A Randomized Controlled Trial of Enhanced Recovery After Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda

Risk factors for failed enhanced recovery after planned caesarean delivery

INTRODUCTION

The introduction of the Enhanced Recovery After Surgery (ERAS) protocol in the context of planned caesarean sections is a recent development, and the risk factors leading to the failure of this protocol remain largely unknown.

OBJECTIVE

To identify the pre-operative maternal and obstetrical characteristics associated with failure of the ERAS protocol.

MATERIALS AND METHODS

The ERAS protocol was implemented at Hôpital Nord, Marseille, in August 2020, based on recent literature. A retrospective cohort study was conducted from November 2020 to 2021, which included women who underwent planned caesarean sections under the ERAS protocol. The primary outcome, protocol failure, was a composite of hospitalization for >5 days due to maternal causes, urinary retention necessitating catheterization, gastrointestinal obstruction, admission to the intensive care unit, or early reintervention. The investigated factors encompassed maternal sociodemographic characteristics, medical, surgical, and obstetric history, along with outcomes of the current pregnancy.

RESULTS

Of the 147 included women, 7.5 % experienced a failure of the ERAS protocol due to extended hospital stays exceeding 5 days for maternal medical reasons or the installation of an indwelling urinary catheter to manage acute urinary retention. Regarding the maternal factors studied, obesity, a history of abdominal surgery, and multiple caesarean sections showed no association with an increased frequency of ERAS failure.

CONCLUSIONS

ERAS failure was seldom observed in the context of a planned caesarean section. No risk factors for ERAS failure were identified, further encouraging us to apply this protocol to all patients undergoing a planned caesarean section.

Adherence to Enhanced Recovery After Surgery (ERAS) With Bellwether Surgical Procedures in Ethiopia: A Retrospective Study

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care approach that aims to improve patient outcomes by reducing physiological stress and promoting organ functional recovery. Implementing ERAS in low-resource settings faces challenges due to limited infrastructure and resources. This study examined the adherence to five ERAS recommendations with Bellwether surgical procedures in Ethiopian surgical facilities.

METHOD

A retrospective database review of the Ethiopian perioperative registry was conducted. A total of 555 patients were included in this study. Data extraction included patient demographics, American Society of Anesthesiologists' Physical Status classification, surgical variables, postoperative hospital length of stay (LOS), and ERAS guidelines components. The primary outcome was adherence to five ERAS guidelines recommendations (early mobilization, feeding initiation, postoperative nausea and vomiting prophylaxis, early catheter removal, and IV fluids discontinuation). The secondary outcomes included: (i) the association between adherence to ERAS guidelines and LOS and (ii) a total unduplicated reach and frequency analysis to determine the two recommendations with the most impact on decreasing LOS for future implementation in low-resource environments.

RESULTS

A total of 555 patients were included across the three surgical categories: CS (274, 49.4%), OBF (126, 22.7%), and laparotomy (155, 27.9%). The primary outcome showed that the overall adherence was 1810 (65.2%) of the total number of the five ERAS guidelines recommendations in the cohort (2275 recommendations). The secondary outcomes showed that adherence to all five ERAS recommendations reduced LOS by 128 h compared to nonadherence to any ERAS elements. Adherence to early mobilization, early removal of urinary catheters, and early feeding each have shown consistent reductions in LOS across all Bellwether surgical procedures.

CONCLUSION

The implementation of a limited set of ERAS recommendations in low-resource environments has the potential to decrease LOS by approximately 5 days for Bellwether surgical procedures.

Enhanced Recovery After Surgery Pathways and Obstetric Anesthesia: A Bibliometric Analysis

