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Trust introduces an enhanced recovery pathway for women with planned caesarean births, reducing the length of postnatal hospital stay and improving maternal satisfaction

Challenge

    • Rise in birth rate and increase in caesarean births, rising costs and demands, and limited resources are some of the challenges facing the delivery of high-quality obstetric care
    • Introduce new methods to improve care at reduced cost
    • Encourage active involvement of the patients

Action

    • Introduced Enhanced Recovery Pathway in Obstetrics to facilitate shorter postnatal hospital stay for women with planned caesarean births
    • Developed clinical guidelines, client information leaflet, client-records booklets and a purpose built database
    • Reduced preoperative fasting time
    • Used standardised measures to prevent nausea and vomiting
    • Used effective pain relief post operation to enable early mobilisation and shorten postnatal hospital stay

Result

    • Increased the proportion of women discharged from hospital within 36 hours of surgery with no increase in readmission rates
    • Increase in the proportion of women receiving high-energy drinks preoperatively that aids in early postoperative mobilisation and shortened postnatal hospital stay
    • Majority of the women reported that they were discharged at an appropriate time with pain well controlled

A multi-professional working party committee working together and adopting the principles of ‘Effective Team Functioning’ and ‘Change Management’ successfully introduced ‘Enhanced Recovery Pathway in Obstetrics (ERPO)’ at Southend Hospital. Enhanced Recovery (ER) was originally developed by Wilmore and Kehlet in 2001 in Colorectal surgery, and since extended to other surgical specialities.

ER has shown to improve outcomes such as reduced hospital stay with no increase in readmission rates, improved patient and staff satisfaction and cost-savings. Despite the fact that expectant mothers are generally young with no significant co-morbidities and well motivated, the principles of ER have not been widely applied.

The scope of practice favours introduction of Enhanced Recovery Pathway in Obstetrics (ERPO). NICE recommends offering early discharge (after 24 hours) to women with uncomplicated caesarean births.

The aim of introducing ERPO was to improve client experience and facilitate shorter postnatal hospital stay for women with planned caesarean births so that the mother and her newborn can spend quality time with the family in their comfortable home surroundings. The significant achievement was a multi-professional working party committee working together to introduce the new innovative service, which has improved client experience.

Challenges

Challenges

1. Stakeholder, in particular, staff engagement

2. Lack of a named Executive sponsor.

3. Resistance to change.

Solutions

1. Formed a multi-professional working party committee.

2. Applied the principles of Effective Team Functioning and Change Management

3. Staff Education, engagement and communication

Actions

1. Formed a multi-professional working party committee

2. Applied principles of ‘Effective Team Functioning’ and ‘Change Management’. The principles of Enhanced Recovery were modified and applied to Obstetrics (women having planned caesarean births.

3. Changes trialled and tested prior to full implementation in a Plan, Do, Study, Act cycle aided by a specific purpose built database developed with the aid of IT experts

4. Clinical guidelines, client information leaflet, a specific client-records booklets and a purpose built database developed.

5. Client satisfaction survey conducted to obtain information from the ‘users perspective’ to identify areas for improvement.

Results

1. A statistically and clinically significant increase in the proportion of women discharged from the hospital within 36 hours of surgery (49.5% vs 66.3% - p value 0.0001) with no increase in readmission rates.

2. A statistically and clinically significant increase in the proportion of women receiving high-energy drinks preoperatively (8% vs 37.9% - p value 0.0001) that in turn aids in early postoperative mobilisation and shortened postnatal hospital stay.

3. Early postoperative mobilisation.

4. A statistically and clinically significant increase in the proportion of women with Visual Analogue Pain Score of < 3 in the postoperative recovery area (79.1% vs 95.4%, p value - 0.001) and in the postnatal ward area (56.2% vs 71.2%, p value 0.0001).

5. Significantly improved client satisfaction. The survey demonstrated that the expectant mothers were involved in their care pathway, Majority of the women reporting that they were discharged at an appropriate time with pain well controlled.

Value

The project has led to improved patient care and client satisfaction, and also staff education. The preoperative fasting time is reduced, standardised measures used to prevent nausea and vomiting and effective pain relief following the operation led to early mobilisation, early return to feeding and shortened postnatal hospital stay. There was no increased in readmission rates. While the financial analysis and cost savings were not calculated, the reduced postnatal hospital stay resulted in more efficient patient turnover.

A client satisfaction survey was conducted. Following the introduction of ERPO, a significantly greater proportion of women experienced better pain control, were discharged home at an appropriate time, were informed abut their care, and felt involved in the care pathway. In phase 1, ERPO was introduced successfully to women with planned caesarean births. This will be extended in the new year (phase 2) to women with uncomplicated caesarean births.

In detail

SUMMARY

•Enhanced Recovery Pathway in Obstetrics (ERPO) was developed and implemented by a multidisciplinary team in Southend Hospital in May 2015. Key to success and sustainability is having a strategic approach to implementation adopting the principles underlying effective team functioning and quality improvement (QI) methods.

