Changes in preoperative and postoperative processes can reduce opioid use for women following cesarean sections, or C-sections, according to new research from Kaiser Permanente.
Among the most significant findings: Women could decrease opioid use without experiencing greater pain.
“We expected to see a reduction in inpatient opioid exposure, but we were surprised to also see a decrease in outpatient opioid prescriptions and the number of opioid pills prescribed at hospital discharge,” Monique Hedderson, a research scientist in the Kaiser Permanente Northern California Division of Research, told FierceHealthcare in an email. “Thus women were able to use fewer opioids when they went home after delivery as well.”
Recent research found that 2.2% of women who are given opioids after a cesarean delivery continued using the painkillers weeks or months later.
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So, in an effort to improve the recovery and experience of a scheduled C-section, Kaiser Permanente tested out some changes that ultimately led to faster recovery and no increased pain without having to use addictive painkillers such as opioids.
Published in the journal Obstetrics & Gynecology, the study compared 4,689 women who underwent scheduled C-sections at Kaiser hospitals in Northern California before the enhanced recovery after surgery (ERAS) program and 4,624 women who delivered after ERAS began.
Some of the tactics used in the ERAS program included allowing carbohydrate drinks presurgery rather than the traditional required fasting. They also pushed patients to get up and walking soon after surgery and focused on educating them on what to expect.
Finally, opioids were switched with local anesthetics and acetaminophen to avoid the use of opioids.
“The decreased opioids was likely associated with maximizing the non-opioid medications,” Kimberly Lee, M.D., an obstetrician-gynecologist at Kaiser Permanente Santa Clara Medical Center, told FierceHealthcare in an email. “We were to maximize the use of non-steroidal pain medications and Tylenol. This was achieved through decoupling the ‘standard’ opioid medications (Norco/Percocet).” In addition, patients who underwent cesarean delivery at Kaiser also used an abdominal binder for additional support.
In this Kaiser study, opioid exposure was cut in half from 10.7 average daily morphine equivalents to 5.4. The amount of time that patients reported acceptable pain scores increased from 82% to 86%. In addition, the first ambulatory movement from patients went down by 2.7 hours, and the first postsurgical ingestion of solid foods decreased by 11 hours.
Lee noted new moms were more alert and engaged in the recovery process and in breastfeeding due to decreased exposure to opioids while hospitalized.
Ultimately, researchers found that patients after ERAS had decreases in opioid exposure and improvements in eating and walking, without a change in the length of hospital stay or surgical site infections.
All of Kaiser Permanente’s 21 Northern California hospitals have adopted ERAS practices for numerous outpatient procedures, including all scheduled C-sections. Lee notes that this transformation in care and delivery model for the team was impactful, so the team hosted sessions to discuss concerns, offer feedback and provide additional support as needed.
Moving forward, Hedderson hopes to evaluate the impact of the ERAS program in a larger study that includes women who experienced urgent or emergency cesarean sections.
“We would also like to look at longer-term follow up to see if the changes that were implemented with this protocol continue in the long-term,” she said.