Enhanced Recovery Caesarean Program at Mater Mothers' Hospital

Aim

To implement evidence-based enhanced recovery principles to optimise the recovery and experience of women giving birth by caesarean section, and in doing so to also allow more timely discharge of both mother and baby back to their home environment, and reduce length of stay.

Outcomes

Enhanced recovery has been shown in the international literature to be associated with improvements in both clinical outcomes (reduced length of stay, reduction in complications, reduction in readmissions) and health service improvements (reduced cost), and with improved patient satisfaction scores and faster recovery from surgery.

Background

Development and implementation of a program to optimise recovery after elective caesareans and enable earlier discharge for healthy, well women and their babies after elective caesareans in accordance to best evidence based practice. Includes inclusion and exclusion criteria, care path, patient info and staff education, streamlining ward processes and facilitated discharges.

Discussion

Since recruitment of the first patient (March 2018), 19% (242/1276) public elective CS at Mater South Brisbane have been through the ERC program.

• 38% of these were discharged within 32 hours of birth.

Average length of stay (LOS) for women in ERC program was 27.5 hours (from time of birth). In comparison, the average LOS for public CS was more than double that at 2.53 days (60.7 hours).

The rate of maternal readmissions to MMH for ERC patients was 6.5% (6/92). Breakdown of reasons for readmission:

• Wound infection = 2
• TOV = 1
• SOB?PE = 1
• Nausea and generally unwell = 1
• Abdo pain= 1

Reasons why women on the ERC program didn't achieve 'next day' discharge:

• 26% maternal medical reasons
• 21% neonatal/baby reasons
• 7% declined early discharge/refused to go
• 15% had an emergency CS (therefore taken off ERC program)
• 6% carepath changed to 'standard' elective CS carepath
• 4% had a vaginal birth
• 5% moved out of catchment
• 16% uncertain

Neonatal readmissions to Mater = 0

Patient experience/satisfaction data is currently being collated.

Initial patient feedback suggested:

• Many women (and families) have given very positive feedback - good to be home quickly, in own bed, with other children etc.
• Many women are getting back to normal activities much faster than we expected - we have heard anecdotes of women doing grocery shopping 2-3 days after their caesarean!
• Some women reported feeling overwhelmed by the series of health practitioners reviewing them on the day of discharge and the volume of information they were receiving, some felt anxious about going home.
• A preliminary audit by pain team has suggested minimal opioid analgesia use within the women on the enhanced recovery program (full data and analysis awaited)

Lessons learnt

• Multiple barriers were encountered from staff across many disciplines initially. This highlighted the importance of framing the program the right way - many staff were resistant, perceiving this as a cost-cutting measure. This was overcome by framing this as an improvement activity, implementing best-practice enhanced recovery principles to help women recover as quickly and efficiently as possible after giving birth by caesarean.
• Some women are initially concerned about the concept of going home the day after their CS - this requires careful explanation about the program, the benefits, reassurance that they won't be discharged home if there are concerns about Mum or Baby, and that homecare support is available.
• We are currently reviewing our Enhanced Recovery program with the aim to expand it to offer enhanced recovery principles to all publicly funded women undergoing a caesarean at Mater Mothers Hospital.