As enhanced recovery after surgery (ERAS) pathways are being used exceedingly all over the world, research on ERAS and obstetric anesthesia is expanding. The necessity for uniform guidelines is highlighted by the notable regional and institutional differences in ERAS pathway implementation. Bibliometric research can identify these differences, which promotes a more consistent use of evidence-based procedures. The present bibliographic analysis reviewed 866 documents from the Scopus database using the keywords "enhanced recovery after surgery, ERAS, and Obstetrics Anesthesia." An increased number of articles were added to the database from 2017, with 175 articles in 2024. VOSviewer software (version 1.6.20, Leiden University, Netherlands) was used to investigate the various aspects of bibliometric analysis. The five aspects that were analyzed were co-authorship, co-occurrence, citation, bibliographic coupling, and co-citation. The United States of America had the maximum number of articles, citations, organizations, co-authorship, and co-citation with other authors, organizations, and countries. In the citations category, Gustafsson had the maximum number of citations in documents, and Anesthesia and Analgesia had the maximum number of citations in a journal. A thorough summary of the development of the field of ERAS in obstetric anesthesia can be found in this bibliometric analysis. This analysis has identified important research contributions, significant authors, and new trends by looking at publications, citations, and collaborations. Future research, policymaking, and clinical practice could benefit greatly from this information.

Enhanced recovery after cesarean (ERAC) versus conventional care: An expanded systematic review and meta-analysis of 18,368 subjects

Background and Aims

Enhanced recovery after cesarean (ERAC) is an interdisciplinary approach to improve patient outcomes following cesarean section. ERAC's execution must be constantly evaluated. Thus, we aimed to analyze parameters associated with ERAC adoption for clinical care in this expanded systematic review.

Material and Methods

A systematic literature search using Epistemonikos, Google Scholar, PubMed, and Scopus was done until February 2023. The appropriate observational and experimental research comparing the effects of ERAC protocols with conventional care on postoperative adverse events, operation-related characteristics, time to first (oral intake, mobilization, bowel movement, and urinary catheter removal), and opioid use. Meta-analyses were conducted using the RevMan 5.4.1. and Comprehensive Meta-Analysis version 3.3 software.

Results

In total, 23 studies were included in this systematic review. ERAC implementation was found to be associated with improvement in terms of shorter postoperative hospital stays and faster time to first liquid intake, first solid diet, urinary catheter removal, and mobilization. Furthermore, the rate of opioid-free treatment, total in-hospital morphine milligram equivalent (MME), daily in-hospital MME, and total prescribed opioid pills at discharge (all parameters, P < 0.01) were significantly better in the ERAC group than in the conventional care group. However, no significant difference was observed regarding postoperative adverse events, blood loss, operation duration, and total prescribed MME at discharge parameters between the two observed groups.

Conclusion

ERAC implementation is associated with better healthcare delivery, as determined by shorter time to first, lower opioid consumption, and shorter postoperative length of stay compared with conventional care. However, it is not associated with a lower dosage of opioid prescription at discharge.

The 2023 Gerard W. Ostheimer Lecture. A Contemporary Narrative Review of Maternal Mortality and Morbidity: Opportunities to Improve Peripartum Outcomes

The Gerard W. Ostheimer lecture is given annually to members of the Society for Obstetric Anesthesia and Perinatology. This lecture summarizes new and emerging literature that informs the clinical practice of obstetric anesthesiology. This is a narrative review of 2022 literature pertinent to maternal morbidity and mortality in all income settings globally. Themes associated with worse maternal mortality rate (MMR), challenges health care workers face, public health priority areas, and initiatives to help countries achieve the United Nations Sustainable Development Goal targets for MMR are discussed. MMRs are higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Cesarean delivery rates are rising most rapidly in LMICs, warranting urgent maternal health care workforce planning efforts in these settings. Globally racial, ethnic, and geographical disparities in maternal mortality continue to be evident in global health care settings. In the United States, the MMR is rising. The evolving changes in abortion legislation in the United States may further negatively impact maternal morbidity and mortality. The need to implement American Society of Anesthesiologists-recommended obstetric anesthesia quality metrics to facilitate benchmarking and to improve patient experience and outcomes is discussed as well as the need for professional society guidance on minimum staffing levels in American labor and delivery units.

Comparison of the Efficacy of Indwelling Gastric Tubes in Preoperative and Postoperative Patients With Oral and Maxillofacial Malignancies

PURPOSE

To explore the optimal plan for the timing of indwelling gastric tube placement in oral and maxillofacial malignant tumor patients.

DESIGN

A prospective randomized controlled trial.

METHODS

80 patients with oral and maxillofacial tumor were selected, and 40 patients were Pre-operative group. The remaining 40 patients were the control group, called Postoperative group. The body weight and hospital stay of the two groups were observed before and after surgery. Blood samples were taken before surgery and 1, 3 and 7 days after surgery to detect hemoglobin and plasma albumin.

