Quality improvement for caesarean section - a

multifactorial approach.

Ian Wrench Consultant AnaesthetistJessop Wing Obstetric Unit

Structure of talk:

Rationale for introduction of enhanced recovery for elective caesarean section

Changes introduced What happened after ER introduced Factors associated with early discharge Key components of ER for caesarean

section - consensus

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

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 maternal readmissions.”

Evidence from other specialties that enhanced recovery programmes improve outcomes: Colorectal Urology Orthopaedics Gynaecology Hepatobiliary etc

Enhanced recovery In general terms the most important aspects of an

enhanced recovery programme are:

Reduction in the stress response to surgery

Excellent perioperative nutrition

Postoperative pain relief that doesn’t rely on strong morphine like pain killers

Rapid postoperative mobilisation

A co-ordinated perioperative care pathway designed and managed by a multidisciplinary team.

A co-ordinated perioperative care pathway designed and managed by a multidisciplinary team.

Membership of multidisciplinary team:

Patient survey.

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

Planning for earlier discharge post elective caesarean section.

• Six months planning• New perioperative pathway• Publicising• Getting consensus

Factors consistent with enhanced recovery

Young fit patients - motivated Spinal anaesthesia Lower abdominal transverse incision with

minimal use of drainsDedicated elective lists (nine per week)

Pre-assessment clinic:A key area in introducing change.

Key staff in introducing change.

Separate Elective Caesarean Section lists.

AM PMMonday List ListTuesday List ListWednesday List ListThursday List ListFriday List

We have nine dedicated elective caesarean section lists per week.

Sheet1

AMPM

Monday ListList

TuesdayListList

WednesdayListList

ThursdayListList

FridayList

Sheet2

Sheet3

What changes did we introduce?

What changes were made?

Patient selection All patients Fitness for discharge determined post-op’

Patient information Verbal – pre-assessment midwife/ anaesthetist Written information

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.

Perioperative oral intake data:

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

Clear Fluids

Food

Pre-op’ 2 hours 6 hours

Post-op’ Immediate One hour

Keeping patients warm:Effect of introducing forced air warming.

S.Aluri, M.Berwetz, M.Walters, M.Woolnough

Chart1

pre-forced air warming

post-forced air warming

Percentage of patients with core temp' < 36 degrees celcius in recovery.

47

15

emails

Jennie.Kerr@uhb.nhs.uk;jenniekerr@doctors.org.uk;

Jules.Allt@uhns.nhs.uk;

Suzanne.Taylor@york.nhs.uk;

jsadashivaiah@nhs.net;

Maria.Okoisor@buckshealthcare.nhs.uk;

JEREMY.CORFE@nnuh.nhs.uk;

seetharama.dinesh@heartofengland.nhs.uk;

priya199@hotmail.com;

nuala.lucas@nhs.net;

Deborah.Horner@bthft.nhs.uk;

jsadashivaiah@nhs.net;

nicola.osborn@heartofengland.nhs.uk;

james.geoghegan@nhs.net;

Bini.Ajay@croydonhealth.nhs.uk;

dthorp-jones@nhs.net;

sangeetapathak@nhs.net;

Sanjay.Rao@stees.nhs.uk;

tommy.mousa@uhl-tr.nhs.uk;

JONATHON.FRANCIS@nnuh.nhs.uk;

parijatbhattacharjee@nhs.net;

Lesley.Woods@nuh.nhs.uk;

vinodpatil@doctors.org.uk;

George.Bugg@nuh.nhs.uk;

Wrench, Ian (Anaesthesia);

Matthew.Hogg@bartshealth.nhs.uk;

Jules.Allt@uhns.nhs.uk;

christopher.marsh1@nhs.net;

paul.ayuk@nuth.nhs.uk;

vicki.clark@nhslothian.scot.nhs.uk;

sue.catling@btopenworld.com;

Issie.Gardner@UHBristol.nhs.uk;

Aarti.Ullal@chsft.nhs.uk;

davidportch@nhs.net;

Dominika.Dabrowska@wmuh.nhs.uk;

