- Email: [email protected]
Improving Outcomes by Reducing Elective Deliveries Before 39 Weeks of Gestation: A Community Hospital's Journey
Improving Outcomes by Reducing Elective Deliveries Before 39 Weeks of Gestation: A Community Hospital's Journey Leslie Altimier, RNC, MSN, Shawna Straub, RN, BSN, cEFM, and Vivek Narendran, MD, MBA
Our goal was to improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH. A retrospective chart review was conducted over a 2-year period. In 2005, after an intense analysis of the Family Birth Center, the overall induction rate and elective induction rate of less than 39 weeks' gestation were at an alarming 26.4% and 12.1%, respectively. Best practice guidelines for scheduling an induction were developed in collaboration with nursing and medical staff. These elective induction guidelines required patients to have completed 39 0/7 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process and these newly developed guidelines were strictly enforced. In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005. Keywords: Elective induction; Elective delivery; Induction rates; Late preterm; Special care nursery
Preterm births are a major challenge for maternal and perinatal care worldwide and a leading cause of neonatal morbidity and mortality.1 Preterm births are generally categorized by gestational age in weeks or by birth weight in grams. Preterm birth is defined as delivery before 37 completed weeks. Early term is defined as delivery between 37 0/7 and 38 6/7 weeks. Late preterm is defined as between 34 0/7 and 36 6/7 weeks.2 The global toll of preterm birth is severe. It is estimated that 28% of the four million annual neonatal deaths are due to preterm birth. Almost 13 million (9.6%) babies are born prematurely worldwide. Eighty-five percent of these premature births occur in Africa and Asia.3 There are huge gaps in data collection available on preterm birth prevalence in certain regions and countries such as Africa, Central Asia, and China; however, wherever trend data are available, rates of preterm birth are increasing. Specifically, the rate of preterm births in the United States has increased 36% in the past 25 years. Late preterm births make up 71% of this increase.4
From the Mercy Hospital Anderson, Cincinnati, OH. Address correspondence to Leslie Altimier, RNC, MSN, Mercy Hospital Anderson, 7500 State Rd, Cincinnati, OH 45225. E-mail: [email protected]. © 2011 Elsevier Inc. All rights reserved. 1527-3369/1102-0411$36.00/0 doi:10.1053/j.nainr.2011.04.011
Because the late preterm births constitute such a large percentage of preterm infants, the economic impact on initial and later hospitalization costs in this population is great. In a study by McLaurin et al,5 the average length of stay of the birth hospitalization for term infants was 2.2 days and the average cost was $2087. Late preterm infants had a substantially longer average length of stay of 8.8 days, which cost $26 054, a cost 18 times higher than in term infants. Late preterm infants were also rehospitalized within 2 weeks of discharge after birth compared with term infants, adding costs and stress to families. In addition to an increased birth hospitalization and rehospitalization, late preterm infants were found to use more health resources throughout the first year of life compared with term infants, further impacting health care costs. Maternal costs likewise were higher among late preterm infants ($6672) compared with term infants ($1943).6 In 2005, preterm birth cost the United States at least $26.2 billion or $51 600 for every infant born prematurely. In 2007, the average medical costs for a preterm baby were more than 10 times as high as they were for a healthy full-term baby. The costs for a healthy baby from birth to his first year of life were $4551. For a preterm baby, the costs were $49 033.7 Late preterm infants are four times more likely than term infants to be diagnosed during the birth hospitalization with at least one of the following medical conditions: • Temperature instability • Hypoglycemia