FINDINGS

The number of postoperative hospitalization days in the pre-operative group was significantly lower than that in the post-operative group; postoperative hemoglobin and plasma albumins were lower in both groups compared with the preoperative level.

CONCLUSIONS

Preoperative nasogastric tube ensured early postoperative administration of gastrointestinal nutrition, promoted postoperative plasma albumin recovery, and shortened the days of hospitalization.

Comparative Analysis of Early Versus Traditional Feeding Protocols in Elective Lower Segment Cesarean Sections

Background Postoperative care following elective lower segment cesarean section (LSCS) traditionally involves delayed oral feeding. However, recent evidence suggests that early feeding may enhance recovery and improve patient outcomes. This study aimed to compare the recovery outcomes of elective LSCS patients between early feeding and traditional feeding protocols. Methods This prospective, comparative study was conducted at the Department of Obstetrics and Gynecology, Government Medical College (GMC) Budaun, over nine months. Women aged 18 to 40 years undergoing elective LSCS with singleton pregnancies and gestational ages between 37 and 42 weeks were included. Participants were randomized into two groups: the early feeding group (EFG) and the traditional feeding group (TFG). The EFG received oral intake as early as two hours post-surgery, progressing to a regular diet within six to eight hours. The TFG followed standard postoperative protocols, beginning oral intake after 12-24 hours. Primary outcomes included time to return of bowel function and length of hospital stay. Secondary outcomes were patient satisfaction and complication rates. Data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY), with p-values < 0.05 considered statistically significant. Results The study included 94 participants (EFG: n = 44, TFG: n = 50). The EFG showed significantly faster return of bowel function, with time to first flatus (23.9 ± 6.2 vs. 34.1 ± 8.8 hours, p < 0.0001) and first stool (54.6 ± 8.5 vs. 91.3 ± 12.3 hours, p < 0.0001). Length of hospital stay was shorter in the EFG (4.3 ± 1.1 vs. 6.7 ± 1.4 days, p < 0.0001). Visual analog scale (VAS) scores before discharge were higher in the EFG (94.4 ± 8.7 vs. 81.4 ± 9.5, p < 0.0001), indicating greater patient satisfaction. Complication rates, including nausea, vomiting, abdominal distension, and wound infections, did not differ significantly between groups. Conclusion Early feeding post-elective LSCS significantly enhances recovery, as evidenced by quicker return of bowel function, reduced hospital stay, and higher patient satisfaction without increasing complication rates. These findings support revising postoperative care protocols to incorporate early feeding strategies.

A scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a patient-centered approach to surgery designed to reduce stress responses and facilitate faster recovery. ERAS protocols have been widely adopted in high-income countries, supported by robust research demonstrating improved patient outcomes. However, in Africa, there is limited evidence regarding its implementation. This review aims to identify the existing literature on the implementation of ERAS principles in Africa, the reported clinical outcomes, and the challenges and recommendations for successful implementation.

METHODS

We conducted a librarian-assisted literature search of electronic research databases between October and November 2023. Titles and abstracts were screened for eligibility, and duplicates were then removed, followed by full-text assessment of potentially eligible studies. We utilized the summative content analysis method to synthesize and group the data into fewer categories based on agreed-upon criteria. Descriptive statistics were used to describe the results.

RESULTS

The search identified 342 potential studies resulting in 15 eligible studies for inclusion in the review. The publication years ranged from 2016 to 2023. The studies originated from three countries: Egypt (n = 10), South Africa (n = 4), and Uganda (n = 1). Successful implementation was associated with reduced hospital length of stay (n = 12), lower mortality rates (n = 3), and improved pain outcomes (n = 7). Challenges included protocol adherence (n = 5) and limitations of the research design to generate strong evidence (n = 3). Recommendations included formal adoption of ERAS principles (n = 5), the need for sustained research commitment, and exploration of the applicability of ERAS in diverse surgical contexts (n = 8). Large-scale implementation beyond individual institutions was encouraged to further validate its impact on patient outcomes and healthcare costs (n = 1).