Sajith.Philip@bartshealth.nhs.uk;

Peter.Yoxall@sthk.nhs.uk

All answers

Respondent number123456789101112131415161718192021

Q1: How many deliveries per year are there in your unit?750054007600390067506000800060007500330043008200550097002500535070008000550050004000

Q2: Approximately how many elective caesarean sections are performed each year in your unit?8001500200090045070012007001000350*15005002000180135070020001500521400

Q3: Do you have a formal enhanced recovery protocol for elective caesarean section in your unit?YesNo but we have plans to introduce oneYesNo but we have plans to introduce oneYesYesNoYesYesNoYesNo but we have plans to introduce oneYesYesYesNoNo but we have plans to introduce oneNoYesNo but we have plans to introduce oneNo but we have plans to introduce one

Q4: If you have an enhanced recovery protocol, what are the principal components or alternatively, could you send us a copy of it?SkippedNot applicableCopy sentNot applicableThe Bradford CARE protocol- can send you the full protocol if necessaryWill send copySkippedJon Francis will send itMinimise dehydration, early hydration and mobilisation including early removal of catheterSkippedI will send you a copySkippedempowering patients with expectations. early eating and drinking. mobilisation at 6 hrs. catheter removal once mobile. TTOs organised on day of surgerycatheter out when spinal wears off. feed and mobilise on day of CS. TTOs written in theatre. home following morningWill send separatelyWe are in the process of formalising what we already do. In essence they all get a regional with Diamorphine followed by oral analgesics. Oral water given in recoverey and food as soon as possible. Urinary catheter out in 6 hoursearly stagesSkippedwill send copySkippedSkipped

Q5: In your unit approximately what proportion of patients who have an elective caesarean section, go home the next day?20 to 50%less than 10%10-20%10-20%20 to 50%20 to 50%less than 10%20 to 50%10-20%20 to 50%less than 10%less than 10%20 to 50%20 to 50%more than 50%20 to 50%less than 10%less than 10%?20 to 50%20 to 50%

Q6: Would your unit be willing to participate in a nationally funded study to evaluate an enhanced recovery care pathway quality improvement intervention for planned Caesarean Section?YesYesYesYesYesYesYesYesYesYesYesNot sureNot sureNot sureYesYesNot sureNot sureYesYesYes

Q7: If the answer to question 5 was YES, would you be willing to act as named Principal Investigator in such a national study?YesYesNo but someone else may doYesYesYesYesYesYesYesYesNo but someone else may doSkippedNo but someone else may doYesYesSkippedOtherYesYesYes

less than 10%20 to 50%

less than 10%20 to 50%

less than 10%20 to 50%

less than 10%10-20%20 to 50%>50%

No protocol442244

Protocol1818559pre-forced air warmingpost-forced air warming

4715

YesNoPlanningYes - 2012

Percentage of units5219291

0.2857142857

All answers

No protocol

Protocol

Percentage of women who go home after a single night in hospital

Percentage of units

Summary stats

Do you have an enhanced recovery protocol for elective caesarean section?

Percentage of units

Histograms

Percentage of patients with core temp' < 36 degrees celcius

protocols

Q1: How many deliveries per year are there in your unit?6048

Q2: Approximately how many elective caesarean sections are performed each year in your unit?1013

YesNoNo but we have plans to introduce one

Q3: Do you have a formal enhanced recovery protocol for elective caesarean section in your unit?1146

Q4: If you have an enhanced recovery protocol, what are the principal components or alternatively, could you send us a copy of it?

less than 10%10-20%20 to 50%more than 50%0.5833333333

Q5: In your unit approximately what proportion of patients who have an elective caesarean section, go home the next day?63101

YesNoNot sure

Q6: Would your unit be willing to participate in a nationally funded study to evaluate an enhanced recovery care pathway quality improvement intervention for planned Caesarean Section?1605

YesNoNo but someone else may do

Q7: If the answer to question 5 was YES, would you be willing to act as named Principal Investigator in such a national study?1503

22619.0909090909

1.821.825.460.91

1818559

Q4: If you have an enhanced recovery protocol, what are the principal components or alternatively, could you send us a copy of it?

