Enhanced recovery after cesarean delivery: is protocol compliance the missing link?

Abstract

We read with great interest the study “Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial” by Teigen et al.1Teigen N.C. 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: 372.e1-372.e10Abstract Full Text Full Text PDF Scopus (38) Google Scholar We applaud the authors’ efforts to contribute to the paucity of level I evidence in the area. Although the Enhanced Recovery After Surgery (ERAS) arm was not associated with an increase in the number of women discharged on postoperative day 2 (primary outcome) or reduction in postoperative narcotic use, it did show a small but significantly reduced postoperative length of stay when compared with standard care (73.5 hours vs 75.5 hours). Recently, Elias et al2Elias K.M. Stone A.B. McGinigle K. et al.The reporting on ERAS compliance, outcomes, and elements research (RECOvER) checklist: a joint statement by the ERAS® and ERAS® USA societies.World J Surg. 2019; 43: 1-8Crossref PubMed Scopus (108) Google Scholar published a standardized framework for the reporting of ERAS-related studies in which they emphasized the importance of providing sufficient details on the ERAS protocol being studied and also provided data on protocol compliance. ERAS protocol compliance has been shown to be a key factor in obtaining improvements in clinical outcomes, including reduced hospital length of stay and complications in both gynecology3Wijk L. Udumyan R. Pache B. et al.International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery.Am J Obstet Gynecol. 2019; 221: 237.e1-237.e11Abstract Full Text Full Text PDF Scopus (73) Google Scholar and colorectal surgery,4ERAS Compliance GroupThe impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry.Ann Surg. 2015; 261: 1153-1159Crossref PubMed Scopus (435) Google Scholar in which there appears to be a dose-response relationship between ERAS compliance and outcome. We wonder if this is also the case for ERAS in cesarean delivery. Although Teigen et al1Teigen N.C. 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: 372.e1-372.e10Abstract Full Text Full Text PDF Scopus (38) Google Scholar provided details on their ERAS protocol, they did not provide information on how well the protocol was adhered to in their ERAS arm. Computerized postoperative orders were placed for each patient on the basis of the study arm to which they were assigned; however, the orders placed may not necessarily translate to orders being carried out (a case of “work perceived vs work completed”). If there was low compliance to the ERAS protocol being studied, it is possible that this might explain the marginal gains seen with implementation. Randomization would not have remedied this potential issue. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trialAmerican Journal of Obstetrics & GynecologyVol. 222Issue 4PreviewOur objective was to determine whether an enhanced recovery after surgery pathway at the time of cesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction compared to standard perioperative care. Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 223Issue 4PreviewWe appreciate the comments of Nelson et al1 in that they addressed the very critical issue of adherence in enhanced recovery protocols. As they correctly stated, our enhanced recovery protocol was designed with randomization to postoperative computerized order sets in an attempt to minimize deviations in protocol adherence. The specific protocol elements required that all orders were signed off by nursing at the time of administration to comply with the completion of the postoperative computerized order set. Full-Text PDF