CONCLUSIONS

Despite the limited number of studies on ERAS implementation in Africa, the available evidence suggests that it reduces the length of hospital stays and mortality rates. This is crucial for the region, given its higher mortality rates, necessitating more collaborative, methodically well-designed studies to establish stronger evidence for ERAS in lower-resource environments.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Effect of Enhanced Recovery after Surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial

Background

With ever increasing rates of emergency caesarean deliveries (CD),incorporating the ERAS protocol might provide a perfect window of opportunity to increase maternal comfort during the postsurgical period, but also improve outcomes and facilitate optimal return of physiological function.

Objective

To determine whether an ERAS pathway at emergency caesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction.

Material & methods

Patients undergoing emergent caesarean delivery at ≥ 34 weeks of gestation were randomized to ERAS or conventional care. The primary outcome was to compare postoperative length of hospital stay. Secondary outcome variables included first oral intake, passage of flatus/defecation, first ambulation, first urination after catheter removal and postoperative pain scores in both groups.

Results

We randomized 142 women (71 each in ERAS versus Conventional arm) undergoing emergency cesarean delivery. Incorporation of ERAS protocol resulted in shorter length of hospital stay (73.92 ± 8.96 in conventional arm vs 53.87 ± 15.02 in ERAS arm; p value <.0001). Significant difference was seen in visual analogue scoring during initial ambulation and rest on day 0 and day 1 between ERAS and conventional arms with mean scores being lower in ERAS arm compared to Conventional arm (p value <.05). In terms of quality of life, ERAS arm had better quality of life compared to conventional arm.

Conclusion

Incorporation of ERAS protocol in emergency caesarean definitely improves patient outcome in terms of early resumption of activities with better quality of life.

A Prospective Longitudinal Quality Initiative toward Improved Enhanced Recovery after Cesarean Pathways

OBJECTIVE

This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery.

STUDY DESIGN

This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge).

RESULTS

Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20-49] vs. 16.8 MME [11.2-33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150-225] vs. 150 MME [112-150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3-4.7] vs. 2.2 [1.3-3.7], p < 0.001).

CONCLUSION

Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery.

KEY POINTS

· Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.. · Implementation of ERAC pathways is associated with lower delta (reported - expected) pain scores.. · The results of ERAC pathways implementation are increased by adopting a patient-centered approach..

Impact of enhanced recovery after surgery (ERAS) guidelines implementation in cesarean delivery: A systematic review and meta-analysis

BACKGROUND

Cesarean delivery rate is increasing, with no prediction of this rate to drop. Implementation of Early Recovery After Surgery (ERAS) program adapted to this high prevalent obstetrical surgical procedure proposes better peri-operative care achievement with improved maternal medical care, namely reduced morbidity, faster return to normal daily activities and improved impact on quality of life. Our aim was to analyze the outcomes of ERAS guidelines implementation in cesarean sections (CS).

MATERIAL AND METHODS

A systematic review was performed across 3 databases (MEDLINE (Pubmed), Scopus and Web of Science), with no time or language filters, for articles comparing outcomes on pregnant women who delivered via CS with ERAS guidelines implementation versus the traditional approach without ERAS implementation. Outcomes established: primary - hospital length of stay; secondary - opioid consumption, readmission rates and maternal complications (overall, surgical site infection and emetic morbidity). Statistical analyses were conducted using Review Manager 5.4 and its results were expressed as mean difference, standardized mean difference and odds ratio, with 95% of confidence intervals. This systematic review was reported according to the PRISMA statement.

RESULTS

This systematic review included 16 studies (3 randomized controlled trials (RCT), 4 prospective cohorts and 9 retrospective cohorts), with a pool analysis of 19,001 women (9752 with the traditional approach and 9249 following ERAS guidelines). Our results showed a significative decrease in length of hospital stay (MD: -13.78 h; CI 95 % -19.28 to -8.28; p < 0.00001) and opioid consumption (SMD: -0.91; CI 95 % -1.51 to -0.32; p = 0.003), with similar readmission rates (OR: 0.85; CI 95 % 0.50 to 1.44; p = 0.53) and maternal complications, namely: overall (OR: 0.87; CI 95 % 0.56 to 1.35; p = 0.53); surgical site infection (OR: 1.13; CI 95 % 0.72 to 1.77; p = 0.60) and emetic morbidity (OR: 0.78; CI 95 % 0.31 to 1.96; p = 0.60).

