An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost

• Published in: American journal of obstetrics and gynecology 2019-10, Vol.221 (4), p.349.e1-349.e9
• Main Authors: Fay, Emily E., Hitti, Jane E., Delgado, Carlos M., Savitsky, Leah M., Mills, Elizabeth B., Slater, JoAnn L., Bollag, Laurent A.
• Format: Article
• Language: English
• Subjects: Adult; Anti-Inflammatory Agents, Non-Steroidal - therapeutic use; cesarean delivery; Cesarean Section - economics; Cesarean Section - methods; direct cost; Early Ambulation; enhanced recovery; Enhanced Recovery After Surgery; Enteral Nutrition; ERAS; Fasting; Female; Fluid Therapy - methods; Health Care Costs - statistics & numerical data; Humans; Ketorolac - therapeutic use; length of stay; Length of Stay - statistics & numerical data; obstetrics; Pain, Postoperative - drug therapy; patient education; Patient Education as Topic; Perioperative Care; Phenylephrine - therapeutic use; Pregnancy; Program Development; Program Evaluation; Retrospective Studies; Vasoconstrictor Agents - therapeutic use
• ISSN: 0002-9378; 1097-6868
• DOI: 10.1016/j.ajog.2019.06.041

Enhanced recovery after surgery pathways provide a multidisciplinary, evidence-based approach to the care of surgical patients. They have been shown to decrease postoperative length of stay and cost in several surgical subspecialties, including gynecology, but have not been well-studied in obstetric patients who undergo cesarean delivery. We sought to determine whether the implementation of an enhanced recovery after surgery pathway for cesarean delivery would decrease postoperative length of stay and postoperative direct cost compared with historic controls. We conducted a retrospective cohort study that compared postoperative length of stay and postoperative direct cost among women on the enhanced recovery after surgery cesarean delivery pathway in the first year of implementation (April 1, 2017, to March 31, 2018; n=531) compared with historic controls (March 1, 2016, to February 28, 2017; n=661). Literature review informed the development of a prototype enhanced recovery after surgery pathway for cesarean delivery based on best practices from previous enhanced recovery after surgery experience in obstetrics (if available) or from other surgical disciplines if there were no available data for obstetrics. When there was not relevant published evidence from obstetrics, the taskforce used clinical experience and expert opinion to develop the pathway. The enhanced recovery after surgery cesarean delivery pathway included preadmission patient education and preoperative, intrapartum, and postoperative elements. Some components reflected standard obstetric care, and others were specific to the enhanced recovery after surgery pathway. Women with pregestational diabetes mellitus who were receiving insulin therapy before pregnancy, women with preeclampsia with severe features, women with complex pain needs, and women with surgical complications were excluded from baseline and implementation groups. Enhanced recovery after surgery cesarean delivery pathway participation was determined by order set usage. Analysis was stratified for women who underwent planned (no labor; n=530) and unplanned (labor; n=662) cesarean delivery. Demographic and clinical characteristics, postoperative length of stay, postoperative direct cost, and readmission rates for the baseline and implementation groups were compared with the use of chi-square and t-tests. During the first year of implementation, 531 of 640 eligible women (83%) were included in the enhanced recovery after surgery ce