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 . 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” . 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 .
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 . 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 . 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 . 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 . The authors felt that the largest obstacle to smooth running of the enhanced recovery programme was lack of communication , 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 , 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 . 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 . We will discuss more on the post-operative phase later in the article.
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 ; however, education of the obstetric surgical patient is limited by temporal, spatial and personnel barriers. Surgical consultations are short and contain large amounts of critical information , while pre-admission discharge planning and goal setting may not always be emphasised enough. Moreover, the patient may have anxiety not only about the hospital admission and surgery but also about how the newborn will cope. This barrier can be overcome by arranging midwife or anaesthetic-led pre-assessment clinics where information can be given and discharge can be planned, as has been reported by Christmas and others . Although patients undergoing caesarean sections are generally young, care needs to be exercised in patient selection for enhanced recovery, as the same principles may not apply for caesareans done for patients in labour or for complex medical patients. A crucial step for identifying, and overcoming, patient factors is the involvement of patients in the design and implementation of enhanced recovery protocols. In our institution, patients who had previously undergone caesarean section were consulted for each part of the process of developing the proposed pathway. Patient selection for consultation included those who had good outcomes after surgery, but also those who had previously experienced less-favourable outcomes. This breadth of patient experience allowed many patient factors to be identified, reflected upon and incorporated into protocol design.
Pre-operative and intra-operative phases
One of the major barriers to developing enhanced recovery in caesarean sections is the lack of provision of elective caesarean section operating lists  and the absence of a fixed list order. A survey of UK units carried out in 2008 showed that only 14 per cent of units in UK had dedicated elective lists . This can lead to uncertainty with timings of the elective caesarean sections having an impact on pre-operative fasting duration, post-operative oral intake, discharge planning of both the mother and baby, and patient satisfaction. Although some authors have reported success in implementation of enhanced recovery in spite of this barrier, we feel that this will be a major obstacle to be overcome to ensure more widespread uptake of enhanced recovery .
There could be some factors of enhanced recovery which are not intuitive to patient preparation, for example to continue taking oral drinks until the day of surgery, and introduction of carbohydrate drinks pre-operatively. These could be met with resistance from staff but could be overcome by communication, education and clear guidelines as mentioned earlier.
The anaesthetic and surgical techniques for caesarean sections are similar in most institutes yet the practices which could support enhanced recovery – e.g. temperature monitoring and warming, routine use of anti-emetics, skin-to-skin contact in theatres and delayed cord clamping – are steps not all institutes have awareness about .
The post-operative period is the phase requiring maximum attention to ensure success of enhanced recovery but, unfortunately, can prove to be challenging. This could be a reflection of the fact that it is the phase of the patient’s journey that involves multiple specialties and greater participation from nursing, midwifery, and pharmacy staff and junior medical staff . Junior nurses and doctors can change frequently in most units in the NHS and thus constant re-education is necessary.
Self-completed patient recovery diaries may be one method by which patients can keep track of their own recovery and help meet protocol targets and these are routinely used in non-obstetric enhanced recovery programmes. In our hospital we are currently piloting a checklist that encourages patients to set targets for the key elements of recovery, such as oral intake, mobilisation and passing urine. This has received good feedback from the patients and makes them feel more engaged in their care – a key aspect of successful enhanced recovery.
Where patients are monitored after surgery and anaesthesia may have an impact on the success of the enhanced recovery. It has been shown in colorectal surgery that post-operative stay can be reduced by designing an ‘electives only’ ward . This may be unrealistic for most institutions but the recovery of patients in specialised post-anaesthesia recovery units can help highlight the hurdles that need to be overcome prior to discharge – fluids can be disconnected, oral intake resumed and mobilisation initiated – all of which, alongside removal of urinary catheters at 12 hours, could lead to higher chances of early successful discharge. These are critical elements of the enhanced recovery process but for them to be done in a specialised post-anaesthesia care unit will need a major investment.
