RSS-Feed abonnieren
DOI: 10.1055/s-0040-1709456
Enhanced Recovery after Surgery for Cesarean Delivery Decreases Length of Hospital Stay and Opioid Consumption: A Quality Improvement Initiative
Funding None.![](https://www.thieme-connect.de/media/ajp/2021S01/lookinside/thumbnails/10-1055-s-0040-1709456_190734-1.jpg)
Abstract
Objective The aim of this study is to assess the effect of a resident-led enhanced recovery after surgery (ERAS) protocol for scheduled prelabor cesarean deliveries on hospital length of stay and postpartum opioid consumption.
Study Design This retrospective cohort study included patients who underwent scheduled prelabor cesarean deliveries before and after implementation of an ERAS protocol at a single academic tertiary care institution. The primary outcome was length of stay following cesarean delivery. Secondary outcomes included protocol adherence, inpatient opioid consumption, and patient-centered outcomes. The protocol included multimodal analgesia and antiemetic medications, expedited urinary catheter removal, early discontinuation of maintenance intravenous fluids, and early ambulation.
Results A total of 250 patients were included in the study: 122 in the pre-ERAS cohort and 128 in the post-ERAS cohort. There were no differences in baseline demographics, medical comorbidities, or cesarean delivery characteristics between the two groups. Following protocol implementation, hospital length of stay decreased by an average of 7.9 hours (pre-ERAS 82.1 vs. post-ERAS 74.2, p < 0.001). There was 89.8% adherence to the entire protocol as written. Opioid consumption decreased by an average of 36.5 mg of oxycodone per patient, with no significant differences in pain scores from postoperative day 1 to postoperative day 4 (all p > 0.05).
Conclusion A resident-driven quality improvement project was associated with decreased length of hospital stay, decreased opioid consumption, and unchanged visual analog pain scores at the time of hospital discharge. Implementation of this ERAS protocol is feasible and effective.
Key Points
-
Enhanced recovery after surgery (ERAS) principles can be effectively applied to cesarean delivery with excellent protocol adherence.
-
Patients who participated in the ERAS pathway had significant decreases in hospital length of stay and opioid pain medication consumption with unchanged visual analog pain scores postoperative days 1 through 4.
-
Resident-driven quality improvement projects can make a substantial impact in patient care for both process measures (e.g., protocol adherence) and outcome measures (e.g., opioid use).
Keywords
enhanced recovery after surgery - cesarean delivery - opioid medications - length of hospital stayPublikationsverlauf
Eingereicht: 13. Dezember 2019
Angenommen: 02. März 2020
Artikel online veröffentlicht:
02. Juni 2020
© 2020. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78 (05) 606-617
- 2 Wilson RD, Caughey AB, Wood SL. et al. Guidelines for antenatal and preoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (part 1). Am J Obstet Gynecol 2018; 219 (06) 523.e1-523.e15
- 3 Caughey AB, Wood SL, Macones GA. et al. Guidelines for intraoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (part 2). Am J Obstet Gynecol 2018; 219 (06) 533-544
- 4 Macones GA, Caughey AB, Wood SL. et al. Guidelines for postoperative care in cesarean delivery: enhanced recovery after surgery (ERAS) society recommendations (part 3). Am J Obstet Gynecol 2019; 221 (03) 247.e1-247.e9
- 5 Fay EE, Hitti JE, Delgado CM. et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol 2019; 221 (04) 349.e1-349.e9
- 6 Corso E, Hind D, Beever D. et al. Enhanced recovery after elective caesarean: a rapid review of clinical protocols, and an umbrella review of systematic reviews. BMC Pregnancy Childbirth 2017; 17 (01) 91
- 7 Hedderson M, Lee D, Hunt E. et al. Enhanced recovery after surgery to change process measures and reduce opioid use after cesarean delivery: a quality improvement initiative. Obstet Gynecol 2019; 134 (03) 511-519
-
8 Accessed October 23, 2018 at: http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
- 9 Sudhof L, Shah NT. In pursuit of value-based maternity care. Obstet Gynecol 2019; 133 (03) 541-551
- 10 ACOG Committee Opinion No. ACOG committee opinion no. 742: postpartum pain management. Obstet Gynecol 2018; 132 (01) e35-e43
- 11 Cattin A, De Baene A, Achon E. et al. [Evaluation of enhanced recovery for elective cesarean section]. Gynécol Obstét Fertil Sénol 2017; 45 (04) 202-209
- 12 Rousseau A, Sadoun M, Aimé I, Leguen M, Carbonnel M, Ayoubi JM. [Comparative study about enhanced recovery after cesarean section: what benefits, what risks?]. Gynécol Obstét Fertil Sénol 2017; 45 (7-8): 387-392
- 13 Coates E, Fuller G, Hind D, Wrench IJ, Wilson MJ, Stephens T. Enhanced recovery pathway for elective caesarean section. Int J Obstet Anesth 2016; 27: 94-95
- 14 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50
- 15 Abdel-Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section. Cochrane Database Syst Rev 2014; (04) CD010322
-
16 SOAP. Accessed December 11, 2019 at: https://soap.org/SOAP-Enhanced-Recovery-After-Cesarean-Consensus-Statement.pdf
- 17 Geisler JP, George KE. Value-based payments in obstetrics and gynecology. ACOG Committee Opinion No. 744. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018; 132: e53-e59
- 18 Peahl AF, Smith R, Johnson TRB, Morgan DM, Pearlman MD. Better late than never: why obstetricians must implement enhanced recovery after cesarean. Am J Obstet Gynecol 2019; 221 (02) 117.e1-117.e7
- 19 Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of new persistent opioid use after vaginal or cesarean birth among US women. JAMA Netw Open 2019; 2 (07) e197863 . Erratum in: JAMA Netw Open 2019;2(8):e1911235
- 20 Smith AM, Young P, Blosser CC, Poole AT. Multimodal stepwise approach to reducing in-hospital opioid use after cesarean delivery: a quality improvement initiative. Obstet Gynecol 2019; 133 (04) 700-706
- 21 Rogers RG, Nix M, Chipman Z. et al. Decreasing opioid use postpartum: a quality improvement initiative. Obstet Gynecol 2019; 134 (05) 932-940
- 22 Prabhu M, Dubois H, James K. et al. Implementation of a quality improvement initiative to decrease opioid prescribing after cesarean delivery. Obstet Gynecol 2018; 132 (03) 631-636
- 23 Gallagher EJ, Bijur PE, Latimer C, Silver W. Reliability and validity of a visual analog scale for acute abdominal pain in the ED. Am J Emerg Med 2002; 20 (04) 287-290