• • • •
rates of infant morbidity, mortality, and readmission rates in the first months of life.8-11 Late preterm birth has been recently recognized as a serious preventable morbidity because of the extensive campaigning efforts by organizations such as the March of Dimes, World Health Organization, and Save the Children's Saving Newborn Lives program. Historically, late preterm infants were thought to be physiologically and metabolically similar to term infants and were referred to as near term infants. More recently, with increasing evidence describing their “immature” physiology and
Respiratory distress Apnea Jaundice Feeding difficulties
In addition, late preterm infants are more likely than term infants to develop hyperbilirubinemia and to be readmitted for feeding difficulties and “rule-out sepsis.” Compared with fullterm infants, late preterm infants are at a higher risk of developing these medical complications, resulting in higher PATIENT NAME
DATE
GESTATIONAL AGE AT TIME OF INDUCTION: EST. FETAL SIZE:
SGA
AGA
WEEKS LGA
PLEASE CHECK ALL THAT APPLY Obstetrical Conditions Postterm Pregnancy (41 0/7 weeks or greater)
Chorioamnionitis Fetal Demise Non Reassuring Antepartum Testing Non reactive NST Oligohydramnios (AFI of 5 cm or less) Premature Rupture of Membranes Abruptio Placentae Other: Maternal Medical Conditions Diabetes Mellitus Preeclampsia/Eclampsia Chronic Hypertension Renal Disease Chronic Pulmonary Disease Severe Fetal Growth Restriction (IUGR) Isoimmunization Other: Elective Induction Psychosocial Reasons Long Distance from Hospital History of Precipitous Labor Other: Gestational Age is at least 39 weeks, AND Bishop’s Score is 5 or more
BPP score of 6 or less
Table 1. Bishop Scoring System (circle all that apply) FACTOR Score 0 1 2 3
Dilation (cm) Closed 1-2 3-4 5-6
Effacement (%) 0-30 40-50 60-70 80
Station + -3 -2 -1,0 +1, +2
Cervical Consistency Firm Moderately Firm Soft —
Position of Cervix Posterior Mid-position Anterior —
FINAL SCORE: Physician Signature
Date
Fig 1. Induction of labor assessment form.
NEWBORN
& INFANT NURSING REVIEWS, JUNE 2011
51
Fig 2. Induction of labor/ augmentation/ cervical ripening order set. 52
VOLUME 11, NUMBER 2, www.nainr.com
morbidity similar to very preterm infants, this population is being referred to as late preterm infants.1,12-15 Some of the factors contributing to this increase in late preterm births are a higher use of assisted reproductive techniques that increase the rates of multiple gestations and changes in clinical practice such as the early induction of labor close to, but not at, full term.16 The practice of elective labor inductions and repeat cesarean births before 39 completed weeks of gestation is not recommended by the American College of Obstetricians and Gynecologists (ACOG), yet is increasing despite ACOG guidelines outlining specific criteria for medically indicated births less than 39 weeks.17 Nationally, the frequency of labor induction has increased from an incidence of 9% in 1989 to 21% in 2004, according to the National Center for Health Statistics.9 This increase in inductions is thought to be due to a variety of factors, which include patient preference, physician practice style, and practice of defensive medicine.18-20 These inductions have led to an increase in unplanned cesarean deliveries, operative vaginal deliveries, increased epidural use, and longer length of stay in labor and delivery units.21-27 Non–medically indicated (elective) deliveries before 39 weeks carry significant risks for the baby with no known benefits to the mother.