CONCLUSIONS

ERAS guidelines applied at CS management are associated with decreased length of stay and opioid consumption, without negatively impact on readmission rates and overall maternal complications, including surgical site infection and emetic morbidity. The reduced number of RCT studies and the heterogeneity of the studies (heterogeneous inter-study protocols) constitutes the major limitation of the evidence found. Still, these findings may be a foremost help to confirm the beneficial impact of an ERAS approach during peri-cesarean management.

Effect of early oral carbohydrate intake after elective Cesarean delivery on maternal body temperature and satisfaction: a randomized controlled trial

PURPOSE

Although the Enhanced Recovery After Cesarean Delivery (ERAC) consensus statement provides recommendations for early postoperative drinking and eating, evidence from high-quality clinical research directly addressing parturients is sparse. Our objective was to assess if early oral carbohydrate intake after elective Cesarean delivery improves maternal recovery.

METHODS

In this randomized controlled trial, we enrolled parturients undergoing elective Cesarean delivery under spinal anesthesia with tympanic membrane temperatures ≤ 36.5 °C immediately upon arrival at the postanesthesia care unit. Parturients were randomized to either 100 mL of oral complex carbohydrate intake (group CC) or 10 mL of water (group C). The primary outcome was maternal tympanic membrane temperature. Other outcomes included maternal thermal comfort score, degree of shivering, satisfaction, degree of thirst and hunger, and gastric emptying assessed by ultrasonography.

RESULTS

We included 90 participants in the final analysis. The mean (standard deviation [SD]) maternal body temperature at 120 min after ingestion was 36.7 (0.3) °C in group CC and 36.6 (0.3) °C in group C (difference in means, 0.14 °C; 95% confidence interval, 0.02 to 0.26; P = 0.02). Furthermore, using repeated measure models, the linear trends of temperature changes over time between groups CC and C were significantly different (P = 0.04). The thermal comfort scores at 120 min after ingestion were higher in group CC than in group C (P = 0.02), and the linear trends of shivering score changes over time between groups CC and C also were different (P = 0.003). The mean (SD) visual analogue scale scores for maternal satisfaction were 84 (13) mm in group CC and 47 (20) mm in group C (P < 0.001). Nevertheless, at 90 and 120 min after ingestion, there were no differences between the two groups in the number of participants with a gastric antrum cross-sectional area > 10.3 cm2.

CONCLUSIONS

Early oral carbohydrate intake after Cesarean delivery helped to restore maternal body temperature postoperatively and improve maternal satisfaction. Nevertheless, the clinical importance of these finding is unclear, given that most of the differences were small. In addition, there was no delay in maternal gastric emptying after consumption of a complex carbohydrate beverage in the early post-Cesarean period.

STUDY REGISTRATION

www.chictr.org.cn (ChiCTR2000031085); first submitted 13 November 2022.

Clinical Outcome in Patient Undergoing LSCS via ERAS Pathway versus Traditional Pathway: A Prospective Observational Study

Introduction

ERAS is an evidence-based management protocol for perioperative care, to accelerate patient recovery. The field of obstetrics has been a late adapter of ERAS pathway for CS, and the literature is limited from Indian population.

Material and Methods

This prospective non-randomized comparative clinical study was conducted on 190 pregnant patients, out of which 95 were subjected to ERAS protocol (Group 1) and remaining 95 cases were enrolled in existing traditional protocol (Group 2). The primary objective was to compare quality of recovery based on obstetric-specific QoR 11 questionnaire between patients undergoing ERAC and traditional protocol for elective LSCS. Secondary objective was to compare perioperative bleeding, breast feeding initiation and difficulties, first oral intake, ambulation attempts, decatheterization, surgical site infection and length of hospital stay.

Results

At 24 h postoperatively, mean QoR score was significantly higher for patients in the ERAC group (85.5 ± 7.46 vs 57.1 ± 11.33, p value < 0.01). In the ERAC group, 50.5% of the mothers started breastfeeding within first hour. The mean duration to start oral intake postoperatively was significantly lower in ERAC group. In the ERAC group, ambulation and decatheterization were attempted within 6 h postoperatively in 86.3%. The mean length of hospital stay was significantly lower for patients in the ERAC group (68.8 ± 1.9 vs 105.4 ± 25.7 h, p value < 0.001).

