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

“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”.

ER is becoming the norm

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

A patient centred approach

94% 92%89%

95%

78%

86%

74%

84%

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1

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?

Patient Experience: Enhanced Recovery compared to National Inpatient Survey

2011-Enhanced Recovery 2010-National Inpatient Survey - elective only

94% 92%89%

95%

78%

86%

74%

84%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

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1

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?

Patient Experience: Enhanced Recovery compared to National Inpatient Survey

2011-Enhanced Recovery 2010-National Inpatient Survey - elective only

ER improves patients experience

……………………………… patients get better sooner

Falling length of stay

170,000 fewer bed days

Increasing day of surgery

admissions

No increase in readmissions

ER reduces length of hospital stay

Orthopaedic:

Hip and knee replacement

Variation in practice – Elective Caesarean Section

Variation in momentum of spreadVariation in adoption of practice

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 PlaatConsultant Obstetric Anaesthetist

Queen Charlotte’s HospitalImperial 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

0

10

20

30

40

50

60

70

80

90

100

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!•

Any questions??

References

• http://www.facebook.com/l.php?u=http%3A%2F%2Fdoctoranddaughter.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%2Fonlinelibrary.wiley.com%2Fdoi%2F10.1111%2Fj.1471-0528.2008.01777.x%2Ffull&h=sAQEGEs3A

• http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.improvingbirth.org%2F2013%2F04%2Fa-family-centered-cesarean-taking-back-control-of-my-sons-birth%2F&h=qAQGnP_F3

http://www.facebook.com/l.php?u=http://doctoranddaughter.co.uk/a-natural-caesarean-section-should-they-all-be-like-this/&h=HAQEkHPZi

http://www.facebook.com/l.php?u=http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2008.01777.x/full&h=sAQEGEs3A

http://www.facebook.com/l.php?u=http://www.improvingbirth.org/2013/04/a-family-centered-cesarean-taking-back-control-of-my-sons-birth/&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 partyDaniel 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?

Staff v Patients views

What happens to our womenPre-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 sections417

Mean length of stay (3.33)2.08

Patients suitabl e for EROS226 (54.2%)

EROS patients went home day 1(6.5%)91 (40.2%)

EROS patients going home day 1 or 2194 (85.8%)

ResultsPre – 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

LSCS60 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

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50

Day 0 Day 1 Day 2 Day 3 Day 4 Day 5 Day >5

Pre-EROS n=441Feb11-April12

EROS Era n=431Aug12-June13

EROS n=159Feb13-June13

% o

f al

l pat

ien

ts

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

How it began…..

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

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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...?

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Working party

• Obstetricians

• Anaesthetists

• Midwifery

• Managerial

Post it note time line

Lesson 1…agree your goals

Patient goals

• Starvation

• Catheter

• Analgesia

• Expectation as per NICE guidelines


Staff goals

• Knowledge of ERAS

• Knowledge of expectation to drive the process

Discussion with other units Discussion within departments

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. Egsignificant 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

0.875

0.5

12.23

4.5

1.25

0.20

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Preop Food

Preop fluid

Postop food

Postop fluid

Phase 2

Phase 1

Hours

Over 8h

Over 10h

Over 2h

Over 4h

Results in a nutshellPilot 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

• 9 concerns– 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).

Pilot 1 Pilot 2

Moderate pain 13 13

Severe pain 1 3

Not given contact no.

7 3

Concerns 9 2

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

Group Work 1

Lunch and Networking

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-Aug2012Sameena 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 measured1.Pre-op Hb2.Type of anesthesia3. Duration of catheterisation4.Duration of immobility5.Level of postoperative review6.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

Thank you

Group Work 2

Refreshments - pick up a drink

How do we support spread and

adoption of practice?

Group discussion and action planning :

next steps

Catherine Calderwood

Close and safe journey home

Enhancing Recovery of Women Undergoing Elective Caesarean Section Workshop

Healthcare

Transcript of Enhancing Recovery of Women Undergoing Elective Caesarean Section Workshop