Postoperative Length of Stay Following Enhanced Recovery After Surgery Protocol Implementation for Scheduled Cesarean Deliveries

Background Cesarean delivery is the most common major surgery worldwide. 1 In 2018, 1.2 million cesarean deliveries occurred in the United States, accounting for nearly 32% of all deliveries.2 Research has shown ERAS benefits include decreased length of stay, improved pain control, and improved patient satisfaction.2,3 Despite its use in numerous surgical specialties, ERAS implementation within obstetrics has been slow.2 The ERAS Society released a three-part guideline specific to cesarean deliveries in 2018 and 2019,4,5,6 yet few studies have assessed the impact of ERAS on cesarean postoperative outcomes.2 An improved perioperative course would be particularly beneficial for mothers undergoing cesarean delivery as they require a quick recovery in order to care for their newborn. The purpose of this retrospective, observational study was to determine how the recovery process following cesarean delivery may be improved by standardizing the perioperative care pathway, with the primary outcome of interest being postoperative length of stay. Methods • Design: Retrospective, observational cohort study at Providence Sacred Heart Medical Center (PSHMC) • This project was approved by the PSHMC Clinical Innovation and Research Council and deemed exempt from human subjects research by Providence Health Care Institutional Review Board. • Human subjects protection: Patient demographic and surgical data from electronic medical records were extracted, deidentified, and encrypted using a REDCap data collection tool • Inclusion Criteria: parturients 18 years of age or older who underwent scheduled cesarean delivery between June 1, 2017 to May 31, 2018 for pre-intervention group and June 1, 2019 to February 29, 2019 for postintervention group. • Exclusion Criteria: urgent or emergent cesarean deliveries, cesarean deliveries occurring in the run-in time period of June 1, 2018 through May 31, 2019, and mothers under the age of 18 years. • Outcome measurement: postoperative length of stay, defined as time of end of surgery to time of discharge • Exposure measurement: defined as post-ERAS protocol implementation following April 1, 2019. • Other variables considered included: age, weeks gestation, BMI, ASA, primary vs repeat cesarean, weeks gestation, and multiparty births. • Statistical analysis: a-prior power analysis, univariate analysis, bivariate analysis, and multivariate analysis Discussion In this retrospective observational study, this facility’s postoperative LOS following cesarean delivery was found to be low, with a median of 52.4 hours. Following ERAS implementation, the median postoperative LOS decreased to 51.2 hours but was not found to be statistically significant in an adjusted model. Cesarean deliveries comprised nearly 29% of all births at this facility, 58.5% of which were scheduled or elective cesarean deliveries. Characteristics of parturients were very similar among the pre- and post-ERAS patient groups; most patients were classified as ASA 2 and a mean age of 31 years. Repeated multivariate analysis using run-in periods of varying lengths and controlling for time consistently showed no significant difference in postoperative LOS between the pre-ERAS and post-ERAS groups. With the postoperative LOS at PSHMC being low prior to protocol implementation, it is likely that other facilities with longer postoperative LOS may see a greater benefit of ERAS implementation. Additional work is still required to further the understanding of ERAS for cesarean deliveries and its impact on postoperative recovery. Future studies of interest includes determining 30-day readmission rates and emergency room visits following discharge. In order to determine the true effect ERAS may have on postoperative length of stay and the recovery process following cesarean delivery, large prospective control trials are needed.https://digitalcommons.psjhealth.org/other_pubs/1110/thumbnail.jp

Opioid Consumption After Scheduled Cesarean Delivery Following Implementation of Enhanced Recovery After Surgery

