Enhancing Recovery of Women Undergoing Elective Caesarean Section Workshop

Enhancing Recovery of Women
Undergoing Elective Caesarean Section
Workshop
25th November 2014
Chair : Catherine Calderwood,
National Clinical Director – Maternity and
Women’s Health

Where are we now?
What is our level of ambition?
Efficient, Effective, Elective Care – NHS
England National Perspective
Celia Ingham Clark

Enhanced Recovery:
Efficient, Effective
Elective Care
Celia Ingham Clark
Director for Reducing
Premature Mortality
NHS England
25th November 2014

Enhanced Recovery Care Pathways

Enhanced Recovery – How far have we come?
• Evidence based
approach
• Improves patient
experience
• Quality is the driving
principle
• Spread beyond original
8 elective surgical
procedures

ER is becoming the norm
“We believe that
enhanced recovery
should now be
considered as standard
practice for most
patients undergoing
major surgery across a
range of procedures
and specialties”.

A patient centred approach
Getting better soonerr
• Patient involvement
and shared decision
making at the heart of
ER
• The potency of patient
involvement helps to
drive spread and
adoption of ER

ER improves patients experience
……………………………… patients get better sooner
Patient Experience: Enhanced Recovery compared to National Inpatient Survey
94% 92%
89%
95%
78%
86%
74%
84%
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Were you involved as much as you
wanted to be about your care and
treatment?
How much information about
your condition or treatment was
given to you?
Did you feel you were involved in
decisions about your discharge
from hospital?
Did hospital staff tell you who to
contact if you were worried about
your condition or treatment after
you left hospital?
2011-Enhanced Recovery 2010-National Inpatient Survey - elective only
92%
89%
78%
86%
74%
as much as you
about your care and
treatment?
How much information about
your condition or treatment was
given to you?
Did you feel you were involved in
decisions about your discharge
from hospital?
Did hospital contact if you your condition you 2011-Enhanced Recovery 2010-National Inpatient Survey - elective only

ER reduces length of hospital stay
Falling length of stay
170,000 fewer bed days
Increasing day of surgery
admissions
No increase in readmissions

Orthopaedic:
Hip and knee replacement

Variation in practice – Elective Caesarean Section
Variation in adoption of practice Variation in momentum of spread

Efficient and Effective Elective Care
• The right person for the right operation at the
right time
• Enhanced recovery plus
• Productivity in the operating room
13

Variation in current practice – Association
of Obstetric Anaesthetists
Felicity Plaat

Variation in current practice Obstetric
Anaesthetists’ Association survey & feasibility
study from a single unit
Dr Felicity Plaat
Consultant Obstetric Anaesthetist
Queen Charlotte’s Hospital
Imperial College Healthcare NHS Trust
London
NHS-IQ Enhanced Recovery CS 2014 15

Background
• Wrench 2014
95% Lead clinicians in favour
3 units have implemented ER
Commonly practised: regular oral analgesia,
minimal fasting, ‘early’ mobilisation
Uncommon: Temperature management, cord
clamping, skin to skin
Concerns… Not resource neutral… safety

Introduction
The enhanced recovery care bundle is associated with
improved patient experience and better clinical
outcomes including earlier discharge. With a view to
introducing a similar care bundle in our unit, we
undertook to determine what aspects of current
management would preclude early (24 hour) discharge.

Method
50 consecutive parturients undergoing Caesarean
section were reviewed prospectively to determine
frequency of clinical interventions, including
observations and medications. The period of time
between surgery and urinary and epidural catheter
removal, transfer to a post-natal ward and to discharge
home were noted.

