Association of an Enhanced Recovery After Cesarean Surgery Protocol With Postpartum Opioid Utilization: Analysis of a Quality Improvement Project

Kathleen M. Antony, MD, MSCI; India Anderson-Carter, MD; Aimee Teo Broman, MA; Sarah E. Gnadt, Pharm D, BCPS; Delores Krickl, BSN; Shefaali Sharma, MD; Luther L. Gaston, MD; Emily M. Buttigieg, MD; Benjamin B. Whiddon, MD, PhD

WMJ. 2024;123(6):474-482.

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ABSTRACT

Introduction: Research has shown that 1 of every 50 to 300 patients can develop chronic opioid use following treatment of acute pain, including after cesarean birth. Our hospital identified that our post-cesarean patients utilized high doses of systemic opioids. This study sought to determine whether implementation of a standardized enhanced recovery after cesarean surgery (ERAS) protocol decreased opioid utilization following cesarean birth.

Methods: An evidence-based ERAS protocol was created and implemented. This protocol included intrathecal morphine and a standardized approach to all phases of perioperative care for both scheduled and unscheduled cesarean deliveries. A before-and-after analysis compared oral morphine milligram equivalents (MME) for 9 months prior to and 9 months after implementation. People with chronic opioid use for any indication or postoperative intubation were excluded. The primary outcome was the cumulative MME utilization in the first 48 hours postoperatively. MME utilization and pain scores at other time points were compared.

Results: Patients who underwent cesarean birth prior to implementation of the ERAS protocol (pre-ERAS) (n = 973) and after implementation (post-ERAS) (n = 1025) were included. The median cumulative opioid dose in the first 48 hours post-cesarean was 122 MME (interquartile range [IQR] 80-164) pre-ERAS compared to 8 MME (IQR 0-48) post-ERAS (P < 0.001). The median cumulative MME was higher in the pre-ERAS period compared to the post-ERAS period for all time points assessed. The prevalence of pain scores > 7 in the first 24 hours was decreased in the post-ERAS period as was the percentage of patients requiring any opioids.

Conclusions: An ERAS protocol for cesarean birth including intrathecal morphine was associated with a 93.8% reduction in cumulative opioid dose by MME and should be considered by all hospitals that offer obstetric services.

Author Affiliations: Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health (UW SMPH), Madison, Wisconsin (Antony, Anderson-Carter, Gaston, Buttigieg); Department of Biostatics and Medical Informatics, UW SMPH, Madison, Wisconsin (Broman); Department of Pharmacy, UnityPoint Health-Meriter, Madison, Wisconsin (Gnadt); Department of Obstetrics and Gynecology, UnityPoint Health-Meriter, Madison, Wisconsin (Krickl); Associated Physicians: Obstetrics and Gynecology, Madison, Wisconsin (Sharma); Madison Anesthesiology Consultants, LLC, UnityPoint Health- Meriter, Madison, Wisconsin (Whiddon).
Corresponding Author: Kathleen M. Antony, MD, MSCI, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Wisconsin School of Medicine and Public Health, 202 S Park St, Madison, WI 53715; phone 608.417.6099; email kantony@wisc.edu; ORCID ID 0000-0003-3537-8030
Funding/Support: The project was supported by the Meriter Foundation and the Clinical and Translational Science Award program, through the National Institutes of Health (NIH) National Center for Advancing Translational Sciences (NCATS), grant UL1TR002373 (ATB) and the University of Wisconsin Department of Obstetrics and Gynecology (KMA). The content is the sole responsibility of the authors and does not necessarily represent the official views of the NIH. The funding source had no role in the design, collection, analysis, or interpretation of data, writing of the report, or decision to submit the article for publication.
Financial Disclosures: None declared.
Acknowledgements: The authors would like to thank members of the multidisciplinary committee, including Jackie Adams, Michael Nyffeler, Jill Cardwell, Lisa Reinke, Sue Briggs, Julie Schurr, Laura Berghan, Shelly Weisheipl, Gregory Bills, Connie Potts, Carla Griffin, Kathy Frigge, Elizabeth Goetz, Janna Lind, Nicolle Hovland, and Nicole Allman, (employed by the University of Wisconsin-Madison, Madison Anesthesiology Consultants, and UnityPoint Health-Meriter) and the leadership teams at UnityPoint Health-Meriter, the Center for Perinatal Care, and the University of Wisconsin School of Medicine and Public Health Department of Obstetrics and Gynecology. They would like to acknowledge Ruth Hallquist, Janna Lind, and Jonathan Garvey (employed by UnityPoint Health-Meriter) for their support and assistance extracting data from the electronic health record. They would also like to acknowledge Carla Ruhland, Carla Griffin, and Ancilla Partners for their support and assistance with data extraction from PeriData.Net for this project (employed by UnityPoint Health-Meriter). PeriData.Net is a comprehensive birth registry maintained by Ancilla Partners, Inc. This registry provides process and outcome measure results as well as birth-level data on how well a given hospital and its providers are administering quality of care before, during, and after the birthing lifecycle. They would finally like to acknowledge Robert Koehler for assisting with the literature review and article acquisition (employed by UnityPoint Health-Meriter).

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