Conclusion

The use of ERAC protocol at cesarean delivery significantly improves quality of recovery and length of hospital stay.

Measuring enhanced recovery in obstetrics: a narrative review

Enhanced recovery after cesarean delivery is a protocolized approach to perioperative care, with the aim to optimize maternal recovery after surgery. It is associated with improved maternal and neonatal outcomes, including decreased length of hospital stay, opioid consumption, pain scores, complications, increased maternal satisfaction, and increased breastfeeding success. However, the pace and enthusiasm of adoption of enhanced recovery after cesarean delivery internationally has not yet been matched with high-quality evidence demonstrating its benefit, and current studies provide low- to very low-quality evidence in support of enhanced recovery after cesarean delivery. This article provides a summary of current measures of enhanced recovery after cesarean delivery success, and optimal measures of inpatient and outpatient postpartum recovery. We summarize outcomes from 22 published enhanced recovery after cesarean delivery implementation studies and 2 meta-analyses. A variety of disparate metrics have been used to measure enhanced recovery after cesarean delivery success, including process measures (length of hospital stay, bundle compliance, preoperative fasting time, time to first mobilization, time to urinary catheter removal), maternal outcomes (patient-reported outcome measures, complications, opioid consumption, satisfaction), neonatal outcomes (breastfeeding success, Apgar scores, maternal-neonatal bonding), cost savings, and complication rates (maternal readmission rate, urinary recatheterization rate, neonatal readmission rate). A core outcome set for use in enhanced recovery after cesarean delivery studies has been developed through Delphi consensus, involving stakeholders including obstetricians, anesthesiologists, patients, and a midwife. Fifteen measures covering key aspects of enhanced recovery after cesarean delivery adoption are recommended for use in future enhanced recovery after cesarean delivery implementation studies. The use of these outcome measures could improve the quality of evidence surrounding enhanced recovery after cesarean delivery. Using evidence-based evaluation guidelines developed by the COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) group, the Obstetric Quality of Recovery score (ObsQoR) was identified as the best patient-reported outcome measure for inpatient postpartum recovery. Advances in our understanding of postpartum recovery as a multidimensional and dynamic construct have opened new avenues for the identification of optimum patient-reported outcome measures in this context. The use of standardized measures such as these will facilitate pooling of data in future studies and improve overall levels of evidence surrounding enhanced recovery after cesarean delivery. Larger studies with optimal study designs, using recommended outcomes including patient-reported outcome measures, will reduce variation and improve data quality to help guide future recommendations.

Enhanced recovery after gynecological surgery: A meta-analysis of randomized controlled trials

Enhanced recovery after surgery protocol is a multidisciplinary and multimodal approach designed to improve perioperative outcomes for patients. This meta-analysis aimed to identify and elaborate on the efficacy of this protocol in women undergoing gynecologic surgery. Four databases were searched for randomized controlled trials from inception to December 2021. A total of 14 studies met the inclusion criteria and were analyzed. There was a significant reduction in the length of stay, the time to first flatus and first defecation, complications, and readmission rates in patients undergoing enhanced recovery after surgery when compared to routine care. The rate of discharge on the first postoperative day significantly increased in patients from the enhanced recovery group. There was no significant difference in the surgery time and blood loss. In conclusion, the enhanced recovery after surgery protocol might have a positive effect on patients undergoing gynecologic surgery. However, there is still heterogeneity between the included studies, and we need more research to draw reliable conclusions that enhanced recovery after surgery is favorable.

Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

OBJECTIVES

To systematically review existing literature on hospital-based quality improvement studies in sub-Saharan Africa that aim to improve surgical and anaesthesia care, capturing clinical, process and implementation outcomes in order to evaluate the impact of the intervention and implementation learning.

DESIGN

We conducted a systematic literature review and narrative synthesis.

SETTING

Literature on hospital-based quality improvement studies in sub-Saharan Africa reviewed until 31 December 2021.

PARTICIPANTS

MEDLINE, EMBASE, Global Health, CINAHL, Web of Science databases and grey literature were searched.

