Next day discharge following Next day discharge following elective caesarean section using elective caesarean section using

Enhanced Recovery Care Enhanced Recovery Care PathwaysPathways..

Ian Wrench (Consultant Anaesthetist)Ian Wrench (Consultant Anaesthetist)Andrea Galimberti (Consultant Obstetrician) Andrea Galimberti (Consultant Obstetrician) Jan Hall (Midwifery Sister – Postnatal ward)Jan Hall (Midwifery Sister – Postnatal ward)Julie Humphries (Midwifery Sister – Postnatal Ward)Julie Humphries (Midwifery Sister – Postnatal Ward)

Structure of talk:Structure of talk:

Rationale for introduction of enhanced Rationale for introduction of enhanced recovery for elective caesarean sectionrecovery for elective caesarean section

Patient surveyPatient survey Multidisciplinary groupMultidisciplinary group Changes made to pathwayChanges made to pathway ResultsResults Conclusions and future directionConclusions and future direction

RationaleRationale

QIPP programme - £20billion savingsQIPP programme - £20billion savings NICE NICE “…women who are recovering well, are apyrexial and do not have “…women who are recovering well, are apyrexial and do not have

complications following CS should be offered early discharge (after 24 hours) from complications following CS should be offered early discharge (after 24 hours) from hospital and follow-up at home, because this is not associated with more infant or hospital and follow-up at home, because this is not associated with more infant or maternal readmissions.” maternal readmissions.”

Evidence from other specialties that enhanced Evidence from other specialties that enhanced recovery programmes improve outcomes:recovery programmes improve outcomes: ColorectalColorectal UrologyUrology OrthopaedicsOrthopaedics GynaecologyGynaecology Hepatobiliary Hepatobiliary etcetc

• Less than 1% of patients leaving on Day 1 (24-48hrs)Less than 1% of patients leaving on Day 1 (24-48hrs)• Average length of stay = 2.45 daysAverage length of stay = 2.45 days

Enhanced recoveryEnhanced recovery

In general terms the most important aspects In general terms the most important aspects of an enhanced recovery programme are: of an enhanced recovery programme are: Reduction in the stress response to surgery Reduction in the stress response to surgery Excellent perioperative nutrition Excellent perioperative nutrition Postoperative pain relief that doesnPostoperative pain relief that doesn’’t rely on t rely on

strong morphine like pain killersstrong morphine like pain killers Rapid postoperative mobilisation Rapid postoperative mobilisation A co-ordinated perioperative care pathway A co-ordinated perioperative care pathway

designed and managed by a multidisciplinary designed and managed by a multidisciplinary team. team.

Patient survey – 58 patients, day 1 or day 2 following elective Patient survey – 58 patients, day 1 or day 2 following elective caesarean section. S. Aluri, caesarean section. S. Aluri, R. Pothireddy, C Anderson, I R. Pothireddy, C Anderson, I WrenchWrench

Planning for earlier discharge post Planning for earlier discharge post elective caesarean section.elective caesarean section.

Multidisciplinary team:Multidisciplinary team:

• AnaesthetistsAnaesthetists• MidwivesMidwives

• Post natal sistersPost natal sisters• Community midwivesCommunity midwives• Senior midwifery Senior midwifery • Breast feeding teamBreast feeding team

• ObstetriciansObstetricians• PharmacistPharmacist• Patient representativePatient representative

• Six months planningSix months planning• New periop’ pathwayNew periop’ pathway• PublicisingPublicising• Getting consensusGetting consensus

What changes did we What changes did we introduce?introduce?

What changes were made?What changes were made?

Patient selectionPatient selection All patients have the new interventions – All patients have the new interventions –

selection happens post surgery according to selection happens post surgery according to how the patient is recoveringhow the patient is recovering

Preadmission counsellingPreadmission counselling Patients are given a leaflet telling them what Patients are given a leaflet telling them what

needs to happen pre-dischargeneeds to happen pre-discharge

You are going to have a planned (elective) caesarean section. Usually you will stay in hospital for at least two days but some women may go home the day after the operation if their recovery is going well. Below is some information about what needs to have happened before you can go home.NEW WORDING:You are going to have a planned (elective) caesarean section. If your recovery is going well you may go home the day after the operation. Below is some information about what needs to have happened before you can go home.

What changes were made?What changes were made?

Carbohydrate loading prior to surgeryCarbohydrate loading prior to surgery All patients (except diabetics) get flat lucozade All patients (except diabetics) get flat lucozade

before theatrebefore theatre

What changes were made?What changes were made?Keep patient warm in theatreKeep patient warm in theatre

Active warming encouraged (Active warming encouraged (S.Aluri, M.Berwetz,

M.Walters, M.Woolnough))

What changes were made?What changes were made?

Avoidance of fluid overload in theatreAvoidance of fluid overload in theatre Usually fluid management is simple – no large Usually fluid management is simple – no large

fluid shiftsfluid shiftsSurgical technique - short incisions/ no Surgical technique - short incisions/ no

drains drains Already have horizontal incision with drains Already have horizontal incision with drains

rarely used.rarely used.

