Quality improvement for caesarean section - a multifactorial approach. Ian Wrench Consultant Anaesthetist Jessop Wing Obstetric Unit

Transcription

1 Quality improvement for caesarean section - a multifactorial approach. Ian Wrench Consultant Anaesthetist Jessop Wing Obstetric Unit

2 Structure of talk: Rationale for introduction of enhanced recovery for elective caesarean section Changes introduced What happened after ER introduced Factors associated with early discharge Key components of ER for caesarean section - consensus

3 Rationale QIPP programme - 20billion savings NICE women who are recovering well, are apyrexial and do not have complications following CS should be offered early discharge (after 24 hours) from hospital and follow-up at home, because this is not associated with more infant or maternal readmissions. Evidence from other specialties that enhanced recovery programmes improve outcomes: Colorectal Urology Orthopaedics Gynaecology Hepatobiliary etc

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5 Enhanced recovery In general terms the most important aspects of an enhanced recovery programme are: Reduction in the stress response to surgery Excellent perioperative nutrition Postoperative pain relief that doesn t rely on strong morphine like pain killers Rapid postoperative mobilisation A co-ordinated perioperative care pathway designed A co-ordinated perioperative care pathway designed and managed by a multidisciplinary team. and managed by a multidisciplinary team.

6 Membership of multidisciplinary team:

7 Patient survey.

8 Patient survey 58 patients, day 1 or day 2 following elective caesarean section. S. Aluri, R. Bhosale, C Anderson, I Wrench

9 Planning for earlier discharge post elective caesarean section. Six months planning New perioperative pathway Publicising Getting consensus

10 Factors consistent with enhanced recovery Young fit patients - motivated Spinal anaesthesia Lower abdominal transverse incision with minimal use of drains Dedicated elective lists (nine per week)

11 Pre-assessment clinic: A key area in introducing change.

12 Key staff in introducing change.

13 Separate Elective Caesarean Section lists. AM PM Monday List List Tuesday List List Wednesday List List Thursday List List Friday List We have nine dedicated elective caesarean section lists per week.

14 What changes did we introduce?

15 What changes were made? Patient selection All patients Fitness for discharge determined post-op Patient information Verbal pre-assessment midwife/ anaesthetist Written information

16 You are going to have a planned (elective) caesarean section. Usually you will stay in hospital for at least two days but some women may go home the day after the operation if their recovery is going well. Below is some information about what needs to have happened before you can go home. NEW WORDING: You are going to have a planned (elective) caesarean section. If your recovery is going well you may go home the day after the operation. Below is some information about what needs to have happened before you can go home.

17 Perioperative oral intake data: Clear Fluids Food Pre-op 2 hours 6 hours Post-op Immediate One hour R.Kaur, S.Glover, L.Powell, A.Philips, H.Roberts, S.Gowri

18 Keeping patients warm: Effect of introducing forced air warming. S.Aluri, M.Berwetz, M.Walters, M.Woolnough

19 Perioperative analgesia Drug and dose Drug and dose Theatre Spinal Diamorphine 300µg Diclofenac 100mg PR Post-op regular Ibuprofen 400mg tds Paracetamol 1g qds Post-op breakthrough pain Oramorph 20mg hourly prn 94% of patients rated post-op pain control good or excellent

20 The Neonate

21 What changes to help the neonate? Breast feeding Problems with breast feeding commonly delay discharge Skin to skin contact at birth between mother and baby improves breast feeding rates Initiative to encourage this in theatre Delayed cord clamping

22 Delayed cord clamping: Placenta Umbilical cord No evidence that it reduces length of stay for term babies. Neonate Increases the amount of blood going to the newborn from the placenta Increases blood haemoglobin levels Should improve neonatal recovery Obstetricians have instituted a new protocol for this

23 Postoperative management: Postoperative mobilisation Service evaluation of spinal anaesthesia (n=50) Takes 7.5 (3-12) hours to wear off (median (range)) For caesarean section finishing at 10am: 13:00 Lower limit 14:00 15:00 16:00 17:00 18:00 Median 19:00 20:00 21:00 22:00 Upper limit Elected to mobilise day after surgery as before. Removal of urinary catheters Removed on mobilising next day as before

