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Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge
  1. Sarah Joanne Bowden1,2,
  2. William Dooley2,
  3. Jennifer Hanrahan2,
  4. Chidimma Kanu2,
  5. Suni Halder3,
  6. Caroline Cormack2,
  7. Sabrina O'Dwyer4,
  8. Natasha Singh2
  1. 1Surgery and Cancer, Imperial College London, London, UK
  2. 2Obstetrics and Gynaecology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
  3. 3Anaesthetics, John Radcliffe Hospital, Oxford, UK
  4. 4Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, London, UK
  1. Correspondence to Dr Sarah Joanne Bowden; s.lever{at}ic.ac.uk

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.

  • obstetrics
  • quality improvement
  • elective caesarean section
  • enhanced recovery after surgery
  • fast-track surgery
  • patient satisfaction

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Footnotes

  • Presented at Historical audit data from 2013 were presented as a conference poster and published in conference proceedings (Halder S, Onwere C, Brennan C, et al. PA.07 Enhanced recovery programme for elective caesarean section: Abstract PA.07. Arch Dis Child Fetal Neonatal Ed 2014;99:A19.1–A19. doi:10.1136/archdischild-2014-306576.52). Interim audit results were presented as conference abstract and published in conference proceedings (Lever S, Chidimma Kanu, Jennifer Hanrahan et al. 24-hour discharge after elective caesarean section: a prospective audit. BJOG: Top scoring abstracts of the RCOG World Congress. 2016;126(S2)pp. 213).

  • Contributors NS planned the study. SH conducted the 2013 enhanced recovery project. SJL, WD, CK, SH, CC, JH and NS designed the fast-track pathway in 2015. SL, JH, WD, SO, NS and SH designed the data collection tools, conducted data collection and performed data analysis. SL, CK, JH and NS led monthly multidisciplinary team meetings. CC designed and oversaw the anaesthetic pathway. SL, CK, SO, WD and NS drafted the manuscript. All authors contributed to the interim drafts and reviewed the final manuscript.

  • Funding This project was part of a service evaluation. Service evaluation was approved by the NHS trust audit department and no further ethical approval deemed to be required. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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