Cesarean Section Quality Initiative Cuts Opioid Use

The enhanced recovery after surgery (ERAS) program, a quality improvement initiative that made changes to preoperative and postoperative processes, leads to reductions in opioid use without increased pain and with faster recovery, according to a study published in the September issue of Obstetrics & Gynecology.

Monique Hedderson, Ph.D., from the Kaiser Permanente Division of Research in Oakland, California, and colleagues evaluated implementation of an ERAS program for patients undergoing elective cesarean delivery. The analysis included 4,689 patients who underwent an elective cesarean delivery in the 12 months before program implementation (pilot sites: March 1, 2015, to Feb. 29, 2016; all other sites: Oct. 1, 2015, to Sept. 30, 2016) and 4,624 patients in the 12 months after ERAS program implementation (pilot sites: April 1, 2016, to March 31, 2017; all other sites: Nov. 1, 2016, to Oct. 31, 2017). Comparisons included opioid exposure, multimodal analgesia use, and other process and outcome measures before and after implementation.

The researchers found that after ERAS implementation, mean inpatient opioid exposure (average daily morphine equivalents) decreased from 10.7 to 5.4 equivalents when controlling for age, race/ethnicity, prepregnancy body mass index, patient-reported pain score, and medical center. There was an increase from 9.7 to 88.8 percent in the use of multimodal analgesia (e.g., acetaminophen and neuraxial anesthesia). The adjusted risk ratio (RR) for meeting multimodal analgesic goals was 9.13 when comparing post-ERAS with pre-ERAS. The proportion of time patients reported acceptable pain scores increased from 82.1 to 86.4 percent. At hospital discharge, outpatient opioids dispensed decreased from 85.9 to 82.2 percent post-ERAS, and the average number of dispensed pills decreased from 38 to 26. For hospital length of stay, surgical site infections, hospital readmissions, or breastfeeding rates, there were no significant changes after ERAS.

"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," the authors write.

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