Results 1
• Parity: Multips – 63%
• Anaesthesia: Combined spinal-epidural - 100%
• Surgery ‘uncomplicated’ [estimated blood loss
<1L] – 100%
• Post operative epidural analgesia – 34%
[1 -4 top-ups]
• Time in Recovery - 4 – 6 hrs – 69%

Results 2
Intervention 0 – 24 hrs
% women
25 – 48 hrs
% women
49 – 72 hrs
% women
Simple analgesia 100 100 100
?
Epidural analgesia 13 19 0
Antiemetics 22 0 0
Uterotonics 0 0 0
Blood / products 0 0 0
VTE prophylaxis 100 100 100
Urinary catheter removed 3 91 6

Results 3
% Women discharged home
100
90
80
70
60
50
40
30
20
10
0
25 - 48 hrs 49 - 72 hrs >72 hrs

Discussion
Better patient experience –
more family centred
Less stressful
Better bonding
Better breastfeeding

Discussion
• Many aspects of enhanced Recovery are
routine in obstetrics
• 91% only required VTE prophylaxis & simple
oral analgesia 24 hours after surgery

Potential Barriers to enhanced Recovery
1. Resistance to change
2. Unpredictability of elective work
3. Bladder care
4. Lack of community resources

Discussion - safety

Conclusions
Women, especially those with children at home are
highly motivated to make their inpatient stay as short
as possible. Our results suggest that post-operative
care can be adapted to minimise delay, but to minimise
pre-operative delays, elective obstetric lists must be
run independently of the emergency workload & close
cooperation with services in the community is key

Building the case for change in practice –
what do women experience and want?
Helen Pickering

Our Birth Journey
The gentle arrival of Annabelle, by Helen Pickering

A Definition of a Gentle Caesarean
Section
An experience which mimics a natural birth, in
that a mother is able to watch her baby being
born. The baby is able to make a slow and calm
transition into the outside world and receive the
blood and stem cells from its own placenta and
cord. The mother and baby to be united skin to
skin immediately following delivery, to begin the
maternal bonding and breastfeeding journey.

A Beautiful Birth
Delayed Cord
Clamping UK

Challenges
• Access to appropriate support
• Advocates for mothers
• Lack of education
• Resistance to change
• Time constraints
• Team working

Opportunities
• Local birth choices group
• Consultant midwife clinic
• Breastfeeding support
• Internet based information and social media
• Time

Testimonial
• Dear Helen
•
• Lovely to hear from you and I am so glad that you are sharing your experience. I think your choices and care about
the birth of your baby had a profound impact on the staff.
•
• Here is an email I received from one of the midwives who was at your daughter’s birth:
•
• Just thought Id send you a quick email with regards to a birth I was involved in where you had seen her to do a birth
plan and just to let you know how it couldn't have gone any better and it will be a birth I'll remember for a long
time.
•
• She was wanting a gentle Caesarean section, delayed cord clamping and immediate skin to skin which all happened
and the joy on her face when the sheet was lowered as baby was being born will stay with me forever and summed
up why I started my midwifery career. We even did biological nurturing with her struggling feeding last time and it
was so nice for everyone being so relaxed and I believe it was a pleasure for everyone to be involved.
•
• It would be nice if this was talked about in community and if this could become the normal for elective caesareans
(well those which would want to) it will be definitely something I will be advocating in my further practice and I
just so thankful that we have you and Gill and all this can be possible for woman and feel that I can now offer this
without being looked upon as crazy.
•
• So, thank you as I think you have enhanced this midwives practice and this will have an ongoing positive effect!
•

References
• http://www.facebook.com/l.php?u=http%3A%2F%2Fd
octoranddaughter.co.uk%2Fa-natural-caesarean-section-
should-they-all-be-like-this%2F&h=HAQEkHPZi
• http://www.facebook.com/l.php?u=http%3A%2F%2Fo
nlinelibrary.wiley.com%2Fdoi%2F10.1111%2Fj.1471-
0528.2008.01777.x%2Ffull&h=sAQEGEs3A
• http://www.facebook.com/l.php?u=http%3A%2F%2Fw
ww.improvingbirth.org%2F2013%2F04%2Fa-family-centered-
cesarean-taking-back-control-of-my-sons-birth%
2F&h=qAQGnP_F3

Refreshments - pick up a drink

Developing a consensus/agreement
of pathway – what does the care
pathway look like?
Daniel Abel
Kings College Hospital

Introducing
Enhanced Recovery in Obstetric Surgery
King’s-EROS working party
Daniel Abell, Terie Duffy, Oli Long, Saju Sharafudeen

Contents
• Pathways and changes
• Auditing
• Results
• Conclusions / Challenges

6 Opportunities
to improve the service we offer women
3 Pathways
to help staff treat clients effectively
1 Checklist

What do women and staff
prioritise in the elective
caesarean section
pathways?