Background With 47,600 opioid overdose related deaths in the U.S. in 2017, the opioid crisis is of national concern.1 Cesarean delivery is the most common surgery worldwide, with over 1.2 million in the U.S. in 2018 alone.2,3 As cesarean delivery is a highly prevalent surgery it has a large capacity to influence the opioid epidemic. Literature is showing that Enhanced Recovery after Surgery (ERAS) and multimodal analgesia are effective means of managing postoperative pain while minimizing opioid use.4,5,6,7,8 This project aims to help discover if introduction of ERAS, and more specifically it’s multimodal analgesia aspect, has helped decrease oral morphine milligram equivalent (MME) consumption of opioids following cesarean delivery. Methods • Design: Retrospective Observational Cohort Study • Human Subjects Protection: Data fully de-identified and stored only in a secure REDCap database; patient care was not altered • Inclusion Criteria: Adult women undergoing scheduled cesarean delivery at Providence Sacred Heart Medical Center, Spokane, WA • Exclusion Criteria: Urgent/emergent cesarean delivery, use of an intravenous opioid patient-controlled analgesia (PCA) device • Measured Outcome: Cumulative 72-hr oral MME consumption following cesarean delivery • Baseline Comparability Demographics: Age, ASA, BMI, gravida/parity, weeks gestation, prior cesarean delivery, multiple birth, estimated blood loss, etc. (table 1) • Statistical Analysis: • A Priori Power Analysis: n=670 (n=335 per group) participants for adequate power (α=0.5, β=0.2) • Bivariate Analysis: Independent Samples T-Test (symmetrical data) and Mann Whitney U Test (skewed data) • Multivariate Analysis: An interrupted time series was conducted for comparison of oral median MME over time • Split File Analysis conduced to confirm accuracy of findings Discussion The implementation of ERAS and use of multimodal analgesia led to a sustained MME decrease among women utilizing opioids post scheduled cesarean delivery. The pre-implementation group (n=464) utilized a median of 90 [IQR 37.5-165] oral MME while the post-implementation group (n=514) used 71.3 [IQR 30-127.5] median oral MME (p\u3c0.01). This was a difference of 18.7 oral MME, or a 21% reduction. The use of multimodal analgesia following scheduled cesarean delivery is an effective means of managing postoperative pain while also reducing the need for opioids.https://digitalcommons.psjhealth.org/other_pubs/1109/thumbnail.jp

Rate of Unscheduled Administration of an Epidural Bolus Among Pregnant Women Receiving Labor Epidurals

Background The labor and delivery process is a painful experience that pregnant women undergo and while various medical options are available for managing labor pain, labor epidurals are the most common.1,3 Breakthrough pain, or inadequate analgesia, is a significant complication of labor epidurals that is typically managed with the administration of an unscheduled epidural bolus. The purpose of this evidence-based practice (EBP) project is to describe the rate of unscheduled epidural bolus administration in pregnant women receiving continuous labor epidurals (CLE) at Providence Sacred Heart Medical Center (PSHMC) and Providence Holy Family Hospital (PHFH). Methods • Design: Retrospective, observational, EBP project • Human subjects protection: De-identified data was extracted into a HIPPA compliant REDCap database after facility approval and IRB exemption • Inclusion Criteria: Parturient women age ≥18 with labor epidurals at PSHMC and PHFH from January 2015 to December 2019 (Table 1) • Outcome Measurement: Unscheduled provider administered epidural bolus after epidural initialization (Figure 1) • Bivariate: T-tests (symmetrical continuous data), Mann Whitney U (skewed continuous data), Chi-Test (categorical data) • Multivariate: Kaplan Meier analysis performed on epidural bolus timing (Figure 2) • Multivariate multivariable: Proportional hazards model was used to identify independent risk factors associated with time to first unscheduled provider administered epidural bolus (Table 2) Discussion We found that approximately 36.7% of parturient women with a CLE required at least one unscheduled provider administered epidural bolus. Gravida 1, elective case type, increased BMI and CLE duration were identified as independent risk factors associated with receiving a provider bolus. Of the identified risk factors, gravida 1 was the most significant with women having a 1.22 increase in risk of requiring an unscheduled provider administered epidural bolus (hazard risk 1.22; 95% CI 1.14 – 1.31; p \u3c0.001). The rate of 36.7% is higher compared to literature reported rates of 30.7% and 14.4% from RCTs and observational studies that had comparable epidural regimens and techniques to our facilities. 2,4,5 Further in-depth investigation is warranted in describing with more detail the patient characteristics and anesthesia provider practices as they relate to unscheduled epidural bolus administration.https://digitalcommons.psjhealth.org/other_pubs/1104/thumbnail.jp