INTERVENTION

We extracted data on intervention characteristics and how the intervention was delivered and evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Importantly, we assessed whether clinical, process and implementation outcomes were collected and separately categorised the outcomes under the Institute of Medicine quality domains. Risk of bias was not assessed.

RESULTS

Of 1573 articles identified, 49 were included from 17/48 sub-Saharan African countries, 16 of which were low-income or lower middle-income countries. Almost two-thirds of the studies took place in East Africa (31/49, 63.2%). The most common intervention focus was reduction of surgical site infection (12/49, 24.5%) and use of a surgical safety checklist (14/49, 28.6%). Use of implementation and quality improvement science methods were rare. Over half the studies measured clinical outcomes (29/49, 59.2%), with the most commonly reported ones being perioperative mortality (13/29, 44.8%) and surgical site infection rate (14/29, 48.3%). Process and implementation outcomes were reported in over two thirds of the studies (34/49, 69.4% and 35, 71.4%, respectively). The most studied quality domain was safety (44/49, 89.8%), with efficiency (4/49, 8.2%) and equitability (2/49, 4.1%) the least studied domains.

CONCLUSIONS

There are few hospital-based studies that focus on improving the quality of surgical and anaesthesia care in sub-Saharan Africa. Use of implementation and quality improvement methodologies remain low, and some quality domains are neglected.

PROSPERO REGISTRATION NUMBER

CRD42019125570.

Quality improvement initiative to address bed shortage in the maternity ward at the National Referral Hospital

Background and Aims

The shortage of beds at the maternity ward is ever increasing with an increasing trend in total birth and cesarean section deliveries thereby increasing the daily number of obstetric patients awaiting admission. This quality improvement (QI) project was conducted to mitigate the problem of bed shortage by implementing modified enhanced recovery after surgery in low-risk cesarean section mothers. We aimed to increase the process measure of second day postoperative discharge in low-risk cesarean section mothers admitted in the maternity ward from 0% to 25% over 2 months period. Simultaneously, the outcome measure of daily number of obstetric patients awaiting admission was assessed.

Methods

The study was conducted at the maternity ward, Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan. Fishbone analysis was used to analyze problems leading to delayed discharge. Interventions were discussed, implemented, and reviewed using Plan, Do, Study, and Act (PDSA) cycle over 8 week period from June 1 to July 31, 2021. Data were collected using the EXCEL sheet and analyzed using STATA 13. Process and outcome measures during the pre and postintervention period were analyzed. Descriptive statistics were used to express the results. Wilcoxon Signed-Rank test was used to determine the statistical significance at p < 0.05.

Results

The postintervention second day postoperative discharge increased to a median value of 65.5% (interquartile range [IQR]: 45-80) compared to the preintervention value of zero. The number of daily waiting obstetric patients decreased from the preintervention median value of 6.0 (IQR: 0-7) to the postintervention median value of 1.0 (IQR: 0-2) which was statistically significant at p = 0.0001.

Conclusion

QI initiative can address bed shortages by increasing the early postoperative discharge, thereby reducing the number of obstetric patients awaiting admissions. The outcome of this QI initiative can be used to provide evidence to modify the existing Standard Operating Procedures in our setup.

Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis

BACKGROUND

Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher.

METHODS

Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation.

RESULTS

Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources.

CONCLUSIONS

Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.

Enhanced Recovery Pathway as a Tool in Reducing Post-operative Hospital Stay After Caesarean Section, Compared to Conventional Care in COVID Era-A Pilot Study

Objectives

To study the implementation of ERAS (Enhanced recovery after surgery) pathway and its effect on duration of post-operative hospital stay and various phases of post-operative care in comparison with conventional care group.

Materials and Method

Prospective study conducted in Amrita institute of medical sciences, Kochi, Kerala. Women planned for elective and scheduled caesarean section were included in the study from September 2020 to October 2020 and compared with women who underwent caesarean section in the same period receiving standard perioperative care. Women who underwent emergency and urgent caesarean section and patients with medical or surgical comorbidities were excluded. Surgical procedure was the same in both arms. Intravenous hydration was goal directed. Oral feeding was started with liquids after 2 hours, solids were given after 4 hours. Intravenous paracetamol and diclofenac were given routinely. Intravenous tramadol and fentanyl were given if needed apart from these analgesics. Foleys catheter was removed after 12 hours. Conventional care group observed 6 h of fasting pre- and post-operatively. Catheter was retained for 24 h, 2500 ml IV fluids were infused on the first day followed by 1000 ml on the second day. The duration of hospital stay was based on clinical criteria and care providers decision.