What happens to our women
Pre-admission
• Manage expectation
• Disseminate Information
Day prior to surgery
• Dedicated Elective LSCS list
• List management
• Phone call
• Starvation policy reiterated
(eat up to 2am, sugary drink 6am)

Day of Surgery
– Staggered admission times
– Midwife, Surgical, Anaesthetic Review
–Manage expectation of recovery
Anaesthetic Technique
– Spinal / CSE
–Reduced IV fluids
– IV Paracetamol, PR Diclofenac

Recovery
• Eat and Drink
• Syntocinon 20U/20mls @ 10mls/hr
• Urinary catheter out prior to ward discharge
• Aggressive management of nausea and
vomiting, and pain control
• Discuss mobilisation prior to ward discharge
• Detailed hand over to ward re ER
• Discharge medications prescribed

Post op Ward
• Encourage to mobilise
• 6 hours post spinal encourage to mobilise
and pass urine
• Aim TWOC 1 and 2
– >200mls
• Triggers at 22:00
– USS
– Residual > 500 and not PU – re-catheterise
– If recatheterised – remove at 06:00 Day 1

Post op day one
• Post Op Hb
• Baby Check
• Education re
– Breast feeding
– Analgesia
– Post op instructions
– Follow up information
Day one post hospital discharge
– Community midwife follow up

The Results – at the beginning
Elective Caesarean sections
417
Mean length of stay (3.33)
2.08
Patients suitabl e for EROS
226 (54.2%)
EROS patients went home day 1(6.5%)
91 (40.2%)
EROS patients going home day 1 or 2
194 (85.8%)

Results
Pre – EROS
Feb-April 12
Embedding
EROS
Aug – Oct 12
King’s-EROS Established
Feb – June 13
All EL
LSCS
EROS Pts
<6hr
EROS pts
>6hr
No. elective
LSCS
60 60 159 60 60
Starvation Fluids
Mobilisation time
(hours)
Catheter
removal (hours)
Time to spont
void
Recatheterisatio
n rate
7 day
readmission

Mobilisation
• Pre EROS: 22.1 hrs
• Embedding EROS: 15.7 hrs
• EROS < 6hr cath removal: 6.9 hrs
• EROS > 6hr cath removal: 15.8 hrs
• All Elective LSCS: 13.3 hrs

Catheter removal

Time to spontaneous void

Recatheterisation Rate
• Pre EROS: 1/60 (1.7%)
• Embedding EROS: 3/60
(5%)
• EROS < 6hr cath removal: 10/60 (16.7%)
• EROS > 6hr cath removal: 1/60 (1.7%)
• All Elective LSCS: 11/159 (3.8%)

Length of Stay
• All Elective LSCS: 59 hrs

Length of Stay
50
45
40
35
30
25
20
15
10
5
0
Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day >5
Pre-EROS n=441
Feb11-April12
EROS Era n=431
Aug12-June13
EROS n=159
Feb13-June13
% of all patients
Day of Discharge

Readmissions
• Pre EROS: 5/60 (8.3%)
• Embedding EROS: 3/60
(5%)
• EROS < 6hr cath removal: 2/60 (3.3%)
• EROS > 6hr cath removal: 2/60 (3.3%)
• All Elective LSCS: 6/159 (3.8%)

Follow Up
• All patients followed up on day 1 hospital
discharge by community midwives
– Findings
• Longer first appointment
• One extra appointment on average
• Day 7 by Obstetric anaesthetic fellow
– Readmissions
– Patient satisfaction
– Reflections

Client Satisfaction Feb – June 13
• Satisfied with programme – 100 EROS clients
– 42 very satisfied, 53 satisfied, 5 neutral
• But: Non EROS clients (45)
– 5 very satisfied, 33 satisfied, 7 neutral
• Recommend to a friend
– 92 Yes, 5 No, 3 Yes until postnatal ward
– Reasons for No
• Wanted to wait longer before recatheterisation
• Pain control and light headed
• Wanted to leave Day 2 but no paperwork and results –
then couldn’t leave til 17:00 next day either

