Decreasing elective deliveries

Decreasing elective deliveries Prior to 39 weeksMelanie Hermann, MSN, RNC-OB, CNS-BCPerinatal Clinical Nurse SpecialistIowa Health Des Moines

objectivesDiscuss the history of the Perinatal Safety Team at Iowa Health Des MoinesDescribe steps taken to help decrease the rate of elective deliveries prior to 39 weeks gestationOutline barriers identified during implementationDiscuss recommendations for implementing a 39 week elective delivery policy IHS & IHDM Perinatal safety teamsBegan in Nov 2006Iowa Health System Board defined perinatal safety as a quality initiativeIHS joined the Institute of Healthcare Improvement ProgramMultidisciplinary group involving obstetricians, nurses, quality, pediatricians, anesthesia, family practice, and hospital leadershipGoal of decreasing the number of elective deliveries < 39 weeks was identified on the charterOther areas of safety also addressed on the charter annuallyBundles (induction/augmentation/vacuum), PPH education, medication safety, etcInduction bundles, augmentation bundles, vacuum bundles, PPH education, HCAHPS scores, etc4

Steps taken2006 Baseline data for meeting elective induction bundles and number of elective inductions and Cesarean sections 39 weeksReassuring fetal statusAll pelvic exam elements documentedNo tachysystole and if there was tachysystole the appropriate treatment was done

Group of evidence based interventions that when executed together, result in better outcomes than when implemented individually. All or nothing. Similar to central line bundle, VAP bundle, sepsis6Steps takenMarch 2007 City wide policy and labor analysis form createdMeetings held with all 4 area hospitals providing OB care All in agreement of developing a policy to not allow elective deliveries < 39 weeksHelped to all be consistent patient/provider couldnt use it against the hospital

Piloted the labor analysis form in 2007Communicated to providers to begin using Feb 2008The form helped the nurse scheduling the induction to know criteria has been metIf there was no form on the chart there was no induction until the information was obtained

Use of labor analysis formSteps takenOct 2009 Hired a procedure schedulerThis helped to streamline the process of screening and ensuring the induction/c-section was appropriateShe now schedules all procedures for all 3 hospitalsA change in how c/sections were scheduled at ILH helped to decrease the number of 39 wksMedical InductionsElective InductionsTotal InductionsIHDM Total Births% InductionsILHIMMCMWILHIMMCMWILHIMMCMWIHDM2008102511N/A79319N/A181830N/A1011424223.8%200979519N/A69249N/A148768N/A916401622.8%20107659026351856411177590976389825%20119456924241576911872693937397323.6%1st Q 201211136043011151661119295920%Barriers encounteredResistance from providersPersistence from patientsNurses put in difficult situations hard stopNoticed a decrease in elective inductions but an increase in medical inductions difficult to achieve agreement among providers on what should be listed a medical indicationsQuality audit conducted to validate the documentation to support medical inductions

recommendationsStrong buy-in from a physician championSupport from administrationProvide education to staff, providers, and patientsPersistencePlan in place for peer review for those cases that fall out

Questions?