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Majority next day discharges: evaluation of an enhanced recovery programme for elective caesarean delivery
Abstract Number: T1A-83
Abstract Type: Original Research
Introduction: Enhanced recovery (ER) after obstetric surgery has become popular internationally, with many units now practicing or planning adoption. However, there is limited evidence on the optimum perioperative interventions, and wide protocol variation exists. We present an analysis of our ER programme for elective caesarean delivery (CD).
Methods: Baseline audit was performed preceding introduction of ER (2014,2016; n=50,57); repeated during introduction (2017; n=120), and at one year (2018; n=29). We compared clinical characteristics, ER components, pathway compliance, length of hospital stay (LOS), time women felt ready for discharge (TRD) and maternal satisfaction. For women included in early introduction, correlation of clinical characteristics and ER components to LOS/TRD were analysed. Graphpad Prism 8.0, USA was used for analysis.
Results: ER was associated with a reduced LOS from median [IQR] 53 [27 to 57] to 34 [28 to 56] hours (h) (P = 0.01). TRD was 25 [24 to 29] h after ER. Next-day discharges increased from 37% to >50%, maternal satisfaction from 79% to >92% of women, both maintained at one year. Pathway compliance was sustained from 49% (2016) to 75% (2017) and 68% (2018). ER components correlated to LOS (Table). Time to first mobilisation (FM) and urinary catheter removal (UCR) had a stronger correlation to TRD: r=0.57 (0.36 to 0.73); P=0.0001 and r=0.46 (0.22 to 0.65); P=0.0003 respectively. FM discriminated between early (≤36 h) vs. delayed (>36 h) LOS (median [IQR] time 8 [7 to 10.75] vs. 9 [8 to 12] h, respectively; P=0.01). There was no difference in LOS for previous CD (P=0.56).
Discussion: Time to FM and UCR, and intraoperative blood loss had the strongest association with LOS. The hallmarks of our programme are an early mobilisation assessment by midwives at 6 h post neuraxial anaesthesia, and UCR from 8 h. We believe these interventions are instrumental to drive early discharge, although we can not attest causation. Our data could indicate the importance of minimising surgical blood loss. Our ER programme has been sustained at one year with a majority of women going home the next day. We found multidisciplinary involvement essential to maintenance, with our postnatal ward midwife lead ‘champions’ sustaining interest in excellent post-CD ER care.
1. Corso E et al. Enhanced recovery after elective caesarean: a rapid review of clinical protocols, an umbrella review of systematic reviews. BMC Preg Childbirth2017; 17: 91