Post-operative pain may contribute to a longer stay in recovery after surgery  and hence good post-operative pain relief is paramount to ensure success of enhanced recovery. A local audit of patient satisfaction with analgesia can aid in addressing any issues and can help achieve the goal of pain-free mothers who are ready for discharge. In the recent past, there have been concerns about post-operative pain relief, with the publication of alerts advising caution when prescribing codeine to breast-feeding mothers. NICE states that codeine may be used as a weak opioid during pregnancy; however, for the breast-feeding mother, NICE and the more recently published statement from the UK medicines information group (UKMi), recommend the use of dihydrocodeine or tramadol instead of codeine [17,18].
One UK group has reported that following withdrawal of codeine from their post-caesarean section analgesia protocol there was an increase in significant post-operative pain and a reduction in patient satisfaction , while others have reported that regular simple analgesia provides sufficient pain relief following hospital discharge after caesarean section . Nevertheless, it remains clear that effective post-operative analgesia planning is necessary to ensure implementation of the enhanced recovery pathway.
While patients can be encouraged to buy over-the-counter painkillers and keep a stock ready at home to prevent delays waiting for the pharmacy to issue these medications, there may still be delays waiting for thromboprophylaxis medications to be issued and this needs to be planned in advance.
To ensure readiness for discharge, these patients should receive an early follow-up on the first post-operative day by the obstetric and anaesthetic teams; however, this can be challenging if other clinical work is urgent.
Any factor that could increase potential of readmission of the baby needs to be considered. Studies show higher mortality and morbidity rates in babies discharged less than 30 hours after delivery . Ideally, the duration of hospital stay after delivery should be long enough to allow identification of early problems and initiation of a screening programme. Most authorities agree that comprehensive newborn examination should be performed, ideally within the first 24 hours of birth and certainly within 72 hours .
Factors like multiple births, admission to the neonatal high-dependency unit and maternal intent to breast-feed could potentially all prolong post-operative stay. Early skin-to-skin contact within 24 hours has been shown to improve initiation of breast-feeding .
While enhanced recovery may reduce in-hospital services, demands on community services and midwifery may significantly increase. There may also be concerns about readmission to the hospital; however, in studies comparing early versus usual discharge times for caesarean sections, there was no difference observed in the number of maternal readmissions, antibiotic use, maternal well-being and anxiety and depression status . Other authors have reported success with the enhanced recovery programme by ensuring that all women discharged following caesarean section were visited at home by a community midwife, allowing ready access to a health professional . It is also important to give clear and consistent advice on discharge from the ward about when and how to seek help. This would ensure that a follow-up system is in place and improve patient satisfaction.
It is important to highlight that one of the important components of enhanced recovery is continuity of care, efficient co-ordination between teams and quick decisions about discharge. The patients operated on towards the end of the week may have to wait until after the weekend to be discharged, and steps will need to be taken to ensure that any variations in implementation of enhanced recovery during the week are mitigated.
The development and implementation of enhanced recovery pathways are associated with both staff and material costs. These costs may include the recruitment of enhanced recovery specialist nurses/midwives, the procurement of pre-operative carbohydrate drinks and the development and production of educational materials such as information videos or leaflets/companion guides. In times of financial austerity, such costs need justification. A recent systematic review analysed 17 studies describing the cost-effectiveness of enhanced recovery progammes . All of the studies under review reported cost savings, primarily associated with lower post-operative morbidity and shorter length of stay. The authors of the systematic review concluded that enhanced recovery programmes are both clinically efficacious and cost effective. Other authors have reported that a maternity unit with around 600 low-risk elective caesarean sections performed annually could save approximately £180,000 per annum .
Although the principles of enhanced recovery are simple, the barriers to its implementation can be challenging. With the role of the anaesthetist expanding into the realms of peri-operative medicine, it is important that we find ways to overcome these barriers, as enhanced recovery has the potential to benefit both patients and institutions.
