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A Quality Improvement Project to Reduce the Incidence of Nonmedically Indicated Elective Deliveries Before 39 Weeks
Pedley, J. and Fortin, N. C.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad Candace L. Rouse, RNC, MSN, Objective CNS-BC, Sinai Hospital of o increase initiation and exclusivity of breastBaltimore, Baltimore, MD Keywords initiation and exclusivity of breastfeeding breastfeeding self-efficacy Joint Commission Perinatal Core Measures
Childbearing Poster Presentation
T
feeding in the hospitalized, postpartum dyad via an educational module for staff registered nurses (RNs). This module consisted of interventions to increase bedside lactation support and build maternal confidence in breastfeeding success, defined as breastfeeding self-efficacy. The specific program objectives with measurable outcomes were set based on the Joint Commission Perinatal Core Measures and Healthy People 2020.
Design The increasing breastfeeding rates program was designed as an evidence-based practice change of increased bedside registered nurse (RN) lactation support. It was based upon education and involvement of the institution’s current Lactation Operations Group (LOG) aligned with education of the bedside RN. It was designed as a quality improvement project with RN education as the intervention.
Sample The target population included hospitalized women in the immediate postpartum period in a coastal mid-Atlantic inner city hospital who desired to breastfeed. A convenience sample of one month’s breastfeeding rates was compared retrospectively (preintervention) with one month’s rates postintervention.
Methods With the breastfeeding rates identified as the problem, the evidence-based practice change began with the assessment of a need for change in the current breastfeeding support and an increase in education for bedside RNs. Implementation Strategies A mandatory 2 1/2 hour educational intervention for all labor and delivery, postpartum and newborn nursery nurses (N = 70) was presented on bedside lactation support aligned with maternal breastfeeding self-efficacy. The intervention included skin-to-skin techniques, rooming in discussions, and scripting for no supplementation. The concept of self-efficacy was addressed, specifically increasing maternal confidence in successful breastfeeding. Results The outcome measures demonstrated an increase in scores for breastfeeding. The initiation of breastfeeding within the first hour of life score increased from 55.4 % to 62.3%, whereas the exclusivity of breast milk feeding while in the hospital increased from 63.1% to 70.78%. Conclusion/Implications for Nursing Practice The advantages of breastfeeding for mother and infant are substantial and include protecting infants from allergens to reducing rates of maternal breast and ovarian cancer. These evidence-based practices for lactation support have the potential to improve health outcomes not only for the hospitalized maternal/infant dyad, but also for society.
A Quality Improvement Project to Reduce the Incidence of Nonmedically Indicated Elective Deliveries Before 39 Weeks Nicole Chesis, MSN, RN, APN, CNS, C-EFM, Advocate Healthcare, Libertyville, IL
Objective o decrease the rate of non-medically indicated elective deliveries (NMIED) at 37 to 38 weeks to less than or equal to 5.0%.
T
Keywords nonmedically indicated elective deliveries early elective deliveries Design induction of labor A plan-do-study-act quality methodology. cesarean
Childbearing Poster Presentation
Sample All inductions and cesareans between 37 to 38.6 weeks from January, 1, 2011 to the present.
JOGNN 2015; Vol. 44, Supplement 1
Methods The March of Dimes (MOD) 39-week toolkit was used to guide the project. The toolkit supported efforts to design policies and best practice guidelines, choose quality improvement tools, and educate physicians, staff, and patients. Implementation Strategies Our team also implemented a measuring tool developed by the Advocate System Obstetric Safety Committee to help drive appropriate patient scheduling and data collection. The project
S49
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
was introduced to staff obstetricians at a monthly meeting and in their offices, was presented at staff meetings, and was championed by the lead charge nurses, unit manager, and obstetric chairman. The project was further supported by perinatal network Maternal Fetal Medicine physicians and Level-III hospital sites. Results In 2010, our preintervention rate for NMIED was 25.0%. After implementing the MOD toolkit in 2011, this rate decreased to 11%, representing a greater than 50% reduction by the year’s end.
Since 2011 we have continued to see a steady decline in NMIED with a current rate of 0.0% for the last 18 months. Conclusion/Implications for Nursing Practice This quality improvement project demonstrates that strong teamwork, project champions, and a working roadmap can lead to improved patient outcomes. Continued monthly data collection with submission to the Advocate System Obstetric Safety Committee and the reporting of patient cases through the chain of command will keep us on track for continued success.
Interprofessional Participation in a Statewide Collaborative to Recognize and Treat Hypertension in Pregnancy Objective o standardize the identification and treatment pregnant/postpartum women presenting with blood pressures ࣙ 160 and/or ࣙ 105 within 30 minutes of validated elevated blood pressure.
