American journal of obstetrics and gynecology | 2019
An Enhanced Recovery After Surgery Pathway for Cesarean Delivery Decreases Hospital Stay and Cost.
BACKGROUND\nEnhanced Recovery After Surgery (ERAS) pathways provide a multidisciplinary, evidence-based approach to the care of surgical patients. They have been shown to decrease postoperative length of stay and cost in several surgical subspecialties including gynecology, but have not been well studied in obstetric patients undergoing cesarean delivery.\n\n\nOBJECTIVE(S)\nWe sought to determine whether the implementation of an enhanced recovery after surgery pathway for cesarean delivery (ERAS CD) would decrease postoperative length of stay and postoperative direct cost compared to historical controls.\n\n\nSTUDY DESIGN\nWe conducted a retrospective cohort study comparing postoperative length of stay and postoperative direct cost among women on the ERAS CD pathway in the first year of implementation (4/1/2017-3/31/2018, n=531) compared to historical controls (3/1/2016-2/28/2017, n=661). Literature review informed the development of a prototype ERAS pathway for cesarean delivery based on best practices from previous ERAS experience in obstetrics (if available) or from other surgical disciplines if there were no available data for obstetrics. When there was not relevant published evidence from obstetrics, the taskforce used clinical experience and expert opinion to develop the pathway. The ERAS CD pathway included pre-admission patient education, preoperative, intrapartum, and postoperative elements. Some components reflected standard obstetric care and others were specific to the ERAS pathway. Women with pre-gestational diabetes on insulin prior to pregnancy, preeclampsia with severe features, those with complex pain needs, and those with surgical complications were excluded from baseline and implementation groups. ERAS CD pathway participation was determined by order set usage. Analysis was stratified for women undergoing planned (no labor, n=530) and unplanned (labor, n=662) cesarean delivery. Demographic and clinical characteristics, postoperative length of stay, postoperative direct cost, and readmission rates for the baseline and implementation groups were compared using chi-square and t-tests.\n\n\nRESULTS\nDuring the first year of implementation, 531 (83%) of 640 eligible women were included in the ERAS CD pathway. Body mass index was marginally higher in the baseline group for unplanned cesarean delivery (32.5±7.1 vs. 31.4±6.7, p=0.04). Otherwise there were no significant differences in demographic or maternal clinical characteristics between baseline or implementation groups overall or for planned or unplanned cesarean delivery. Compared to baseline, implementation of the ERAS CD pathway resulted in a significant decrease in postoperative length of stay by 7.8% or 4.86 hours overall (p<0.001) and for both planned (p=0.001) and unplanned (p=0.002) cesarean delivery. Total postoperative direct costs decreased by 8.4% or $642.85 per patient overall (p<0.001) and for both planned (p<0.001) and unplanned (p<0.001) cesarean delivery. There were no significant differences in readmission rates.\n\n\nCONCLUSION(S)\nImplementation of an ERAS pathway for women having planned or unplanned cesarean delivery was associated with significantly decreased postoperative length of stay and significant direct cost-savings per patient, without an increase in hospital readmissions. Given that cesarean delivery is one of the most common surgical procedures performed in the United States, positively impacting postoperative length of stay and direct cost for women undergoing cesarean delivery could have significant healthcare cost-savings.