What changes were made?What changes were made?

Non-opiate oral analgesics/ NSAIDs Non-opiate oral analgesics/ NSAIDs where possible postoperativelywhere possible postoperatively New oramorph regime introduced – service New oramorph regime introduced – service

evaluation shows it to be effectiveevaluation shows it to be effective TTOTTO’’s prescribed in theatre so that this isns prescribed in theatre so that this isn’’t a t a

problem to organise laterproblem to organise laterPrevention of postoperative nausea and Prevention of postoperative nausea and

vomitingvomiting No changes made – rarely prevents dischargeNo changes made – rarely prevents discharge

New Oramorph regime:New Oramorph regime:C.Meer, B.Kasa, R.GoyalC.Meer, B.Kasa, R.Goyal

Formerly parenteral regime with Formerly parenteral regime with subcutaneous cannula – service evaluation subcutaneous cannula – service evaluation of 67 patients:of 67 patients: 79% - not used79% - not used 63% - Pain or erythema 63% - Pain or erythema 39% - taken out as uncomfortable39% - taken out as uncomfortable

Change to hourly oramorph regime – service Change to hourly oramorph regime – service evaluation of 128 women:evaluation of 128 women: 94% rated pain control good or excellent (as 94% rated pain control good or excellent (as

before)before) 98% of midwives – less work (oramorph not 98% of midwives – less work (oramorph not

controlled drug – one qualified only)controlled drug – one qualified only)

What changes were made? What changes were made? perioperative oral intake:perioperative oral intake:

No restriction on preoperative fluidsNo restriction on preoperative fluids Clear fluids up to two hours preopClear fluids up to two hours preop’’ (includes (includes

lucozade)lucozade) Food up to 6 hours preopFood up to 6 hours preop’’

Early intake of fluids and food Early intake of fluids and food postoperativelypostoperatively Well established guidelines – clear fluids up to Well established guidelines – clear fluids up to

one hour then whatever they want in terms of one hour then whatever they want in terms of food and fluidfood and fluid

Perioperative oral intake data:Perioperative oral intake data:

R.Kaur, S.Glover, L.Powell, A.Philips, H.Roberts, S.Gowri

What changes were made? What changes were made? The neonateThe neonate

Breast feedingBreast feeding Problems with breast feeding commonly delay Problems with breast feeding commonly delay

dischargedischarge Skin to skin contact at birth between mother and baby Skin to skin contact at birth between mother and baby

improves breast feeding rates – low rates in theatreimproves breast feeding rates – low rates in theatre New initiative to encourage this in theatre New initiative to encourage this in theatre

Delayed cord clampingDelayed cord clamping Increases the amount of blood going to the newborn Increases the amount of blood going to the newborn

from the placentafrom the placenta Increases blood haemoglobin levelsIncreases blood haemoglobin levels Should improve neonatal recoveryShould improve neonatal recovery Obstetricians have instituted a new protocol for this Obstetricians have instituted a new protocol for this

and it is being usedand it is being used

Postoperative management:Postoperative management: Postoperative mobilisationPostoperative mobilisation

Spinal anaesthesia takes 4 to 9 hours to wear offSpinal anaesthesia takes 4 to 9 hours to wear off 8 hours post op is in the evening for most8 hours post op is in the evening for most Fewer staff then - ?safe to mobilise?Fewer staff then - ?safe to mobilise? Patients ambivalent about early mobilisationPatients ambivalent about early mobilisation Elected to mobilise day after surgery as before.Elected to mobilise day after surgery as before.

Removal of urinary cathetersRemoval of urinary catheters No change – removed on mobilising as beforeNo change – removed on mobilising as before

Telephone service evaluation:Telephone service evaluation:

19 women were followed up by telephone on 19 women were followed up by telephone on dischargedischarge

100% reported they were able to do daily 100% reported they were able to do daily activitiesactivities

96% reported feeling 96% reported feeling ‘‘back to normalback to normal’’ 82.3% reported no pain. 82.3% reported no pain. 76.5% breastfeeding rate; 100% reported no 76.5% breastfeeding rate; 100% reported no

problems at all in looking after the babyproblems at all in looking after the baby No readmissions or problems reported in women No readmissions or problems reported in women

or neonates discharged on day 1 or neonates discharged on day 1

SummarySummary

Enhanced recovery successfully Enhanced recovery successfully introduced for elective caesarean sectionintroduced for elective caesarean section

15 - 20% of patients leave on day one 15 - 20% of patients leave on day one Previously around 1%Previously around 1%

No increase in readmission ratesNo increase in readmission rates No evidence of problems in the communityNo evidence of problems in the community

Future developmentsFuture developments

Apply to emergency caesarean sectionsApply to emergency caesarean sections Increase uptake of skin to skin and delayed cord Increase uptake of skin to skin and delayed cord

clamping in theatreclamping in theatre Patient self administration of postopPatient self administration of postop’’ analgesia analgesia

Successful application for funding for lockable Successful application for funding for lockable bedside cabinetsbedside cabinets