Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

Abstract

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery.

Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge.

Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02).

Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic.

Key Points

• ERAS after cesarean reduces inpatient opioid consumption.

• ERAS after cesarean increases the proportion of women not consuming any opioids.

• This pathway can be feasibly adopted elsewhere.

Keywords

opioid - cesarean - enhanced - recovery - enhanced recovery after surgery

Note

A.D.M. works part time for the Philadelphia Department of Health.

Authors' Contributions

J.L.T., O.M.H., S.H.E., A.D.M., and E.J.D. conceived the study question and assisted with implementation of the quality initiative. J.L.T., O.M.H., J.E.T., and H.M.S. helped to conceive the study design and interpreted the results. J.L.T. and O.M.H. performed data collection and J.E.T. performed data analysis. J.L.T., O.M.H, and J.E.T. drafted the manuscript. All authors made substantial contributions in critically revising the manuscript. All authors fulfilled all conditions required for authorship and approved this submission.

Publikationsverlauf

Eingereicht: 10. November 2020

Angenommen: 17. Juni 2021

Artikel online veröffentlicht:
26. Juli 2021

• References

• 1 Garimella V, Cellini C. Postoperative pain control. Clin Colon Rectal Surg 2013; 26 (03) 191-196
• 2 Krebs EE, Gravely A, Nugent S. et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA 2018; 319 (09) 872-882
• 3 Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy 2013; 33 (04) 383-391
• 4 Agency for Healthcare Research and Quality. Pfuntner A, Wier LM, Stocks C. Most Frequent Procedures Performed in U.S. Hospitals, 2010: Statistical Brief #149. Rockville (MD): Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Accessed February 2013 at: https://pubmed.ncbi.nlm.nih.gov/23596641/
• 5 Madsen AM, Stark LM, Has P, Emerson JB, Schulkin J, Matteson KA. Opioid knowledge and prescribing practices among obstetrician-gynecologists. Obstet Gynecol 2018; 131 (01) 150-157
• 6 Osmundson SS, Schornack LA, Grasch JL, Zuckerwise LC, Young JL, Richardson MG. Postdischarge opioid use after cesarean delivery. Obstet Gynecol 2017; 130 (01) 36-41
• 7 Bateman BT, Cole NM, Maeda A. et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol 2017; 130 (01) 29-35
• 8 Bateman BT, Franklin JM, Bykov K. et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am J Obstet Gynecol 2016; 215 (03) 353.e1-353.e18
• 9 Peahl AF, Dalton VK, Montgomery JR, Lai YL, Hu HM, Waljee JF. Rates of new persistent opioid use after vaginal or cesarean birth among US women. JAMA Netw Open 2019; 2 (07) e197863
• 10 American College of Obstetricians and Gynecologists. Committee opinion no. 742: postpartum pain management. Obstet Gynecol 2018; 132 (01) e35-e43
• 11 Wilson RD, Caughey AB, Wood SL. et al. Guidelines for antenatal and preoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (part 1). Am J Obstet Gynecol 2018; 219 (06) 523.e1-523.e15
• 12 Caughey AB, Wood SL, Macones GA. et al. Guidelines for intraoperative care in cesarean delivery: enhanced recovery after surgery society recommendations (Part 2). Am J Obstet Gynecol 2018; 219 (06) 533-544
• 13 Macones GA, Caughey AB, Wood SL. et al. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019; 221 (03) 247.e1-247.e9
• 14 Towers CV, Shelton S, van Nes J. et al. Preoperative cesarean delivery intravenous acetaminophen treatment for postoperative pain control: a randomized double-blinded placebo control trial. Am J Obstet Gynecol 2018; 218: 353e1-353e4
• 15 Teigen NC, Sahasrabudhe N, Doulaveris G. et al. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial. Am J Obstet Gynecol 2020; 222 (04) 372.e1-372.e10
• 16 Hedderson M, Lee D, Hunt E. et al. Enhanced recovery after surgery to change process measures and reduce opioid use after cesarean delivery, a quality improvement initiative. Obstet Gynecol 2019; 134 (03) 511-519
• 17 Smith AM, Young P, Blosser CC, Poole AT. Multimodal stepwise approach to reducing in-hospital opioid use after cesarean delivery. Obstet Gynecol 2019; 133 (04) 700-706
• 18 Ong CKS, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110 (04) 1170-1179
• 19 Tan M, Law LS, Gan TJ. Optimizing pain management to facilitate Enhanced recovery after surgery pathways. Can J Anaesth 2015; 62 (02) 203-218
• 20 Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Obstet Gynecol 2016; 128 (01) 138-144
• 21 Sarin A, Litonius ES, Naidu R, Yost CS, Varma MG, Chen LL. Successful implementation of an enhanced recovery after surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery. BMC Anesthesiol 2016; 16 (01) 55
• 22 Meyer LA, Lasala J, Iniesta MD. et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol 2018; 132 (02) 281-290
• 23 Patel MS, Day SC, Halpern SD. et al. Generic medication prescription rates after health system-wide redesign of default options within the electronic health record. JAMA Intern Med 2016; 176 (06) 847-848
• 24 Fay EE, Hitti JE, Delgado CM. et al. An enhanced recovery after surgery pathway for cesarean delivery decreases hospital stay and cost. Am J Obstet Gynecol 2019; 221 (04) 349.e1-349.e9
• 25 Holland E, Bateman BT, Cole N. et al. Evaluation of a quality improvement intervention that eliminated routine use of opioids after cesarean delivery. Obstet Gynecol 2019; 133 (01) 91-97
• 26 Prabhu M, McQuaid-Hanson E, Hopp S. et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol 2017; 130 (01) 42-46
• 27 Prabhu M, Dubois H, James K. et al. Implementation of a quality improvement initiative to decrease opioid prescribing after cesarean delivery. Obstet Gynecol 2018; 132 (03) 631-636