Materials and Methods Mercy Hospital Anderson (MHA) in Cincinnati, OH, is a level II maternity service, which performs approximately 1850 deliveries per year. In 2005, inductions were identified as a major quality issue, with the overall induction rate reaching a high of 23.6% and elective inductions less than 39 weeks' gestation reaching a high of 11.8%. The department of Obstetrics and Gynecology and the Family Birth Center Nursing Leadership at MHA began evaluating elective inductions after an intense quality analysis performed by Knox and Simpson.28 To improve the quality of care provided to our obstetric patients, we wanted to more clearly identify those women needing medical inductions and minimize those undergoing unnecessary elective inductions. In 2005, published studies, as well as our own data regarding induction rates and outcomes, were reviewed. After looking at
best practices, we elected to focus our efforts on minimizing elective inductions and births before 39 completed weeks of gestation. In addition, we also changed our philosophy with regard to oxytocin use in the labor and delivery unit. Guidelines for scheduling an induction were developed in collaboration with nursing and medical staff. These scheduling guidelines for elective induction required patients to have completed 39 0/7 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. An “Induction of labor assessment form” was developed as a means to ensure that all relevant information was available to the nurses before initiating oxytocin (Fig 1). This form included the estimated gestational age, Bishop score, and the indication for induction. The form was to be faxed to the obstetrics department at the time the induction was scheduled, along with the “Induction of labor/ augmentation/cervical ripening order set” (Fig 2). The intent was to implement a “no paper, no pit” policy.29 Oxytocin was standardized to 30 units of pitocin in 500 milliliters of lactated Ringer's solution. This change in practice stipulated that a single dosing regimen be used rather than the previous practice of dosing according to individual provider preference. In addition, an algorithm for the management of tachysystole based on whether or not the fetal status was reassuring was initiated. In 2006, the induction scheduling process and the newly developed guidelines were strictly enforced. To enforce the induction guidelines, the Interdisciplinary Perinatal Practice Committee conducted a monthly review of all inductions that did not meet the criteria. The attending physician responsible for the induction was contacted and educated about the guidelines. Peer review was performed, and letters from the Medical Director of the Obstetrics and Gynecology department were sent to physicians who scheduled inductions that did not follow the guidelines. Outcomes included elective inductions less than 39 0/7 weeks, cesarean birth rate for elective inductions among nulliparas, the overall induction rate, special care nursery (SCN) admissions, and neonatal transports to a higher level III neonatal intensive care unit. At the same time, a quality improvement intervention was initiated by MHA in collaboration with the Institute for Healthcare Improvement (IHI) IMPACT Perinatal Community project. The IHI is an independent, not-for-profit organization spearheading the quality improvement movement in health care
Table 1. Reduction of Elective Induction Rates Total deliveries Total inductions Total inductions/total deliveries = total induction rate (%) Elective inductions b39 wk Elective inductions b39 wk/total deliveries = elective inductions rate (%) No. of nulliparas No. of nulliparas with cesarean delivery Rate of cesarean delivery for nulliparas (%)
NEWBORN
2005
2006
2007
1858 490 26.4%
1901 459 24.1%
1844 407 22.1% (P = .58)
225 12.1%
184 9.7%
712 266 37.4%
753 237 31.5%
& INFANT NURSING REVIEWS, JUNE 2011
8 1.97% (P b .001) 707 178 25%
53
Table 2. Elective Inductions, Unanticipated SCN Admissions, and Neonatal Transports to Level III Neonatal Intensive Care Unit Variable Elective inductions b39 wk Unanticipated SCN admissions 34 0/7–38 6/7 wk Neonatal transports to a level III facility
2005
2006
2007
34 0/7–38 6/7 wk 225 67 26
34 0/7–38 6/7 wk 184 51 20
34 0/7–38 6/7 wk 8 39 14
throughout the world. The IHI white paper “Idealized design of perinatal care” established an induction of labor bundle that was implemented. This included four criteria that had to be met before induction: (1) gestational age at least 39 0/7 weeks; (2) pelvic assessment documented in the medical record; (3) reassuring fetal status; and (4) tachysystole, if present, accurately identified and appropriately managed. When oxytocin was used to augment labor, the gestational age requirement was replaced with estimated fetal weight. All four components had to be met to achieve compliance with the bundle.30 Nursing and medical staff were held accountable to this newly established safety and quality measure. The implementation of an informed consent process was instituted for any woman receiving pitocin for induction or augmentation of labor. The compliance rate with the consent process was monitored. To simplify the process, the induction of labor assessment form was combined with the cervical ripening/ induction of labor order set; and a statement of informed consent was added. Estimated fetal weight was to be documented as small for gestational age, appropriate for gestational age, or large for gestational age. When medically indicated, approval for an elective induction less than 39 weeks' gestation had to be obtained from the medical director. Adherence by both nursing and medical staff members to this safety standard was established. This quality induction management program was aimed at improving outcomes and was therefore exempt from formal institutional review board approval. The overall induction rate and the elective induction rate were monitored throughout the quality initiative. Data collection sheets were entered electronically into a Web-based Excel database, and data were analyzed. Statistical analysis was performed by using χ2 and Yates continuity correction.