Results

In ERAS arm, post-operative hospital stay was significantly reduced in comparison with conventional care group. (53.91 vs 77.71 h-p = 0.00) Early feeding, early ambulation, early catheter removal, multimodal and preemptive analgesia all contributed to early recovery of the patient.

Conclusion

In ERAS pathway length of post-operative stay was significantly reduced as compared to conventional care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13224-021-01461-6.

Impact of enhanced recovery after cesarean delivery on maternal outcomes: A systematic review and meta-analysis

BACKGROUND

This meta-analysis explores the impact of enhanced recovery after cesarean delivery (ERAC) on maternal outcomes.

METHODS

We searched 4 databases (Web of Science, Embase, PubMed and CINAHL) in October 2020 without date limiters, for studies quantitatively comparing ERAC implementation to a control group. The primary outcome was length of hospital stay and secondary outcomes included time to mobilization and time to urinary catheter removal, opioid consumption, readmission rates and cost savings. Mean differences and odds ratios (MD and OR with 95% confidence intervals) were calculated. Levels of evidence were assessed using GRADE.

RESULTS

Twelve studies involving 17,607 patients (9693 without ERAC and 7914 with ERAC) were included. ERAC was associated with reduced: length of hospital stay (MD -0.51 days [-0.94, -0.09]; p = 0.018; I2 = 99%), time to first mobilization (MD -11.05 h [-18.64, -3.46]; p = 0.004; I2 = 98%), time to urinary catheter removal (MD -13.19 h [-17.59, -8.79]; p < 0.001; I2 = 97%) and opioid consumption (MD -21.85 mg morphine equivalents [-33.19, -10.50]; p = < 0.001; I2 = 91%), with no difference in maternal readmission rate (OR 1.23 [0.96, 1.57]; p = 0.10; I2 = 0%). Three studies reported cost savings associated with ERAC. The GRADE levels of evidence were rated as low or very low quality for all study outcomes.

CONCLUSION

ERAC is associated with reduction in length of stay, times to first mobilization and urinary catheter removal and opioid consumption. ERAC does not significantly affect maternal hospital readmission rates following discharge. Further studies are required to determine which ERAC interventions to implement and which outcomes best determine ERAC efficacy.

The successful implementation of the Enhanced Recovery After Surgery (ERAS) program among caesarean deliveries in Bhutan to reduce the postoperative length of hospital stay

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary perioperative care program to optimize and enhance postoperative recovery. It has a beneficial role in decreasing the length of hospital stay and improving the quality of care. This study aims to observe the successful implementation of ERAS in reducing the length of hospital stay (LOS) among caesarean deliveries.

METHODS

A pre-and post-implementation study of ERAS protocol was conducted, among cohort of women who underwent caesarean deliveries from January to December 2020 in the Department of Obstetrics and Gynaecology, Mongar Regional Referral hospital. Data collected retrospectively and analyzed in SPSS (IBM SPSS trial version); and comparison of length of hospital stay between the two groups were tested by t-test.

RESULTS

One hundred seventy-one patients were included in the study: 87 in the pre-ERAS and 84 in the post-ERAS cohort. Post implementation, LOS decreased by an average of 21.0 (CI 16.11-24.64; p-value < 0.001) hours in the postoperative period. A greater proportion of patients were discharged on day-2 (2.3% in pre-ERAS and 81% in ERAS; p-value < 0.001).

CONCLUSION

Implementation of ERAS protocol can significantly decrease the postoperative length of hospital stay without increasing the complications and readmission rates.

The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS. Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software. Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD -7.47 h, 95% CI: -8.36 to -6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: -1.23, 95% CI: -1.32 to -1.15, p < 0.00001), opioid use (SMD: -0.46, 95% CI: -0.58 to -0.34, p < 0.00001), and hospital cost (SMD:-0.54, 95% CI: -0.63 to -0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62). Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.