Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

Abstract

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

The research frontier of cesarean section recovery: A bibliometric analysis

“…In 2019, the Society of Obstetrical Anaesthesia and Perinatology (SOAP) compiled a consensus document regarding ERAC, which provides recommendations from SOAP on the elements that should be included in ERAS paths, including basic core elements and other recommended elements ( 17 ). For the postoperative care, elements include as follow: (1) offer ice chips and water within 1 h postoperatively, consider gum chewing (gum chewing starting right after CS three times a day for about 30 min until the first flatus ( 35 ); (2) advance to regular diet within 4 h postoperatively; (3) heparin/saline lock IV once oxytocin infusion complete and tolerating fluids ( 36 ); (4) maintain normoglycemia with <180–200 mg/dl; (5) minimize opioid consumption and continue scheduled nonopioid analgesia ( 37 ); (6) ambulation should occur soon after motor function returns, beginning with dangling and out of bed to chair and progressively increasing to 3–4 times after postoperative day 1; (7) removal of urinary catheter 6–12 h postoperatively (early removal of the indwelling urinary catheter in patients who underwent elective CS showed significant less dysuria, less urinary frequency and a decrease in the incidence of significant bacteriuria ( 20 ); (8) provide early and robust lactation support (early breastfeeding, adequate sucking stimulation, proper sucking technique, and limited formula may be effective in improving long-term breastfeeding for mothers who have delivered by cesarean section ( 38 ); (9) coordinate and streamline discharge processes to facilitate early discharge; (10) limit unnecessary interruptions to maximize rest and bonding. The latest expert consensus also stresses the core outcome, which include compliance with enhanced recovery protocol; fasting times; times to mobilization and urinary catheter removal; provision of optimal analgesia (maternity satisfaction, compliance with analgesia, opioid consumption or requirement and incidence of nausea or vomiting); early breastfeeding success; length of hospital stay; and hospital re-admissions ( 39 ).…”

Measuring enhanced recovery in obstetrics: a narrative review

“… 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 Seven new studies have been published since these reviews, which fulfill the same inclusion criteria. 12 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 There have been a number of identified perceived barriers to successful ERAS implementation, including staff shortages, lack of policy support, poor doctor–patient collaboration, poor multidisciplinary collaboration, and high costs. 32 The reasons are broad, but engaging the multidisciplinary team through consensus on guideline development, involvement in audit and quality improvement, and development of patient education materials are strategies that could improve implementation.…”

“…There have since been 11 new peer-reviewed ERAC studies published that fulfill the same inclusion criteria as Sultan et al, 12 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 and 2 published meta-analyses comparing ERAC with standard care. 33 , 46 In the 22 ERAC implementation studies published to date, the outcomes described are wide-ranging and heterogeneous ( Table 1 ).…”

“…LOS was reduced in the ERAC group in most studies, 12 , 13 , 15 , 16 , 18 , 19 , 20 , 22 , 24 , 25 , 27 , 28 , 37 but unchanged in the rest. 14 , 17 , 21 , 23 , 29 Other process metrics include proportion of patients discharged on days 1 and 2, ERAC pathway compliance, and time to achieving interim clinical milestones such as first mobilization and urinary catheter removal. The main advantages of process metrics such as these are that they possess qualities of good key performance indicators.…”

“…Of the 22 studies, only 1 reported reduced maternal readmission rates, 25 whereas 12 found no increase, 12 , 13 , 14 , 17 , 18 , 19 , 20 , 21 , 22 , 28 , 30 , 37 and the remaining 9 studies did not report this outcome. 15 , 16 , 23 , 24 , 27 , 29 , 35 , 36 , 37 One RCT showed a reduction in readmission rates associated with ERAC implementation. 25 Eight studies examined complication rates after CD (heterogeneous use of outcomes).…”