Barriers to implementation of enhanced recovery in obstetrics
Kanika Dua, Sohail Bampoe and Adam Shonfeld look at the complications associated with post-operative recovery in obstetrics and how to overcome them
Enhanced recovery, or ‘fast-track’ surgery, was pioneered by Henrik Kehlet in Denmark in the early 1990s. The term refers to a multimodal package of techniques which aims to decrease post-surgical organ dysfunction and complications and to improve post-operative recovery [1]. Though initially associated with minimally invasive laparoscopic surgery, other types of open surgeries have been integrated into the pathway and obstetrics is fast catching up.
Features for planned caesarean section that are already consistent with fast-track surgery include a generally young and fit population, minimal interruption of oral intake, avoidance of general anaesthesia and a motivated patient group.
This is being increasingly recognised and next-day discharge is in keeping with National Institute of Health and Care Excellence (NICE) guidance (see Figure 1), which states that “women who are recovering well, are apyrexial and do not have complications following caesarean section should be offered early discharge (after 24 hours) from hospital and follow-up at home, because this is not associated with more infant and maternal readmissions” [2]. Caesarean section is one of the most common surgical procedures performed by the NHS and most patients are discharged at least two days post-surgery [3].
A recently published national survey of obstetric units in the country showed that although many units were in support of the concept of enhanced recovery, in obstetrics only 6 per cent already had an enhanced recovery programme, were implementing one or were considering doing so [4]. Hence, in spite of potential benefits in terms of improved psychosocial and postnatal experience, reduction in maternal and neonatal nosocomial infection and the possibility of improving breastfeeding rates, the update of enhanced recovery in obstetrics has been slow [5,6].
For the successful implementation of obstetric enhanced recovery, we need a good understanding of the principles of enhanced recovery and good communication between the various stakeholders as the service redesigns are implemented at local levels. These have been studied in the recent past in colorectal surgery and there are lessons to be learnt which could be applied to obstetrics. The overarching themes of the barriers were felt to be patient-related, staff-related, practice-related and resources [7]. It is important to set up appropriate patient and staff expectations through proper education to bring about a change in attitude and behaviour.
The role of protocols
Setting up enhanced recovery programmes and developing guidelines and protocols takes time and multidisciplinary investment; however, setting up a protocol alone is not enough to ensure compliance and adherence.
The process of developing guidelines, targeting the involved professionals, implementing social and cultural change and organising the correct economics is time consuming.
Studies have shown that some of the factors to improve compliance were to have clear objectives, fewer new skills and compatibility of the guidelines with existing values held by team members [7]. In their study, Lyon and co-workers identified staff-related barriers as the key theme – and in particular felt that changing attitude and behaviour of staff can be difficult [7]. The authors felt that the largest obstacle to smooth running of the enhanced recovery programme was lack of communication [7], hence clear verbal and written communication is imperative for the success of such protocols. Several institutes where enhanced recovery has been successful have reported that close multi-disciplinary working and effective team management are the most important factors to ensure success [8], and Abell and colleagues from the Kings College EROS programme have also suggested that allowing each team member to take ownership of relevant steps helps in maintaining the motivation and cementing the success [9]. Enhanced recovery programmes have been shown to receive good patient feedback and this can help in maintaining staff engagement. It is also extremely important to seek staff feedback and opinions to ensure success of the programme.
Maessen et al. conducted a study to evaluate the role of protocols in determining success of enhanced recovery programmes and found that protocol compliance in the post-operative phase can be the most challenging [10]. We will discuss more on the post-operative phase later in the article.
Patient factors
One of the important principles underpinning the enhanced recovery pathway is an active role being played by the patient before, during and after the surgery. This gives the patient a sense of ‘coherence and control’, which are useful traits, linked to positive aspects of recovery [11]; however, education of the obstetric surgical patient is limited by temporal, spatial and personnel barriers. Surgical consultat