T
Design Plan-do-study-act cycles (PDSA) were used to implement the evidence-based guidelines from the California Maternal Quality Care Collaborative (CMQCC) Preeclampsia Toolkit. Physician, pharmacy, and nursing staffs were educated on the guidelines and the acute hypertensive order set developed by the Memorial Care Women’s Best Practice Team. The team actively participated in the CMQCC Preeclampsia Collaborative. Sample All pregnant/postpartum women presenting perinatal care areas with elevated blood pressures. Methods Initial elevated blood pressures are reevaluated within 15 minutes using a manual sphygmomanometer and appropriate size cuff. Physicians are contacted, the acute hypertensive order set is initiated, and labetalol or hydralazine are immediately administered. Blood pressures are reassessed every 15 to 20 minutes and medication treatment is continued until blood pressures reach values less than threshold. Upon event completion, a debrief is conducted. Implementation Strategies Perinatal nursing staff were educated on the use of a manual sphygmomanometer and choice of appropriate cuff. A self-learning module with compe-
S50
tency evaluation was required. Postpartum nurses were taught to administer intravenous hydralazine. Physicians were provided written communication of the new protocol and order set. The pharmacist assured that the necessary level of drugs was in stock. Rolling manual blood pressure kits with assorted cuffs and guidelines were distributed. Electronic message boards were used to continually educate staff. Debrief forms provided feedback to the implementation team to complete PDSA cycles, enhance adherence to the guidelines, and improve feedback to staff. Results The baseline data from April 2013 indicate that 14.3% of women with blood pressures meeting the criteria were treated. By June 2014, 84.2% were treated within 30 minutes and 89.5% were treated within 60 minutes.
Connie von Kohler, RNC, MSN, CPHQ, Miller Children’s Hospital, Long Beach, Long Beach, CA Diane Beck, BSN, RNC-OB, Center for Women at Long Beach Miller Children’s Hospital, Long Beach, CA Cathy L. Villarreal, RNC-MNN, BSN, Miller Children’s and Women’s Hospital Long Beach, Long Beach, CA Janet L. Trial, EdD, CNM, MSN, Miller’s Children’s & Women’s Hospital Long Beach, Long Beach, CA Keywords
preeclampsia Conclusion/Implications for Nursing Practice eclampsia Understanding the potential for maternal morbidblood pressure ity and mortality has increased the recognition of care providers and enhanced the treatment of acute hypertension. Methodology and implemenChildbearing tation strategies were effective in achieving the standardized identification and treatment of preg- Poster Presentation nant/postpartum women presenting with hypertension. Unanticipated challenges included providing training in the basic fundamentals of blood pressure measurement and obtaining institutional approval for intravenous hydralazine to become standard practice for postpartum nurses. Next steps in nursing practice include evaluation of hypertensive patient within one week of hospital discharge and implementation in the emergency department.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
http://jognn.awhonn.org
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad Candace L. Rouse, RNC, MSN, Objective CNS-BC, Sinai Hospital of o increase initiation and exclusivity of breastBaltimore, Baltimore, MD Keywords initiation and exclusivity of breastfeeding breastfeeding self-efficacy Joint Commission Perinatal Core Measures
Childbearing Poster Presentation
T
feeding in the hospitalized, postpartum dyad via an educational module for staff registered nurses (RNs). This module consisted of interventions to increase bedside lactation support and build maternal confidence in breastfeeding success, defined as breastfeeding self-efficacy. The specific program objectives with measurable outcomes were set based on the Joint Commission Perinatal Core Measures and Healthy People 2020.
Design The increasing breastfeeding rates program was designed as an evidence-based practice change of increased bedside registered nurse (RN) lactation support. It was based upon education and involvement of the institution’s current Lactation Operations Group (LOG) aligned with education of the bedside RN. It was designed as a quality improvement project with RN education as the intervention.
Sample The target population included hospitalized women in the immediate postpartum period in a coastal mid-Atlantic inner city hospital who desired to breastfeed. A convenience sample of one month’s breastfeeding rates was compared retrospectively (preintervention) with one month’s rates postintervention.
Methods With the breastfeeding rates identified as the problem, the evidence-based practice change began with the assessment of a need for change in the current breastfeeding support and an increase in education for bedside RNs. Implementation Strategies A mandatory 2 1/2 hour educational intervention for all labor and delivery, postpartum and newborn nursery nurses (N = 70) was presented on bedside lactation support aligned with maternal breastfeeding self-efficacy. The intervention included skin-to-skin techniques, rooming in discussions, and scripting for no supplementation. The concept of self-efficacy was addressed, specifically increasing maternal confidence in successful breastfeeding. Results The outcome measures demonstrated an increase in scores for breastfeeding. The initiation of breastfeeding within the first hour of life score increased from 55.4 % to 62.3%, whereas the exclusivity of breast milk feeding while in the hospital increased from 63.1% to 70.78%. Conclusion/Implications for Nursing Practice The advantages of breastfeeding for mother and infant are substantial and include protecting infants from allergens to reducing rates of maternal breast and ovarian cancer. These evidence-based practices for lactation support have the potential to improve health outcomes not only for the hospitalized maternal/infant dyad, but also for society.
