From the 2019 HVPAA National Conference
Dr. Kathy Matthews (NYP-Weill Cornell Medical Center), Dr. Robert White (NYP-Weill Cornell Medical Center), Dr. Sharon Abramovitz (NYP-Weill Cornell Medical Center), Dr. Robin Kalish (NYP-Weill Cornell Medical Center)
Background
Enhanced recovery after surgery (ERAS) was developed to standardize clinical care pathways and communication across multidisciplinary teams to improve patient recovery. ERAS enhances the patient experience through active participation in the recovery process, while reducing hospital length of stay (LOS). ERAS encompasses 4 main stages:
1. Planning and preparing before surgery
2. Reducing physical stress of the operation
3. Managing post-operative analgesia with a standardized regimen
4. Early feeding and ambulation
Objective
The objective of our quality improvement initiative was to implement an ERAS protocol for scheduled cesarean sections (CS) and evaluate its efficacy.
Methods
We prospectively monitored patients 3 weeks prior to and 3 weeks subsequent to implementation of an ERAS for CS protocol. Patients were provided with a detailed information sheet explaining what to expect before, during and after their CS, both in the obstetrician’s office and on arrival for pre-operative laboratory testing. On the day of scheduled surgery, patients were maintained on an ERAS pathway of care, and were given a survey asking how well they were informed of items such as NPO guidelines, pain management options, and LOS.
Results
There were 38 patients in the pre-ERAS implementation group and 33 patients in the post-ERAS implementation group. The pre-ERAS group had a mean LOS of 3.5 days +/- 1.03 and the post-ERAS group of a mean LOS of 3.0 days +/- 0.35, demonstrating a reduction of 0.5 days (p=0.005). Over 50% of patients completed a phone survey following their scheduled CS. Subgroup analysis of satisfaction scores between pre-ERAS (n=20) and post-ERAS (n=19) groups did not show a statistical difference. Scores ranged from 1-5 with 1 representing completely unsatisfied and 5 representing completely satisfied; both groups had a median score of 5 [IQR 4-5], p=0.99.
Conclusion
A reduced LOS in patients undergoing scheduled CS was achieved in the first 3 weeks of implementing an ERAS protocol, without any evidence of a compromised patient experience.
Clinical Implications
A shorter LOS offers substantial cost savings for the health care system, room for more throughput, and less risk to patients. We also view ERAS as an approach to reduce racial and ethnic disparities and achieve impartial post-surgical healthcare through the utilization of standardized protocols and guidelines. The implementation of ERAS for CS required input and partnership with providers in multiple departments and roles. Future goals include sustainability of the ERAS program, implementation in patients requiring intrapartum CS, expansion to other hospitals within our system, and further evaluation of outcomes.