24 Summary of changes All patients Patient information Minimal interruption of food and fluids Warming Oral post-op analgesia Skin to skin and delayed cord clamping Mobilisation and catheter out next day

25 What happened following introduction of enhanced recovery for elective caesarean section in Sheffield?

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27 Timing of events in relation to change in proportion of day one discharge post elective CS: 90,000 saving? 2015: 33% next day discharge

28 Readmission rate following introduction of ER:

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30 Summary The proportion of women discharged on Day 1 1.6% in the first quarter of % in the first quarter of 2014 The 30-day readmission rate 4.4% for those discharged on Day 1 5.6% for Day 2 No evidence of patient harm or dissatisfaction

31 Problem areas/ could have done better: Patient information TTO s Prescribe in theatre - patchy Dispensing on the ward Self administration of drugs Needs staff training to administer Interaction with pharmacy Lockable bedside cabinets Baby checks Clinic set up with specialist neonatal nurse

32 Factors influencing length of stay:

33 Methods Service evaluation of all (708) elective caesarean sections in 2013 Debbie Deloughry information officer Annabel Allison statistical analysis Sources of data Theatre database - ORMIS Haematology Obstetric Anaesthetic Database Jessop Wing patient electronic data - JMIS

34 Results of statistical analysis: Factors independently associated with a longer postoperative stay earlier gestation multiple birth intention to breast feed longer surgery more time in the post-anaesthesia recovery unit Women presenting for obstetric surgery with the indication one previous caesarean section were more likely to leave hospital earlier compared to most other indications.

35 Gestation and day of discharge:

36 Stated maternal intentions for neonatal feeding preoperatively: Percentage of women Artificial Breast Breast & Artificial 0.0 Day one Day two >Day two Day of discharge

37 Perioperative timings and day of discharge:

38 Indication for caesarean section: All vs first day discharge.

39 Results of statistical analysis: Factors independently associated with a longer postoperative stay earlier gestation multiple birth intention to breast feed longer surgery more time in the post-anaesthesia recovery unit Women presenting for obstetric surgery with the indication one previous caesarean section were more likely to leave hospital earlier compared to most other indications.

40 Factors not found to influence length of stay: Maternal age BMI Neonate Apgar Birth weight Need for resus Smoking status Parity Change in haemoglobin level Length of anaesthetic time

41 Factors not found to be statistically significant but may have an influence. Parity = 0 Time of day of surgery

42 Day of discharge and parity = 0:

43 Effect of time of day of surgery on next day discharge: Need for dedicated elective lists? Percentage who went home after one nights stay am to 10 am 10am to midday midday to 2pm 2pm to 4pm 4pm to 6pm Time of day for elective caesarean section.

44 Grant application in progress for multi-center study: POSTER (PERI-OPERATIVE STRATEGIES TO ENHANCE RECOVERY AFTER ELECTIVE CAESAREAN SECTION)

45 Consensus meeting to decide components of pathway: Membership of group: 1.Three patient representatives 2.Four anaesthetists 3.Obstetrician 4.Uro-gynae consultant 5.Midwife 6.Three specialist researchers i. Ethnographer ii. Research nurse experienced with design methodology iii. Trialist 7.Neonatologist

46 ESSENTIAL components of the perioperative pathway for POSTER: Pre & intra-operative: Patient education Fluid and food restriction timing. Patient selection. Selection of only low-risk mothers for elective caesarean section. Avoidance of maternal hypothermia (less than 36 0 C). Subcuticular wound closure. WHO checklist

47 ESSENTIAL components of the perioperative pathway for POSTER: post-operative: Regularly prescribed non-opioid analgesia with breakthrough oral pain relief prescribed for as required. Formal bladder care protocol including early removal of catheter. Reduce organisational barriers to early discharge. Routine post-operative review of patients by obstetric team. Specific follow up post-discharge by midwife or suitably qualified person. Infant temperature routinely measured and appropriately managed.

48 To summarise:

49 Key elements of enhanced recovery for elective caesarean section: Many patients post elective CS may go home next day Communication is key With patients With colleagues Enthusiastic staff particularly post-op ward Maintain momentum over a long period Neonate/ breastfeeding delay discharge

50 Thank you Any questions?