Kaiser Permanente Division of Research and the Permanente Medical Group, Oakland, and the Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco California.
Obstet Gynecol. 2019 Sep;134(3):511-519. doi: 10.1097/AOG.0000000000003406.
To evaluate implementation of an enhanced recovery after surgery (ERAS) program for patients undergoing elective cesarean delivery by comparing opioid exposure, multimodal analgesia use, and other process and outcome measures before and after implementation.
An ERAS program was implemented among patients undergoing elective cesarean delivery in a large integrated health care delivery system. We conducted a pre-post study of ERAS implementation to compare changes in process and outcome measures during the 12 months before and 12 months after implementation.
The study included 4,689 patients who underwent an elective cesarean delivery in the 12 months before (pilot sites: March 1, 2015-February 29, 2016, all other sites: October 1, 2015-September 30, 2016), and 4,624 patients in the 12 months after (pilot sites: April 1, 2016-March 31, 2017, all other sites: November 1, 2016-October 31, 2017) ERAS program implementation. After ERAS implementation mean inpatient opioid exposure (average daily morphine equivalents) decreased from 10.7 equivalents (95% CI 10.2-11.3) to 5.4 equivalents (95% CI 4.8-5.9) controlling for age, race-ethnicity, prepregnancy body mass index, patient reported pain score, and medical center. The use of multimodal analgesia (ie, acetaminophen and neuraxial anesthesia) increased from 9.7% to 88.8%, the adjusted risk ratio (RR) for meeting multimodal analgesic goals was 9.13 (RR comparing post-ERAS with pre-ERAS; 95% CI 8.35-10.0) and the proportion of time patients reported acceptable pain scores increased from 82.1% to 86.4% (P<.001). Outpatient opioids dispensed at hospital discharge decreased from 85.9% to 82.2% post-ERAS (P<.001) and the average number of dispensed pills decreased from 38 to 26 (P<.001). The hours to first postsurgical ambulation decreased by 2.7 hours (95% CI -3.1 to -2.4) and the hours to first postsurgical solid intake decreased by 11.1 hours (95% CI -11.5 to -10.7). There were no significant changes in hospital length of stay, surgical site infections, hospital readmissions, or breastfeeding rates.
Implementation of an ERAS program in patients undergoing elective cesarean delivery was associated with a reduction in opioid inpatient and outpatient exposure and with changes in surgical process measures of care without worsened surgical outcomes.
通过比较实施选择性剖宫产术患者的阿片类药物暴露、多模式镇痛使用以及其他过程和结果指标，评估围手术期快速康复（ERAS）方案的实施情况。
在一个大型综合医疗服务系统中，对接受选择性剖宫产术的患者实施了 ERAS 方案。我们进行了 ERAS 实施前后的前瞻性研究，比较了实施前后 12 个月期间过程和结果指标的变化。
研究纳入了 4689 例在 12 个月前（试点站点：2015 年 3 月 1 日-2 月 29 日，所有其他站点：2015 年 10 月 1 日-9 月 30 日）和 4624 例在 12 个月后（试点站点：2016 年 4 月 1 日-3 月 31 日，所有其他站点：2016 年 11 月 1 日-10 月 31 日）接受 ERAS 方案的患者。ERAS 实施后，住院期间阿片类药物（平均每日吗啡当量）的平均暴露量从 10.7 当量（95%CI 10.2-11.3）降至 5.4 当量（95%CI 4.8-5.9），同时控制了年龄、种族-民族、孕前体重指数、患者报告的疼痛评分和医疗中心。多模式镇痛（即对乙酰氨基酚和脊麻）的使用率从 9.7%增加到 88.8%，达到多模式镇痛目标的调整风险比（RR）为 9.13（RR 比较 ERAS 后与 ERAS 前；95%CI 8.35-10.0），患者报告可接受疼痛评分的比例从 82.1%增加到 86.4%（P<.001）。出院时医院开出的阿片类药物从 ERAS 前的 85.9%下降到 82.2%（P<.001），开出的药丸数量从 38 粒减少到 26 粒（P<.001）。首次术后活动的时间减少了 2.7 小时（95%CI -3.1 至 -2.4），首次术后固体摄入的时间减少了 11.1 小时（95%CI -11.5 至 -10.7）。住院时间、手术部位感染、医院再入院率或母乳喂养率均无显著变化。
在接受选择性剖宫产术的患者中实施 ERAS 方案与阿片类药物的住院和门诊暴露减少以及手术过程护理措施的变化有关，而不会导致手术结果恶化。