A Quality Improvement Project to Reduce the Incidence of Nonmedically Indicated Elective Deliveries Before 39 Weeks Nicole Chesis, MSN, RN, APN, CNS, C-EFM, Advocate Healthcare, Libertyville, IL
Objective o decrease the rate of non-medically indicated elective deliveries (NMIED) at 37 to 38 weeks to less than or equal to 5.0%.
T
Keywords nonmedically indicated elective deliveries early elective deliveries Design induction of labor A plan-do-study-act quality methodology. cesarean
Childbearing Poster Presentation
Sample All inductions and cesareans between 37 to 38.6 weeks from January, 1, 2011 to the present.
JOGNN 2015; Vol. 44, Supplement 1
Methods The March of Dimes (MOD) 39-week toolkit was used to guide the project. The toolkit supported efforts to design policies and best practice guidelines, choose quality improvement tools, and educate physicians, staff, and patients. Implementation Strategies Our team also implemented a measuring tool developed by the Advocate System Obstetric Safety Committee to help drive appropriate patient scheduling and data collection. The project
S49
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
was introduced to staff obstetricians at a monthly meeting and in their offices, was presented at staff meetings, and was championed by the lead charge nurses, unit manager, and obstetric chairman. The project was further supported by perinatal network Maternal Fetal Medicine physicians and Level-III hospital sites. Results In 2010, our preintervention rate for NMIED was 25.0%. After implementing the MOD toolkit in 2011, this rate decreased to 11%, representing a greater than 50% reduction by the year’s end.
Since 2011 we have continued to see a steady decline in NMIED with a current rate of 0.0% for the last 18 months. Conclusion/Implications for Nursing Practice This quality improvement project demonstrates that strong teamwork, project champions, and a working roadmap can lead to improved patient outcomes. Continued monthly data collection with submission to the Advocate System Obstetric Safety Committee and the reporting of patient cases through the chain of command will keep us on track for continued success.
Interprofessional Participation in a Statewide Collaborative to Recognize and Treat Hypertension in Pregnancy Objective o standardize the identification and treatment pregnant/postpartum women presenting with blood pressures ࣙ 160 and/or ࣙ 105 within 30 minutes of validated elevated blood pressure.
T
Design Plan-do-study-act cycles (PDSA) were used to implement the evidence-based guidelines from the California Maternal Quality Care Collaborative (CMQCC) Preeclampsia Toolkit. Physician, pharmacy, and nursing staffs were educated on the guidelines and the acute hypertensive order set developed by the Memorial Care Women’s Best Practice Team. The team actively participated in the CMQCC Preeclampsia Collaborative. Sample All pregnant/postpartum women presenting perinatal care areas with elevated blood pressures. Methods Initial elevated blood pressures are reevaluated within 15 minutes using a manual sphygmomanometer and appropriate size cuff. Physicians are contacted, the acute hypertensive order set is initiated, and labetalol or hydralazine are immediately administered. Blood pressures are reassessed every 15 to 20 minutes and medication treatment is continued until blood pressures reach values less than threshold. Upon event completion, a debrief is conducted. Implementation Strategies Perinatal nursing staff were educated on the use of a manual sphygmomanometer and choice of appropriate cuff. A self-learning module with compe-
S50
tency evaluation was required. Postpartum nurses were taught to administer intravenous hydralazine. Physicians were provided written communication of the new protocol and order set. The pharmacist assured that the necessary level of drugs was in stock. Rolling manual blood pressure kits with assorted cuffs and guidelines were distributed. Electronic message boards were used to continually educate staff. Debrief forms provided feedback to the implementation team to complete PDSA cycles, enhance adherence to the guidelines, and improve feedback to staff. Results The baseline data from April 2013 indicate that 14.3% of women with blood pressures meeting the criteria were treated. By June 2014, 84.2% were treated within 30 minutes and 89.5% were treated within 60 minutes.
Connie von Kohler, RNC, MSN, CPHQ, Miller Children’s Hospital, Long Beach, Long Beach, CA Diane Beck, BSN, RNC-OB, Center for Women at Long Beach Miller Children’s Hospital, Long Beach, CA Cathy L. Villarreal, RNC-MNN, BSN, Miller Children’s and Women’s Hospital Long Beach, Long Beach, CA Janet L. Trial, EdD, CNM, MSN, Miller’s Children’s & Women’s Hospital Long Beach, Long Beach, CA Keywords
preeclampsia Conclusion/Implications for Nursing Practice eclampsia Understanding the potential for maternal morbidblood pressure ity and mortality has increased the recognition of care providers and enhanced the treatment of acute hypertension. Methodology and implemenChildbearing tation strategies were effective in achieving the standardized identification and treatment of preg- Poster Presentation nant/postpartum women presenting with hypertension. Unanticipated challenges included providing training in the basic fundamentals of blood pressure measurement and obtaining institutional approval for intravenous hydralazine to become standard practice for postpartum nurses. Next steps in nursing practice include evaluation of hypertensive patient within one week of hospital discharge and implementation in the emergency department.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
http://jognn.awhonn.org