Editor's note:Be sure to read the lead CE article in this issue on enhanced recovery after surgery (ERAS) by Elizabeth A. M. Frost, MD, co-editor of Topics in Pain Management.
Hospitals continue to implement enhanced recovery after surgery (ERAS) programs and report improved outcomes in patients. A newly published set of core outcomes could lead to better research of the use of ERAS for patients undergoing cesarean delivery.
In the past, researchers have determined that ERAS protocols can benefit patients who undergo cesarean delivery -the most commonly performed inpatient surgical procedure worldwide. However, these researchers have lacked consensus on the core outcomes to assess when studying enhanced recovery after cesarean delivery.
Now, the authors of a recent study have presented results from an international consensus to develop a core set of outcomes for enhanced recovery after cesarean delivery. These are outcomes that could be considered when designing future enhanced recovery studies.
The study by Sultan et al1 was published in August in the journal Anesthesiology. Authors include members of the Consensus Regarding core outcomes for enhAnced recovery after cesarean DeLivery studiEs (CRADLE), also known as the CRADLE Study. Three authors, including lead author Pervez Sultan, MBChB, are from the Stanford University School of Medicine. Sultan is an Arline and Pete Harman Endowed Faculty Scholar of the Stanford Maternal and Child Health Research Institute.
Other authors are from the University of California San Francisco and Tel Aviv Sourasky Medical Center, Israel.
The authors carried out the study because existing impact studies had shown a great deal of heterogeneity in their reported outcomes from enhanced recovery after cesarean delivery. This study aimed to develop a standardized core outcome set for use in future studies that examine enhanced recovery after cesarean delivery.
As a result of the study, the authors reduced the number of outcomes in the final core outcome set from 98 to 15, and for those 15 outcomes, there was strong consensus (>=70% stakeholder agreement).
The Obstetric Quality of Recovery-10 item composite measure was also included in the final core outcome set. Other core outcomes in the set include:
* Length of hospital stay;
* Compliance with enhanced recovery protocol;
* Maternal morbidity (hospital readmissions or unplanned consultations);
* Provision of optimal analgesia (maternal satisfaction, compliance with analgesia, opioid consumption or requirement, and incidence of nausea or vomiting);
* Fasting times;
* Breastfeeding success; and
* Times to mobilization and urinary catheter removal.
Areas identified as requiring further research included readiness for discharge and analysis of cost savings.
To produce the core outcome set, the authors conducted an international consensus study involving physicians, patients, and a director of midwifery and nursing services. The team used a 3-round modified Delphi approach (2 rounds of electronic questionnaires and a third-round e-discussion).
An initial list of outcomes was based on a previously published systematic review. The team then obtained consensus for the final core outcome set, including definitions for key terms and preferred units of measurement.
"Strong consensus was defined as 70% or greater agreement and weak consensus as 50 to 69% agreement. Of the 64 stakeholders who were approached, 32 agreed to participate," according to the authors.
Stakeholders Invited
The authors of the study appear to have invited a diverse and comprehensive group of stakeholders to participate. They sought representatives from among obstetricians and maternal-fetal medicine specialists, anesthesiologists, midwives, staff nurses, and patients.
The authors also contacted corresponding authors of previously published studies and guidelines related to enhanced recovery after cesarean delivery. These previous studies and guidelines were written by professional societies, and identified through a systematic review of the literature.
The intent was that, by identifying experts in this way, the resulting guidelines would reflect an international breadth of experience and result in inclusion of a broad range of ethno- demographic backgrounds, according to the authors.
"Furthermore, this approach would ensure representation from varied practices of peripartum care and cesarean delivery within different cultural and health care settings and ensure development of the most relevant and generalizable core outcome set possible for the majority of clinicians and researchers," the authors wrote.
Stakeholders included were from the United States, Canada, the United Kingdom, France, Serbia, Africa, and China.
Female Anesthesiologists Who Gave Birth
One interesting invitation to stakeholders specifically went out to female anesthesiology faculty.
"These faculty members were approached to represent the views of patients," the authors wrote. "In order to be considered for this role, the faculty members needed to have experienced childbirth in a hospital setting at least twice within the preceding 5 years (between 2015 and 2020)."
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