•ERPO principles (optimal prenatal care, standardised management of peri-operative pain relief and measures to prevent nausea and vomiting, and early postoperative rehabilitation) were applied to women undergoing planned caesarean births with encouraging results - reduced length of postnatal hospital stay with no increase in readmission rates for the mother or the baby, and improved maternal satisfaction.

•In phase 2, ERPO principles will be applied to women with uncomplicated emergency caesarean section. The implementation strategy can easily be replicated by other units. The spread and sustainability of this innovation in the wider NHS can be facilitated by the development of a regional/ national toolkit. BACKGROUND Rise in birth rate and increase in caesarean births, rising costs and demands, and limited resources are some of the challenges facing the delivery of high-quality obstetric care. New and innovative methods are needed to improve care at reduced cost.

Since its initial description by Wilmore & Kehlet in 2001 in colo-rectal surgery, the principles of enhanced recovery (ER) have been successfully applied to other surgical specialities including gynaecology with proven benefits to the patients, staff, the organisations and the wider NHS. Expectant mothers are generally young with no comorbidities and form the ideal group to apply the principles of ER.

The scope of practice favours the introduction of ER in Obstetrics. NICE recommends offering early discharge (after 24 hours) to women with uncomplicated planned caesarean births, who are recovering well. The national survey of lead obstetric anaesthetists support the introduction of ER in Obstetrics.

Despite this, the principles of ER have not been widely applied to obstetrics. However, only a handful of units across UK have introduced it. AIMS and OBJECTIVES To develop and implement ERPO in obstetrics – initially, in women undergoing elective caesarean section, and subsequently extend this to uncomplicated emergency caesarean section.

Implement and monitor the different elements of ER pathway (prenatal care, peri-operative care and care in the community) in Plan Do Study Act cycle with continued improvements, aided by a specifically designed database. Encourage active involvement of the patients in the pathway and to seek feedback from the “users” to identify areas of improvement. Promote the spread of this innovation to the wider NHS along the lines of ERP in other specialities.

METHODS

Implementation of ERPO A multidisciplinary working party committee was formed and at met at regular intervals; the project lead coordinated the service improvement initiative applying the principles of effective team functioning; champion midwifes were identified. The existing service was mapped, baseline data collected in a designated proforma. ER principles were modified as applicable to obstetrics.

The pre-launch data collection continued as the ERPO was being embedded and developed. Improvements were trialled, tested and developed prior to full implementation on 30th April 2015. Evidence based guidelines, patient information leaflet, clinical records booklet and a specially designed database were developed; post-launch data was recorded in this database developed with the support of IT team.

Materials

The various elements of ERPO pathway from antenatal care through to the community were analysed from the available data. Three groups were compared Group 1 (n=200)

- pre-launch period (Feb to Jul 2014) Group 2 (n=336)

- ERPO was being developed/embedded (Aug 2014 to April 2015) Group 3 (n=642)

- post-launch period (May 2015 to Aug 2016)

Client satisfaction survey was conducted to obtain information from the “users perspective” to identify areas for improvement.

Patient satisfaction with pain management was an important component of the service evaluation audit. The target pain score to monitor postoperative pain relief was < 3 on a Visual Analogue Score (VAS) of 0-10. Postoperative pain relief was considered “good” when > 90% of women were satisfied with pain management4. Data was expressed as mean ± SD (95% CI), median (inter-quartile ranges, IQR) or proportions as appropriate. A p-value of < 0.05 was considered significant.

All statistical analysis were done using statistical software (STATA 14.1, Timberlake Consultants UK) Results There is no significant difference in the patient characteristics (age, parity, BMI, number of previous caesarean sections) between the three groups. Significantly greater proportion of women received high energy drinks preoperatively.

The introduction of ERPO resulted in early mobilisation, early removal of urinary catheter (with no increase in re-catheterisation rates), greater proportion of women discharged within 36 hours of surgery with no increase in readmission rates, and better control of paint in the postoperative recovery area and the postoperative ward. The client satisfaction survey showed a significant improved in client satisfaction rates. Conclusions It is feasible to apply the principles of ERP to Obstetrics with benefits to the patients, staff and the hospital.

The introduction of ERPO has shown A statistically significant increase in the proportion of women discharged from the hospital within 36 hours after surgery. There is no increase in readmission rates for the mother or the baby. Early removal of urinary catheter is not associated with increase in readmission rates. Early mobilisation Improved maternal satisfaction.

Mother and the baby are able to spend quality time together with the family in their comfortable home surroundings The client satisfaction survey demonstrates that expectant mothers were involved in their care pathway. Majority of the women reporting they were discharged at an appropriate time with pain well controlled. We aim to extend the principles of ERPO to unplanned emergency caesarean section (phase 2) in January 2017.

 

Key individuals

Narayanaswamy VENKAT RAMAN