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Slides from the Enhanced Recovery of Women Undergoing Elective Cesarean Section workshop. November 2014
Citation preview
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%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
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
0.8
0.9
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
NHS-IQ Enhanced Recovery CS 2014 16
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.
NHS-IQ Enhanced Recovery CS 2014 17
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.
NHS-IQ Enhanced Recovery CS 2014 18
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%
NHS-IQ Enhanced Recovery CS 2014 19
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
NHS-IQ Enhanced Recovery CS 2014 20
?
Results 3
% Women discharged home
0
10
20
30
40
50
60
70
80
90
100
25 - 48 hrs 49 - 72 hrs >72 hrs
NHS-IQ Enhanced Recovery CS 2014 21
Discussion
NHS-IQ Enhanced Recovery CS 2014 22
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
NHS-IQ Enhanced Recovery CS 2014 23
Potential Barriers to enhanced Recovery
1. Resistance to change
2. Unpredictability of elective work
3. Bladder care
4. Lack of community resources
NHS-IQ Enhanced Recovery CS 2014 24
Discussion - safety
NHS-IQ Enhanced Recovery CS 2014 25
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
NHS-IQ Enhanced Recovery CS 2014 26
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
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
• Pre EROS: 21.9 hrs
• Embedding EROS: 14.4 hrs
• EROS < 6hr cath removal: 3.1 hrs
• EROS > 6hr cath removal: 19.3 hrs
• All Elective LSCS: 13.4 hrs
Time to spontaneous void
• Pre EROS: 25.4 hrs
• Embedding EROS: 18.9 hrs
• EROS < 6hr cath removal: 8.7 hrs
• EROS > 6hr cath removal: 23.1 hrs
• All Elective LSCS: 18.2 hrs
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
• Pre EROS: 79.2 hrs
• Embedding EROS: 63.4 hrs
• EROS < 6hr cath removal: 47.9 hrs
• EROS > 6hr cath removal: 61.8 hrs
• All Elective LSCS: 59 hrs
Length of Stay
0
5
10
15
20
25
30
35
40
45
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
-15
-10
-5
0
5
10
Tim
e in
ho
urs
fro
m c
ath
ete
r re
mo
val
to m
ob
ilis
ati
on
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...?
4
8
24
10
42
13
5
0
5
10
15
20
25
30
How long do you expect to stay...?
4
8
24
10
42
13
5
0
5
10
15
20
25
30
Working party
• Obstetricians
• Anaesthetists
• Midwifery
• Managerial
Post it note time line
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
• Patient information
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)
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
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
• Patient information
– 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