Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

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Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis

Perioperative Medicine ◽

10.1186/s13741-021-00209-0 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

E. M. Langnas ◽

Z. A. Matthay ◽

A. Lin ◽

M. W. Harbell ◽

R. Croci ◽

...

Keyword(s):

Time Series ◽

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Interrupted Time Series ◽

Total Daily Dose ◽

Interrupted Time Series Analysis ◽

Opioid Use ◽

Opioid Prescription ◽

Daily Dose

Abstract Introduction Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear. Study design We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends. Results Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01). Conclusion Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.

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The Association between Implementation an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

American Journal of Perinatology ◽

10.1055/s-0041-1732378 ◽

2021 ◽

Author(s):

Jennifer A. McCoy ◽

Sarah Gutman ◽

Rebecca F. Hamm ◽

Sindhu K. Srinivas

Keyword(s):

Cesarean Delivery ◽

Pain Control ◽

Enhanced Recovery ◽

Median Number ◽

Baseline Survey ◽

Quality Improvement Initiative ◽

Opioid Use ◽

Pain Scores ◽

Patient Reported ◽

Hospital Patients

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16–30] vs. POST 17.5 [range: 4–25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2–6] vs. POST 3[range: 1–5], p = 0.03). Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

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Enhanced Recovery After Surgery Pathway for Cesarean Delivery: Effect on Opioid Use and Pain Scores [5K]

Obstetrics and Gynecology ◽

10.1097/01.aog.0000558858.22192.c3 ◽

2019 ◽

Vol 133 (1) ◽

pp. 119S-119S ◽

Cited By ~ 1

Author(s):

Emily E. Fay ◽

Carlos C. Delgado ◽

Jane Hitti ◽

Leah Savitsky ◽

Elizabeth Mills ◽

...

Keyword(s):

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Use ◽

Pain Scores

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Enhanced Recovery after Surgery (ERAS) at cesarean delivery to reduce postoperative length of stay: some details need to be improved

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2019.12.022 ◽

2020 ◽

Vol 222 (5) ◽

pp. 512

Author(s):

Hu Qiang ◽

Sun Yuanshui

Keyword(s):

Length Of Stay ◽

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Postoperative Length

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Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1693699 ◽

2019 ◽

Vol 35 (09) ◽

pp. 695-704 ◽

Cited By ~ 2

Author(s):

Carol E. Soteropulos ◽

Sherry Y.Q. Tang ◽

Samuel O. Poore

Keyword(s):

Systematic Review ◽

Length Of Stay ◽

Breast Reconstruction ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Fluid Management ◽

Patient Counseling ◽

Opioid Use ◽

Full Spectrum ◽

Alloplastic Breast Reconstruction

Background Enhanced Recovery after Surgery (ERAS) principles have received focused attention in breast reconstruction. Many protocols have been described in the literature for both autologous and alloplastic reconstruction. This systematic review serves to better characterize successful ERAS protocols described in the literature for potential ease of adoption at institutions desiring implementation. Methods A systematic review of ERAS protocols for autologous and alloplastic breast reconstruction was conducted using Medline, the Cochrane Database, and Web of Science. Results Eleven cohort studies evaluating ERAS protocols for autologous (n = 8) and alloplastic (n = 3) breast reconstruction were included for review. The majority compared with a retrospective cohort of traditional perioperative care. All studies described the full spectrum of implemented ERAS protocols including preoperative, intraoperative, and postoperative phases of care. Most frequently reported significant outcomes were reduced length of stay and opioid use with ERAS implementation. No significant change in major complication or readmission rate was demonstrated. Conclusion Based on this systematic review, several core elements that make up a successful perioperative enhanced recovery protocol for breast reconstruction have been identified. Elements include patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis dependent on reconstructive method, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of ambulation postoperatively. Implementation of ERAS protocols in both autologous and alloplastic breast reconstruction can positively enhance patient experience and improve outcomes by reducing length of stay and opioid use, without compromising successful reconstructive outcomes.

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