INDIANAPOLIS — Fighting the opioid epidemic while improving our state's maternal mortality rate are two major health issues on the radar for people who work at Franciscan Health on Indy's south side.
Doctors, nurses, and other employees teamed up to implement a new protocol for scheduled cesarean section mothers.
It's called Enhanced Recovery After Cesarean (ERAC) and it is a combination of protocols and applications for patient care from before surgery to postpartum.
"From a patient experience standpoint, it's going to improve our C-section experience immensely," said Melanie Boosey, a clinical nursing manager for labor and delivery at Franciscan Health.
It all starts with a paper brochure expecting mothers with a scheduled C-section get from their OB's office. It details the surgery prep like how long to fast, when to drink fluids, etc.
"We used to make women fast for 12 hours before they had their surgery — and now, they don't have to fast as long," said Boosey. "They can have a little bit of food before they go to bed at night, before their surgery. They have a carbohydrate drink that they, like a Gatorade, they can have in the morning before they come in just to get them pre-hydrated."
Once the patient gets to the hospital and checked in, they get more fluids, and non-narcotic pain management medication.
In surgery, they get a spinal block so they won't feel any pain.
The mothers get anti-nausea medicine and steroids as well as Tylenol and an anti-inflammatory called Toradol.
The big change in care for ERAC patients is even in postpartum, they try to treat pain by using addictive opioids while instead utilizing Motrin and Tylenol around the clock and other methods.
"Well we are making an incision that's about six inches long, horizontally, in the lower abdomen to deliver a baby," says Doctor Scott Bowers, a practicing OBGYN as well as an M.D. Physician and the Director of Quality for the Franciscan Women and Children's service line.
He, along with Boosey and several others, were part of the group to help bring the protocol to Franciscan. They both say this protocol is a big step in addressing the opioid epidemic in our state.
"It not only helps a mother use less narcotics but it also helps with baby's feeding," said Bowers. "Opioids are very addictive, which has been part of the problem. It has not just been the access to the narcotics, but the addictive nature of the narcotics. So many people get addicted to the narcotics not trying to be addicted, but it started out with some type of surgery."
Patients in the protocol are encouraged to talk with their nurses about any pain or discomfort they may be experiencing and the nurses chart that on a scale and work to find ways to ease discomfort.
Narcotics are available for breakthrough pain if a mother requests them, but they are noticing the majority of moms are not wanting them.
"We have seen our pain scores go down with this program," said Boosey.
Their patients are able to get up and move around faster without narcotics, which can help in the recovery process.
"It increases your motility. It kind of gets your everything going again," said Boosey. "It decreases your pain."
C-section moms are encouraged to get up and move around to help their bodies heal and that can help decrease pain. The protocol is also leading to shorter hospital stays, especially because moms are able to get up and move around sooner and nursing outcomes have improved without the use of opioids.
"It just gives you the confidence to know that I can do this," said Boosey.
Part of the program is recognizing different things that contribute to pain and different methods hospitals can use to help patients manage pain.
"We help bring evidence to the bedside," said Christine Hunkele, a clinical nurse specialist for Franciscan Health, who attends conferences, reads and researches best practices in medicine for moms and babies. "I'm looking at literature, looking at trends around the country."
Part of her work on their ERAC program is looking at a similar successful program with colorectal surgeries called ERAS, and finding ways to utilize the best parts of that protocol in c-section surgeries.
She says in terms of this newer protocol, so far so good.
"It's going wonderfully. We are seeing a lot less usage of narcotics. We have our moms getting up and moving around more. Their pain scores are a lot less," said Hunkele. "We are starting to recognize that there's a lot more to pain than just, ouch it hurts."
Hunkele says there are a number of factors that can contribute to a postpartum mother's discomfort after surgery.
"From nerve pain at the incision site to, 'I've got an upset stomach, because I've got constipation,' or 'I've just got an upset stomach because I haven't eaten in a long time,'" said Hunkele. She says nurses use the pain chart and ask questions to get an idea of how their patients feel after surgery.
"The nurse is going to use that to help understand where you are as an individual," Hunkele said.
She says some ways they can help manage pain include spreading out medications like Tylenol and Motrin around the clock and not waiting until they feel pain to take those medications.
They can give you non-narcotic medications to reduce nausea or inflammation which can contribute to discomfort.
The anesthesiologist performs what is called tap blocks around the incision site to help reduce pain from the actual incision site.
They can provide ice packs or heat packs to the patient.
They also provide and encourage moms to wear an abdominal binder for support for a few weeks after surgery.
"We definitely have an opioid problem in this country and we know that our maternal patients; they are usually their first introduction to the hospital and a lot of times to new medications happens in the maternal world," said Hunkele. "We want to try to prevent that process from the very beginning if we can."
Danielle Pamer is a Beech Grove resident and a new mom to baby Esme.
She had a scheduled c-section with Dr. Bowers after learning her baby was breech and their efforts to get the baby to flip were unsuccessful. She was part of the new ERAC protocol at Franciscan Health.
"I've never had surgery before and the whole team was literally just amazing," says Pamer. "It was exciting. My husband actually looked over the drape and got to see her legs."
Pamer says her pain was manageable with the Tylenol and Motrin around the clock and didn't feel like she needed anything addictive.
"I didn't want to take it and not be alert if she needed me," says Pamer, who is now recovering at home as she navigates life as a new mom.
"It has been amazing," says Pamer. "It's like a whole other love that you just never knew that you could have."
For more details on the ERAC protocol or to talk to someone about the program, click hereor read more about maternal health studies here.
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