Results This study was a retrospective chart audit of all deliveries between January 2005 and December 2007. From 2005 to 2007, the overall induction rate dropped from 26.4% in 2005 to 24.1% in 2006 and 22.1% in 2007 (P = .59); and the percentage of elective inductions between 36 0/7 and 38 6/7 weeks' gestation dropped from 12.1% in 2005 to 9.7% in 2006% and 1.97% in 2007 (P b .001) (Table 1). The number of infants between 36 0/7 and 38 6/7 weeks' gestation that were electively induced and admitted to the SCN decreased from 67 in 2005 to 51 in 2006 and to 39 in 2007 (P b .001) (Table 2). Similarly, admissions to SCN following elective primary cesarean
54
deliveries and elective repeat cesarean deliveries decreased; however, the decrease was not statistically significant. Neonatal transports to a higher level III facility went from 26 in 2005 to 20 in 2006 and 14 in 2007. Patient safety culture scores through the Agency for Healthcare Research and Quality were measured every 2 years in the Family Birth Center (FBC). In 2006, the FBC patient safety culture score was 74%; and in 2008, it increased to 91%. Compliance with the informed consenting process likewise improved from 40% in 2006 to 97% in 2007.
Conclusion Elective delivery before 39 weeks' gestation is associated with significant neonatal morbidity. The ACOG has advocated the restriction of elective term delivery to women with a confirmed gestational age of at least 39 weeks for more than 2 decades.31,32 Quality improvement efforts targeted at decreasing elective inductions at MHA have been successful, and the results sustained. To ensure that progress is being sustained, data collection and medical record review are ongoing; and direct feedback is provided to the nursing staff by their peers when deficiencies in documentation are identified. An engaged medical director reviews any questionable provider documentation and gives similar feedback to the physicians and nurse midwives. Ongoing education is provided to all new staff in the FBC, including medical staff and midwives. This education is not only clinically focused, but team focused.33 The entire staff has completed team training and simulation training; which have enhanced our teamwork and interdisciplinary professionalism. Simple interventions such as staff education and the implementation of elective induction guidelines at community hospitals can contribute toward decreasing the overall prematurity rate in this country. This improvement not only optimizes medical outcomes but can have a direct impact on minimizing health care resources and costs.
References 1. http://www.who.int/fch/depts/rhr/en. [Accessed March 1, 2011]. 2. Main E, Oshiro B, Bingham D, Dang-Kiduff L, Kowalewski L. Elimination of non–medically indicated (elective) deliveries before 39 weeks gestational age. California Maternal Quality Care Collaborative toolkit to transform maternity Care–CMQCC). Developed under contract # 0886012 with the California Department of Public Health;
VOLUME 11, NUMBER 2, www.nainr.com
Maternal, Child and Adolescent Health Division; first edition published by March of Dimes, July, 2010. 3. Howson C, Merialdi M, Lawn J, Reavejo J, Say L, editors. March of Dimes White paper on preterm birth: the global and regional toll. New York: March of Dimes Foundation; White Plains; 2009. 4. Davidoff MJ, Dias T, Russell R, et al. The changing distribution of gestational age in the United States. White Plains, NY: March of Dimes Foundation; 2005. 5. McLaurin K, Hall C, Jackson A, Owens O, Mahadevia P. Persistence of morbidity and cost differences between latepreterm and term infants during the first year of life. Pediatrics. 2009;123:653-659. 6. Raju T, Higgins R, Stark A, Leveno K. Optimizing care and outcomes for late-preterm (near-term) infants: a summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics. 2006;118:1207-1214. 7. Prematurity task force initiative. www.preemievoices.com [Accessed April 25, 2011]. 8. Kramer MS, Demissie K, Yang H, Platt RW, Suave R, Liston R. The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. JAMA. 2000;284: 843-849. 9. Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, Barfield W, Weiss J, Evans S. Risk factors for neonatal morbidity and mortality among “healthy” late preterm newborns. Semin Perinatol. 2006;30:50-60. 10. Tomashek KM, Shapiro-Mendoza CK, Weiss J, et al. Early discharge among late preterm and term newborns and risk of neonatal morbidity. Semin Perinatol. 2006;30:61-68. 11. Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants. Pediatrics. 2004;114:372-376. 12. National vital statistics reports, vol 54, No 2, September 8, 2005. 13. http://marchofdimes.com. [Accessed January 15, 2011]. 14. http://www.savethechildren.org. [Accessed March 1, 2011]. 15. http://www.who.int/pmnch/en. [Accessed February 3, 2011]. 16. Beck S, Wojdyla D, Say L, et al. The worldwide incidence of preterm births: a systematic review of maternal mortality and morbidity. Bull World health Organ. 2010;88:31-38, doi:10.2471/BLT.08.062554. 17. Martin JA. United States vital statistics and the measurement of gestational age. Paediatr Perinat Epidemiol. 2007;21 (Suppl 2):13-21. 18. Luthy DA, Malmgren JA, Zingheim RW. Cesarean delivery after elective induction in nulliparous women: the physician effect. AM J Obstet Gynecol. 2004;191:1511-1515.
