Title : Improving implementation of enhanced recovery after cesarean section protocol in resource limited setting of Koidu Government Hospital Sierra Leone 2024/25. A quality improvement project from evidence to reality
Abstract:
Introduction: Enhanced recovery after cesarean section (ERAC) is an evidence-based, standardized peri-operative care program aimed at improving quality of surgical care, decrease surgical related complications, and increase patient satisfaction.
The ERAC care bundles include but are not limited to, the utilization of the WHO surgical safety checklist, opioid-free analgesia, and evidence based peri-operative practices. The protocol address issues such as insufficient analgesia, a delayed restoration of bowel function, delayed ambulation and delayed catheter removal factors that contribute to slower recovery and prolonged hospital stay.
Although koidu government hospital is providing comprehensive maternity care, the implementation of ERAC protocol has been below expected standard. According to our baseline survey, adherence to ERAC protocol was low (17.1%). There was no standardized protocol in place; Utilization of the WHO surgical safety checklist was only 13.3%, and just 15.9% patients received opioid free analgesia, additionally, pain was not recorded as a vital sign, and evidence based post-operative care in the area of postoperative feeding, ambulation and catheter removal was inconsistent.
Objective: The project aimed to improve adherence to protocol, reduce complications, and enhance recovery following cesarean sections at Koidu Government Hospital 2024/25.
Methods: We employed standardized Quality Improvement (QI) tools, such as fish bone diagram and priority matrix to conduct root cause analysis. Based on findings, we implemented three series of Plan-Do-Study-Act (PDSA) cycles. The key interventions included, designing evidence based and standardized protocol, checklist and guidelines for peri-operative care, providing training and capacity building, documenting pain as a 6th vital sign, and performing regional block to achieve opioid free analgesia. In addition, monitoring and evaluation were conducted on daily, weekly and monthly bases.
Result: Data from 689 cesarean mothers was collected after the implementation, and results demonstrated significant improvements across multiple Key Performance Indicators (KPIs), Utilization of the WHO surgical safety check list found 95.6 %, regional analgesia was performed for 79% of cesarean mother, and pain was assessed and documented as 6th vital sign for 97.3% of surgical patients. Oral feeding, ambulation and catheter removal were standardized according to ERAC Protocol. Postoperative complications drastically decreased from 12.71% to 5.78%, and the average hospital stay decreased from 4.64 days to 3.12 days.
Conclusion: The Quality Improvement Project demonstrated that, the successful implementation of ERAC protocol improve recovery and outcome following cesarean section.
Keywords: Cesarean delivery, Enhanced recovery, quality improvement, patient outcome.