What we could still improve on
• The catheter!
• Reducing fasting times
• Patient information
• Decisions around patient inclusion
(particularly around catheter removal)
• Staff involvement - OWNERSHIP
• Follow up

Conclusions
• Enhanced Recovery in Obstetrics is going to
be important over the next 5 years
• It is possible to set up a workable
programme in obstetrics
• Requires full multi-disciplinary team
approach
• Requires fail safe follow up plans in place
• Rewarding for both patients, staff, and
hospital management

Developing a consensus/agreement
of pathway – what does the care
pathway look like?
Kirsty MacLennan
Central Manchester University FT

Enhanced Recovery in Obstetrics
Dr Kirsty MacLennan
Consultant Anaesthetist
St Mary’s Hospital
CMFT

Audit of current practice
• Patient survey
• Both emergency and elective
– Fasting times
– Catheter
– Mobilisation
– Analgesia
– LOS
– Patient expectation

Fasting
• Pre op
– 58% > 8hrs fluid
– 68% > 10hrs food
• Post op
– 64% >2hrs fluid
– 66% >4 hours food
• 40% would prefer to E+D sooner

Catheter and mobilisation times
• Most 20-26hrs post op
both removal and
mobilisation
• Recurring theme…

Time of catheter removal in relation to
time of first mobilisation
10
5
0
-5
-10
-15
Time in hours from catheter removal to mobilisation
Line demonstrates time of catheter removal.
Time Zero – catheter out

Patient expectation
• 16% would have mobilised sooner if offered
• 18% felt analgesia not timely

How long do you expect to stay...?
4
8
24
10
4
2
13
5
30
25
20
15
10
5
0

Working party
• Obstetricians
• Anaesthetists
• Midwifery
• Managerial
Post it note time line

Lesson 1…agree your goals
Discussion with other units
Discussion within departments
Patient goals
• Starvation
• Catheter
• Analgesia
• Expectation as per NICE
guidelines
Staff goals
• Knowledge of ERAS
• Knowledge of expectation
to drive the process

Lesson 2…agree on your paperwork
• First hurdle is agreeing
• Don’t do what I did!

Lesson 3….play to your units strengths
K I S S

What do we like
• Fixed times
• Fixed jobs
• Fixed protocol

Staff training
• Posters with clear pathways
• Trust ERAS support (Kathleen Cooper)
• Midwifery lead (Kirsten Watson)
• Anaesthetic fellow (Niamat Aldamluji)

Exclusion criteria
• Diabetes – including gestational / diet controlled / tablet / IDDM
• Placenta praevia/abnormally adherent placenta
• BMI > 39
• Pre-eclampsia
• Multiple pregnancy
• Cardiac patients
• Patients in whom surgery is expected to be complex eg large fibroid uterus, 3 or more previous
sections
• Women with haematological disorders requiring haematological support post operatively. Eg
significant factor deficiencies

Pilot Launch
• Starvation
• 2hrs fluids
• 6 hours food

Catheter time
• Obstetrician discussion
• Agree upon plan
– At least 6 hours depending on time arrival in
recovery
– Land before 1pm catheter out at 6pm
– Land after 1 pm catheter out at midnight

Mobilise
• As soon as catheter out
• Aim 3 walks in 24 hours

Discharge
• Aim discharge 36 hours post op

Results in a nutshell
• 2 pilots
• n= 52 Aug – Nov 13 exclusions
• n= 54 Nov – Jan 14 no exclusions

Oral intake
11.75
4.5
0.5
0.875
12.23
4.5
1.25
0.20
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Postop fluid
Postop food
Preop fluid
Preop Food
Phase 2
Phase 1
Hours
Over 8h
Over 10h
Over 2h
Over 4h

Results in a nutshell
Pilot 1 Pilot 2
Catheter removal
(median)
9.75 hrs 9.0 hrs
Sat out (median) 9.5 hrs 9.25 hrs
Mobilised (median) 10 hr 9.25
Anti-emetics 100% 100%
Analgesics 100% 100%
Re-catheterised 3 3
Discharge (median) 31.25 hrs 32 hrs

Length of stay
• Pre ERAS
– 60% more than 3 days average of 5 days
• Pilot 1 exclusions
– 61.5% 24-36 h median 31.25h
• Pilot 2 no exclusions
– 61.1% 24-36 h median 32 h

Delayed discharges
Reason Phase 1 Phase 2
Neonatal 9 14
Social/domestic 4 1
Medical 7 6
Total 20 21

Follow-up
Moderate pain 13 13
Severe pain 1 3
Not given contact
no.
Concerns 9 2
• 9 concerns
Pilot 1 Pilot 2
7 3
– 4 anaesthetic (mainly pain)
– 4 surgical concerns
– 1 patient was unsure how to self administer LMWH.
Vs. 2/54 patients had concerns (pain, leaving early).