Skipped

Not applicable

Copy sent

Not applicable

The Bradford CARE protocol- can send you the full protocol if necessary

Will send copy

Skipped

Jon Francis will send it

Minimise dehydration, early hydration and mobilisation including early removal of catheter

Skipped

I will send you a copy

Skipped

empowering patients with expectations. early eating and drinking. mobilisation at 6 hrs. catheter removal once mobile. TTOs organised on day of surgery

catheter out when spinal wears off. feed and mobilise on day of CS. TTOs written in theatre. home following morning

Will send separately

We are in the process of formalising what we already do. In essence they all get a regional with Diamorphine followed by oral analgesics. Oral water given in recoverey and food as soon as possible. Urinary catheter out in 6 hours

Embryo stages

Perioperative analgesiaDrug and dose Drug and dose

Theatre Spinal Diamorphine 300µg Diclofenac 100mg PR

Post-op’ regular Ibuprofen 400mg tds Paracetamol 1g qds

Post-op’breakthrough pain

Oramorph 20mg hourly prn

94% of patients rated post-op’ pain control good or excellent

The Neonate

What changes to help the neonate?

Breast feeding Problems with breast feeding commonly delay discharge

Skin to skin contact at birth between mother and baby

improves breast feeding rates

Initiative to encourage this in theatre

Delayed cord clamping

Delayed cord clamping:

Umbilical cord

Neonate

• Increases the amount of blood going to the newborn from the placenta• Increases blood haemoglobin levels• Should improve neonatal recovery• Obstetricians have instituted a new protocol for this

Placenta

No evidence that it reduces length of stay for term babies.

Postoperative management: Postoperative mobilisation

Service evaluation of spinal anaesthesia (n=50)

Takes 7.5 (3-12) hours to wear off (median (range))

For caesarean section finishing at 10am:

Elected to mobilise day after surgery as before.

Removal of urinary catheters

Removed on mobilising next day as before

13:00Lower limit

14:00 15:00 16:00 17:00 18:00Median

19:00 20:00 21:00 22:00Upper limit

Summary of changes

All patients Patient informationMinimal interruption of food and fluidsWarmingOral post-op’ analgesia Skin to skin and delayed cord clampingMobilisation and catheter out next day

What happened following introduction of enhanced

recovery for elective caesarean section in Sheffield?

Timing of events in relation to change in proportion of day one discharge post elective CS:

£90,000 saving?

2015: 33% next day discharge

Readmission rate following introduction of ER:

• The proportion of women discharged on Day 1 • 1.6% in the first quarter of 2012 • 25.2% in the first quarter of 2014

• The 30-day readmission rate• 4.4% for those discharged on Day 1 • 5.6% for Day 2

• No evidence of patient harm or dissatisfaction

Summary

Problem areas/ could have done better:

Patient information TTO’s

Prescribe in theatre - patchy Dispensing on the ward

Self administration of drugs● Needs staff training to administer● Interaction with pharmacy● Lockable bedside cabinets

Baby checks ● Clinic set up with specialist neonatal nurse

Factors influencing length of stay:

Methods Service evaluation of all (708) elective

caesarean sections in 2013 Debbie Deloughry – information officer Annabel Allison – statistical analysis Sources of data

Theatre database - ORMIS Haematology Obstetric Anaesthetic Database Jessop Wing patient electronic data - JMIS

• Factors independently associated with a longer postoperative stay

• earlier gestation• multiple birth • intention to breast feed • longer surgery • more time in the post-anaesthesia recovery unit

• Women presenting for obstetric surgery with the indication ‘‘one previous caesarean section’’ were more likely to leave hospital earlier compared to most other indications.

Results of statistical analysis:

Gestation and day of discharge:

Stated maternal intentions for neonatal feeding preoperatively:

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

Day one Day two >Day two

Perc

enta

ge o

f wom

en

Day of discharge

Artificial

Breast

Breast & Artificial

Perioperative timings and day of discharge:

Indication for caesarean section: All vs first day discharge.