NEWBORN
19. Wing DA. Elective induction of labor in the USA. Curr Opin Obstet Gynecol. 2000;12:457-462. 20. Rayburn WF, Zhang J. Rising rates of labor induction: present concerns and future strategies. Obstet Gynecol. 2005;105:690-697. 21. Macer JA, Macer CL, Chan LS. Elective induction versus spontaneous labor: a retrospective study of complications and outcome. AM J Obstet Gynecol. 1992;166: 1690-1696. 22. Sorensen TK, Williams MA, Zingheim RW, Reisner DP, Luthy DA. Evaluation of a program to introduce active management of labor in a large urban hospital. Presented at the XIV Annual meeting of the American College of Obstetricians and Gynecologists District XIII, San Diego, CA; 1995. 23. Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean delivery: a review of 7001 consecutive inductions. Am J Obstet Gynecol. 1999;180: 628-633. 24. Cammu H, Martens G, Ruyssinck G, Amy J. Outcome after elective labor induction in nulliparous women: a matched cohort study. Am J Obstet Gynecol. 2002;186:240-244. 25. Kaufman KE, Bailit FJ, Grobman W. Elective induction: an analysis of economic and health consequences. Am J Obstet Gynecol. 2002;187:858-863. 26. Rayburn W. Minimizing the risks from elective induction of labor. J Reprod Med. 2007;52:671-676. 27. Batista L, Chung JH, Lagrew DC, Wing DA. Complications of labor induction among multiparous women in a community-based hospital system. Am J Obstet Gynecol. 2007;197:241.e1-241.e7. 28. Simpson K, Knox E. Quality analysis of the Mercy Hospital Anderson Family Birth Center. Private Consultation; 2005. 29. Cherouny PH, Federico FA, Haraden C, Leavitt Gullo S, Resar R. Idealized design of perinatal care. IHI innovation series white paper. Cambridge (Mass): Institute for Healthcare Improvement; 2005. Available at http://www. ihi.org. [Accessed March 1, 2010]. 30. Straub S. Implementing best practice safety initiatives to diminish patient harm in a hospital-based family birth center. Newborn in Infant Nursing Reviews. 2010;10:151-156. 31. American College of Obstetricians and Gynecologists. Induction of labor. Washington, DC: The College; 1999. Practice Bulletin no 10. 32. American College of Obstetricians and Gynecologists. Assessment of fetal lung maturity. Washington: DCL The College; 1996. Technical bulletin no.230. 33. TeamSTEPPS. Available at:http://teamstepps.ahrq.gov/ index.htm. [Accessed April 1, 2011].
