increased from 33% to 51% (p<0.001), early postoperative resumption of nutrition increased from 17% to 57% (p<0.001), and opioid consumption decreased significantly from 13.1 mg morphine equivalents to 7.7 mg (p<0.001), while the use of multimodal analgesics increased from 5% to 87% (p<0.001). CONCLUSION: ERAS program implementation successfully altered the process-of-care metrics for cesarean section surgical patients across two pilot hospitals. Further research is needed to determine the impact of ERAS implementation on complications and other outcomes following surgery among women undergoing cesarean sections.

Enhanced recovery after elective cesarean sections

“…In the current study, ERAS protocol allowed early mobilization in a significantly shorter interval after OR discharge than the control group. The results drawn from this study were in agreement with the results of Lee et al 2018 [16] who found that the early ambulation raised significantly (p 0.001) from 33% to 51% when ERAS protocols were implemented on women undergoing elective CS.…”

“…This was in agreement with what Lee et al 2018 [16] published earlier that early postoperative resumption of oral intake raised from 17% to 57% (p 0.001) when ERAS protocol was implemented on cases without adverse outcomes, while according to Teoh et al 2007 [17] they found that earlier solid intake resulted in more nausea (10.2 % versus 2 %, with p-value of 0.033), which was self-limiting. Guo et al 2015 [18] published earlier about comparing delayed oral feeding and early oral feeding, they found that early oral feeding promoted a rapid resumption of intestinal sounds, flatus, bowel motion, and regular oral intake (P<0.001 for all) where they stated that "There are no obvious advantages in withholding fluid and food after cesarean.…”

“…The mean amount of opiates used was significantly higher in the control group with significantly lower pain score among women included in the case group who received local infiltration anaesthesia as a step of our ERAS protocol. Lee et al 2018 [16] published similar information that showed that opioid dosage decreased significantly (p 0.001) from 13.1 mg morphine to 7.7 mg. On the other hand, the use of multimodal analgesia increased (p 0.001) from 5% to 87%. Furthermore, according to Adesope et al 2016 [21] revealed that local anesthetic wound infiltration significantly reduced opioid consumption at 24 hours.…”

Calf muscle pump exercise and preventive measures: as means for prevention of deep vein thrombosis and its manifestations among a postpartum cesarean section

“…This difference might be due to the implementation of the intervention and women's wishing to prevent DVT and its manifestations post-cesarean section. This finding was parallel with [36] who stated that early ambulation increased from one third tomore than half in a cesarean section population who attended enhanced recovery after surgery program.…”

Patient anxiety of verticalization on day 0 after a Cesarean section

“…According to the standards of the enhanced recovery after surgery (ERAS) protocol, multimodal analgesic therapy allows for maximum reduction of pain. At the same time, patients stay aware, which increases the chances of early verticalization [ 3 , 4 ]. The main purpose of rapid post-operative verticalization is the prophylaxis of thrombophlebitis, prevention of respiratory and digestive complications, prevention of post-operative adhesions and the improvement of blood supply to tissues [ 5 ].…”