• Factors independently associated with a longer postoperative stay

• earlier gestation• multiple birth • intention to breast feed • longer surgery • more time in the post-anaesthesia recovery unit

• Women presenting for obstetric surgery with the indication ‘‘one previous caesarean section’’ were more likely to leave hospital earlier compared to most other indications.

Results of statistical analysis:

Factors not found to influence length of stay:

• Maternal age • BMI • Neonate

• Apgar• Birth weight• Need for resus’

• Smoking status • Parity• Change in haemoglobin level • Length of anaesthetic time

Factors not found to be statistically significant but may

have an influence.

Parity = 0

Time of day of surgery

Day of discharge and parity = 0:

0

5

10

15

20

25

8am to 10 am 10am tomidday

midday to 2pm 2pm to 4pm 4pm to 6pm

Percentage who went

home after one nights stay.

Time of day for elective caesarean section.

Effect of time of day of surgery on next day discharge:

Need for dedicated elective lists?

Grant application in progress for multi-center study:

POSTER

(PERI-OPERATIVE STRATEGIES TO ENHANCE RECOVERY AFTER ELECTIVE CAESAREAN SECTION)

Consensus meeting – to decide components of pathway:

Membership of group:

1.Three patient representatives2.Four anaesthetists 3.Obstetrician4.Uro-gynae consultant5.Midwife6.Three specialist researchers

i. Ethnographerii. Research nurse –

experienced with design methodology

iii. Trialist7.Neonatologist

ESSENTIAL components of the perioperative pathway for POSTER: Pre & intra-operative:

Patient education Fluid and food restriction timing. Patient selection. Selection of only low-risk

mothers for elective caesarean section. Avoidance of maternal hypothermia (less than

360C). Subcuticular wound closure. WHO checklist

ESSENTIAL components of the perioperative pathway for POSTER:

post-operative: Regularly prescribed non-opioid analgesia with

breakthrough oral pain relief prescribed for as required. Formal bladder care protocol including early removal of

catheter. Reduce organisational barriers to early discharge. Routine post-operative review of patients by obstetric

team. Specific follow up post-discharge by midwife or suitably

qualified person. Infant temperature routinely measured and

appropriately managed.

To summarise:

Key elements of enhanced recovery for elective caesarean section:

Many patients post elective CS may go home next day

Communication is key With patients With colleagues

Enthusiastic staff – particularly post-op’ ward Maintain momentum over a long period Neonate/ breastfeeding – delay discharge

Thank youAny questions?

Quality improvement for caesarean section - a multifactorial approach.Structure of talk:RationaleSlide Number 4Enhanced recoveryMembership of multidisciplinary team:�Patient survey.�Slide Number 8Planning for earlier discharge post elective caesarean section.�Factors consistent with enhanced recoveryPre-assessment clinic:�A key area in introducing change.�Slide Number 12Slide Number 13What changes did we introduce?What changes were made?Slide Number 16Perioperative oral intake data:Keeping patients warm:�Effect of introducing forced air warming. �S.Aluri, M.Berwetz, M.Walters, M.Woolnough��Perioperative analgesiaSlide Number 20What changes to help the neonate?Delayed cord clamping:Postoperative management:Summary of changesWhat happened following introduction of enhanced recovery for elective caesarean section in Sheffield?Slide Number 26Slide Number 27Readmission rate following introduction of ER:Slide Number 29SummaryProblem areas/ could have done better:Factors influencing length of stay:�MethodsResults of statistical analysis:Gestation and day of discharge:Stated maternal intentions for neonatal feeding preoperatively:Perioperative timings and day of discharge:Indication for caesarean section: �All vs first day discharge.Results of statistical analysis:Factors not found to influence length of stay:Factors not found to be statistically significant but may have an influence.Slide Number 42Slide Number 43Grant application in progress for multi-center study: �Consensus meeting – to decide components of pathway:ESSENTIAL components of the perioperative pathway for POSTER: Pre & intra-operative:�ESSENTIAL components of the perioperative pathway for POSTER:� post-operative:To summarise:Key elements of enhanced recovery for elective caesarean section:Thank you