Enhanced recovery pathways (ERP) were first described by by Wilmore and Kehlet in the early 21st century and used initially in the management of patients undergoing colorectal surgery. They have been successfully introduced in a variety of surgical specialties, and more recently for women undergoing category 4 caesarean section (CS). The key aims include improved patient satisfaction, early return to normal function and early discharge, in line with NICE Guidance.
Stage 1: Following approval from the trust audit department, an initial service evaluation was undertaken to record current practice and outcomes for patients having category 4 caesarean section. We recorded the following information; preoperative fasting times (fluids and food), presence of ketonuria (measured with dipstick at catheter insertion), postoperative fasting time, time to mobilisation, catheter removal and discharge.
50 patients were included.
We noted that fasting times were prolonged and many women had high levels of urinary ketones by the time they arrived in theatre.
Following this, a new enhanced recovery pathway was designed and implemented by a multidisciplinary team. A patient flowchart was included along with the following;
• Carbohydrate drink to take on the morning of surgery.
• Pre-operative information leaflet with details regarding fasting times.
Mobilisation and urinary catheters removed at 8 hours post CS.
Postop paracetamol plus NSAID (if not contraindicated) plus oral morphine if required. Discharge on day 1 post-operatively if no complications.
Early writing of TTOs to facilitate discharge and briefing of the community midwife teams.
tage 2: Audit of compliance with the ERP and repeat service evaluation of outcomes
The ERP was implemented in June 2015 and was re-evaluated between October and November 2015. 51 patients were included.
The re-evaluation consisted of; a comparison with previous audit, adherence to enhanced recovery flow chart, compliance with premedication and carbohydrate drinks, timing to first food and drink after surgery and patient satisfaction.
Compliance with premedication was excellent. 100% took ranitidine and 86% paracetamol. Almost all women (96%) complied with taking the carbohydrate drink preoperatively. One patient couldn’t tolerate it and one was diabetic therefore it was not given.
Ketosis: Following introduction of the ERP there was a statistically significant 25 reduction (p<0.01, chi-squared test) in the presence of urinary ketones (see
chart). Of these patients there were 6 morning and 5 afternoon cases.
Analgesia: All patients received appropriate analgesia, and none required IV or IM morphine. All patients had post operative anti-emetics prescribed and 16% of patients required these.
Mobilisation: Patients mobilsed on average 4 hours sooner post operatively, with 20% mobilising less than 8 hours post spinal, and 24% of patients had their urinary catheter removed within 8 hours post spinal. Only two patients required re-catheterisation.
Discharge: Day 1 discharge increased dramatically, with 47% of women achieving this.
Satisfaction: 43% were very satisfied, 47% were satisfied and for 10% the information was not available.
We have shown the successful implementation of an ERP for category 4 caesarean sections. We have been able to measure improvement in outcomes via service evaluation before and after its introduction.
Areas of success;
Reduced fasting times
Significant reduction in ketosis
Earlier mobilisation and catheter removal and subsequent decrease in length of hospital stays
Patients happy to play an active part in their care with high satisfaction.
Areas for improvement;
Encourage clear fluid intake up to 2 hours preoperatively
Encourage earlier postoperative oral intake, as this contributes significantly to the
overall fasting time (pre and postop combined).