Kanika Dua (ST6), Sohail Bampoe (ST7) and Adam Shonfeld (consultant) are all at the Department of Obstetric Anaesthesia at St George’s University Hospitals NHS foundation trust in London
Kitching, A. & O’Neil, S. (2009) Fast track surgery and anaesthesia. Continuing Education in Anaesthesia, Critical Care & Pain 9(2), 39–43
NICE. Clinical guideline 132 on caesarean section. http://publications.nice.org.uk/caesarean-section-cg132/guidance#care-of-the-woman-after-cs (accessed September 2015)
NHS statistics. www.hscic.gov.uk/catalogue/PUB03071/nhs-mate-eng-2010-2011-rep.pdf
Aluri, S. & Wrench, I.J. (2014) Enhanced recovery from obstetric surgery: a UK survey of practice. Int. J. Obstet. Anesth. 23, 157–160
Brown, S., Small, R., Faber, B., et al. (2002) Early postnatal discharge from hospital for healthy mothers and term infants. Cochrane Database Syst Rev. (3):CD002958
Prior, E., Santhakumaran, S., Gale, C., et al. (2012) Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature. Am. J. Clin. Nutr. 95, 1113–1135
Lyon, A., Solomon, M.J. & Harrison, J.D. (2014) A qualitative study assessing the barriers to implementation of enhanced recovery after surgery. World J. Surg. 38(6), 1374–1380
Wrench, I.J. et al. (2015) Introduction of enhanced recovery for elective caesarean section enabling next day discharge: a tertiary centre experience Int. J. Obstet. Anesth. 24, 124–130
Abell, D., Long, O., Skelton, V., (2013) Correspondence. Enhanced recovery in obstetrics. Int. J. Obstet. Anesth. 22, 349–361
Maessen, J., Dejong, C.H.C., Hausel, J., et al. (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br. J. Surg. 94(2), 224–231
Petrie, K., Chamberlain, K. & Azariah, R. (1994) The psychological impact of hip arthroplasty. ANZ J. Surg 64, 115–117
Kahokehr, A., Sammour, T., Zargar-Shoshtari, K., et al. (2009) Implementation of ERAS and how to overcome the barriers. Int. J. Surgery 7, 16–19
Christmas, J. & Bamber, J. (2015) Maternal satisfaction with analgesia following hospital discharge after caesarean section. Int. J. Obstet. Anesth. 24, 85–93
Lucas, D.N. & Gough, K.L. (2013) Enhanced recovery in obstetrics – a new frontier? Int. J. Obstet. Anesth. 22, 92–95
www.oaa-anaes.ac.uk/assets/_managed/editor/File/Surveys/posters/83_johal_2009oaa_jersey.pdf (accessed November 2015)
Vickers, R. & Das, B. (2013) Enhanced recovery in obstetrics. Correspondence. Int. J. Obstet. Anesth. 22, 349–361
NICE guideline (2010) Analgesia mild-to-moderate pain. http://cks.nice.org.uk/analgesia-mild-to-moderate-pain#!scenario: 4. (accessed Sept 2015)
UK Medicines Information (2013) Codeine and breastfeeding: is it safe and what are the alternatives? www.ukmi.nhs.uk/ukmi/ukminews/default.asp?pageRef=1&sortorder=1
Courtenay-Evans, N.M. & Stacey R.G. (2014) Changes in analgesia requirements after withholding codeine from breastfeeding mothers following caesarean section. Int. J. Obstet. Anesth. 23, S24
Aylin, P., Alexandrescu, R., Jen, M.H., et al. (2013) Day of week of procedure and 30 day mortality for elective surgery: retrospective analysis of hospital episode statistics. BMJ 346, 8–22
Stowers, M.D.J., Lemanu, D.P. & Hill, A.G. (2015) Health economics in enhanced recovery after surgery programs. 62(2), 219–230
Halder, S., Onwere, C., Brennan, C., (2014) Enhanced recovery programme for elective caesarean section. Arch. Dis. Child Fetal Neonatal Ed. 99, A19. http://dx.doi.org/10.1136/archdischild-2014-306576.52