Satisfaction
• 69.2% (36/52) preferred to leave hospital next
day vs. 61% (33/54)
• 95.6% (44/46) were very satisfied- satisfied vs.
97.5% (40/41)

Patients comments
The good
• Midwives were great and very
professional, listened to their patients
and were very supportive
• I, initially, had concerns about ERP but it
worked very well and will definitely
want the same level of care if I come
back in the future
• It was a great experience and we had a
very supportive and responsible staff
• Very nice and relaxed atmosphere
which helped with my anxiety due to a
previous experience
• Energy drinks helped with hunger pain
and tasted good (4 patients)
The bad
• Hourly Observations were horrible
• We should be given the choice to stay
an extra night
• Uncomfortable in the sitting area for 6
hours starved
• Husband had to stop going to work to
look after me. I was too tired to go
home
• I was pushed out of hospital and it was
getting too late
• I felt that the midwife was too
aggressive telling me that “this is what
we do and you have to leave tonight”. I
think that if you take the responsibility
for looking after patients the least you
can do is to listen to them

The future
– DVD
– Patient diary
– Section School
• Roll out to emergency
– Starvation in labour
– Increase patient and staff awareness

Where to next?
Key challenges and solutions to
implement care pathway – what lessons
have we learnt?
Sameena Muzaffar
Emma Torbe

Emma Torbé, Specialist Trainee Obstetrics and Gynaecology,
SHA Service Improvement Fellow Aug 2011-Aug2012
Sameena Muzaffar Consultant Obstetrician and Gynaecologist

 What we wanted to achieve/ where were
aiming for
 Understand the starting point
 What were the obstacles in the way
 How we got there – the journey
 What we achieved / where we actually landed
up

 People - Stakeholder analysis
 Time
 Resources
 PDSA cycles

 Pathway was agreed and signed off by all the
consultants senior midwives.
 Executive support
 Regular stakeholder meetings
 2 patient information leaflets were created
 Development took 2 months

 Informing staff
 Informing patients
 Launch day
 Feedback from staff and patients
 Data collection

 Data collection
 Discharge times
 Change of management
 Change over of clinical staff

 A retrospective case note review of 100
patients undergoing elective caesarean section
before the introduction of ERP (Oct 11-Dec11)
and 100 patients undergoing elective
caesarean section two months after the
introduction of ERP (April12-July12))
 Parameters measured
1.Pre-op Hb
2.Type of anesthesia
3. Duration of catheterisation
4.Duration of immobility
5.Level of postoperative review
6.Length of stay (LOS)

Pre ER Post ER P Values
Major anaemia (<9gms/dl) % 6 0
Minor anaemia (9-10.5gms/dl) % 12 3
Anaemia (<10.5 gms/dl) % 18 3 0.218
Duration of catheterisation (mean) 1.5 0.9 0.006
Duration of im-mobilization (mean) 1.5 0.9 0.006
Length of stay (mean) 3.0 2.4 0.01
Obstetric Review % 38 79 0.03
Readmission % 12 5 0.09
Regional Anaesthesia 100 100

100% very satisfied/satisfied with their care
100% recommend RHCH to a friend
100% would have another baby at RHCH

 Length of stay remains the same
 Practice spreading into Emergency Caesarean
Section

 What you want to achieve/ where are you
aiming for
 Understand the starting point
 What are the obstacles in the way
 How are you going to get there
 What you can achieve / where you are actually
going to arrive
 Embedding the changes will lead to
sustainable change

How do we support spread and
adoption of practice?
Group discussion and action planning :
next steps
Catherine Calderwood

Enhancing Recovery of Women Undergoing Elective Caesarean Section Workshop

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