& INFANT NURSING REVIEWS, JUNE 2011
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Our goal was to improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH. A retrospective chart review was conducted over a 2-year period. In 2005, after an intense analysis of the Family Birth Center, the overall induction rate and elective induction rate of less than 39 weeks' gestation were at an alarming 26.4% and 12.1%, respectively. Best practice guidelines for scheduling an induction were developed in collaboration with nursing and medical staff. These elective induction guidelines required patients to have completed 39 0/7 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. In 2006, the induction scheduling process and these newly developed guidelines were strictly enforced. In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005. Keywords: Elective induction; Elective delivery; Induction rates; Late preterm; Special care nursery
Preterm births are a major challenge for maternal and perinatal care worldwide and a leading cause of neonatal morbidity and mortality.1 Preterm births are generally categorized by gestational age in weeks or by birth weight in grams. Preterm birth is defined as delivery before 37 completed weeks. Early term is defined as delivery between 37 0/7 and 38 6/7 weeks. Late preterm is defined as between 34 0/7 and 36 6/7 weeks.2 The global toll of preterm birth is severe. It is estimated that 28% of the four million annual neonatal deaths are due to preterm birth. Almost 13 million (9.6%) babies are born prematurely worldwide. Eighty-five percent of these premature births occur in Africa and Asia.3 There are huge gaps in data collection available on preterm birth prevalence in certain regions and countries such as Africa, Central Asia, and China; however, wherever trend data are available, rates of preterm birth are increasing. Specifically, the rate of preterm births in the United States has increased 36% in the past 25 years. Late preterm births make up 71% of this increase.4
From the Mercy Hospital Anderson, Cincinnati, OH. Address correspondence to Leslie Altimier, RNC, MSN, Mercy Hospital Anderson, 7500 State Rd, Cincinnati, OH 45225. E-mail: [email protected]. © 2011 Elsevier Inc. All rights reserved. 1527-3369/1102-0411$36.00/0 doi:10.1053/j.nainr.2011.04.011
Because the late preterm births constitute such a large percentage of preterm infants, the economic impact on initial and later hospitalization costs in this population is great. In a study by McLaurin et al,5 the average length of stay of the birth hospitalization for term infants was 2.2 days and the average cost was $2087. Late preterm infants had a substantially longer average length of stay of 8.8 days, which cost $26 054, a cost 18 times higher than in term infants. Late preterm infants were also rehospitalized within 2 weeks of discharge after birth compared with term infants, adding costs and stress to families. In addition to an increased birth hospitalization and rehospitalization, late preterm infants were found to use more health resources throughout the first year of life compared with term infants, further impacting health care costs. Maternal costs likewise were higher among late preterm infants ($6672) compared with term infants ($1943).6 In 2005, preterm birth cost the United States at least $26.2 billion or $51 600 for every infant born prematurely. In 2007, the average medical costs for a preterm baby were more than 10 times as high as they were for a healthy full-term baby. The costs for a healthy baby from birth to his first year of life were $4551. For a preterm baby, the costs were $49 033.7 Late preterm infants are four times more likely than term infants to be diagnosed during the birth hospitalization with at least one of the following medical conditions: • Temperature instability • Hypoglycemia
• • • •
rates of infant morbidity, mortality, and readmission rates in the first months of life.8-11 Late preterm birth has been recently recognized as a serious preventable morbidity because of the extensive campaigning efforts by organizations such as the March of Dimes, World Health Organization, and Save the Children's Saving Newborn Lives program. Historically, late preterm infants were thought to be physiologically and metabolically similar to term infants and were referred to as near term infants. More recently, with increasing evidence describing their “immature” physiology and
Respiratory distress Apnea Jaundice Feeding difficulties
In addition, late preterm infants are more likely than term infants to develop hyperbilirubinemia and to be readmitted for feeding difficulties and “rule-out sepsis.” Compared with fullterm infants, late preterm infants are at a higher risk of developing these medical complications, resulting in higher PATIENT NAME
DATE
GESTATIONAL AGE AT TIME OF INDUCTION: EST. FETAL SIZE:
SGA
AGA
WEEKS LGA
PLEASE CHECK ALL THAT APPLY Obstetrical Conditions Postterm Pregnancy (41 0/7 weeks or greater)
Chorioamnionitis Fetal Demise Non Reassuring Antepartum Testing Non reactive NST Oligohydramnios (AFI of 5 cm or less) Premature Rupture of Membranes Abruptio Placentae Other: Maternal Medical Conditions Diabetes Mellitus Preeclampsia/Eclampsia Chronic Hypertension Renal Disease Chronic Pulmonary Disease Severe Fetal Growth Restriction (IUGR) Isoimmunization Other: Elective Induction Psychosocial Reasons Long Distance from Hospital History of Precipitous Labor Other: Gestational Age is at least 39 weeks, AND Bishop’s Score is 5 or more
BPP score of 6 or less
Table 1. Bishop Scoring System (circle all that apply) FACTOR Score 0 1 2 3
Dilation (cm) Closed 1-2 3-4 5-6
Effacement (%) 0-30 40-50 60-70 80
Station + -3 -2 -1,0 +1, +2
Cervical Consistency Firm Moderately Firm Soft —
Position of Cervix Posterior Mid-position Anterior —
FINAL SCORE: Physician Signature
Date
Fig 1. Induction of labor assessment form.
