Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge

Abstract

Enhanced recovery after surgery (ERAS) aims to improve perioperative care, hasten recovery to the normal physiological state and shorten length of stay (LoS). There is evidence that ERAS programmes following elective caesarean section (ELCS) confer benefit through faster return to physiological state and reduced LoS for mother and baby. Baseline audit of ELCS in 2013 revealed a mean LoS of 3 days. We piloted an ERAS discharge pathway promoting day 2 discharge, which rose from 5.0% to 40.2%. 19.2% of women went home on day 1. Many women fed back that they would prefer day 1 discharge. We hypothesised that a day 1 discharge pathway for low-risk women could benefit both women and services at our maternity unit. From October 2015, we developed a 'fast-track pathway' (FTP) using a Plan-Do-Study-Act approach. Between October 2015 and April 2016, we prospectively audited clinical outcomes, LoS and maternal satisfaction from all women placed on the FTP. We held regular multidisciplinary team meetings to allow contemporaneous analysis. Satisfaction was analysed by Likert scale at postoperative surveys. Women were identified in antenatal clinic after meeting predefined low-risk criteria. 27.3% of women (n=131/479) delivering by ELCS entered the FTP. 76.2% of women on the FTP were discharged on day 1. Mean LoS fell to 1.31 days. 94.2% of women who established breast feeding at day 1 were still breast feeding at 7 days. Overall satisfaction at day 7 was 4.71 on a 5-point Likert scale. 73.1% of women reported good pain control. Additional financial savings are estimated at £99 886 annually. There were no related cases of readmission. Day 1 discharge after ELCS is safe and acceptable in carefully selected, low-risk women and has high satisfaction. There may be resultant financial savings and improved flow through a maternity unit with no detected adverse effect on breast feeding, maternal morbidity or postnatal readmissions.

Keywords: elective caesarean section; enhanced recovery after surgery; fast-track surgery; obstetrics; patient satisfaction; quality improvement.

Figure 1

Study profile. EBL, estimated blood loss; PET, pre-eclamptic toxaemia; PIH, pregnancy-induced hypertension; PPH, postpartum haemorrhage. Patients who were booked for a category 4 elective caesarean at Chelsea and Westminster Hospital were preoperatively assessed for allocation to fast-track pathway between 1 October 2015 and 31 March 2016. 131 of women were randomly invited and agreed to participate; all other women were allocated to the standard care enhanced recovery pathway. 30 women were removed from the pathway by the operating obstetrician immediately after surgery due to a maternal or neonatal perioperative contraindication. 24 women were unable to go home at day 1 due to reasons described. 77 women complete successful day 1 discharge and were followed up. 52 of 77 women were contactable at day 7.

Figure 2

Run chart: day 1 discharge success rate on fast-track protocol during quality improvement project. FT, fast-track; FTP, fast-track protocol; PDSA, Plan-Do-Study-Act cycle. Run chart to demonstrate trends in day 1 discharge success rate over time period of 1 October 2015 to 1 April 2016. Raw data (solid line), average fit (dotted line), interventions and events are demonstrated (arrows).

Figure 3

Run chart: day 1 discharge success rate on fast-track protocol during sustainability re-audit. Run chart to demonstrate trends in day 1 discharge success rate over time period 1 September 2017 to 1 March 2018, in comparison with quality improvement project period of 1 October 2015 to 1 April 2016. Raw data (solid line) and average fit (dotted line).