NEWBORN
& INFANT NURSING REVIEWS, JUNE 2011
51
Fig 2. Induction of labor/ augmentation/ cervical ripening order set. 52
VOLUME 11, NUMBER 2, www.nainr.com
morbidity similar to very preterm infants, this population is being referred to as late preterm infants.1,12-15 Some of the factors contributing to this increase in late preterm births are a higher use of assisted reproductive techniques that increase the rates of multiple gestations and changes in clinical practice such as the early induction of labor close to, but not at, full term.16 The practice of elective labor inductions and repeat cesarean births before 39 completed weeks of gestation is not recommended by the American College of Obstetricians and Gynecologists (ACOG), yet is increasing despite ACOG guidelines outlining specific criteria for medically indicated births less than 39 weeks.17 Nationally, the frequency of labor induction has increased from an incidence of 9% in 1989 to 21% in 2004, according to the National Center for Health Statistics.9 This increase in inductions is thought to be due to a variety of factors, which include patient preference, physician practice style, and practice of defensive medicine.18-20 These inductions have led to an increase in unplanned cesarean deliveries, operative vaginal deliveries, increased epidural use, and longer length of stay in labor and delivery units.21-27 Non–medically indicated (elective) deliveries before 39 weeks carry significant risks for the baby with no known benefits to the mother.
Materials and Methods Mercy Hospital Anderson (MHA) in Cincinnati, OH, is a level II maternity service, which performs approximately 1850 deliveries per year. In 2005, inductions were identified as a major quality issue, with the overall induction rate reaching a high of 23.6% and elective inductions less than 39 weeks' gestation reaching a high of 11.8%. The department of Obstetrics and Gynecology and the Family Birth Center Nursing Leadership at MHA began evaluating elective inductions after an intense quality analysis performed by Knox and Simpson.28 To improve the quality of care provided to our obstetric patients, we wanted to more clearly identify those women needing medical inductions and minimize those undergoing unnecessary elective inductions. In 2005, published studies, as well as our own data regarding induction rates and outcomes, were reviewed. After looking at
best practices, we elected to focus our efforts on minimizing elective inductions and births before 39 completed weeks of gestation. In addition, we also changed our philosophy with regard to oxytocin use in the labor and delivery unit. Guidelines for scheduling an induction were developed in collaboration with nursing and medical staff. These scheduling guidelines for elective induction required patients to have completed 39 0/7 weeks of gestation and to have a Bishop score of at least 8 for nulliparas and 6 for multiparas. An “Induction of labor assessment form” was developed as a means to ensure that all relevant information was available to the nurses before initiating oxytocin (Fig 1). This form included the estimated gestational age, Bishop score, and the indication for induction. The form was to be faxed to the obstetrics department at the time the induction was scheduled, along with the “Induction of labor/ augmentation/cervical ripening order set” (Fig 2). The intent was to implement a “no paper, no pit” policy.29 Oxytocin was standardized to 30 units of pitocin in 500 milliliters of lactated Ringer's solution. This change in practice stipulated that a single dosing regimen be used rather than the previous practice of dosing according to individual provider preference. In addition, an algorithm for the management of tachysystole based on whether or not the fetal status was reassuring was initiated. In 2006, the induction scheduling process and the newly developed guidelines were strictly enforced. To enforce the induction guidelines, the Interdisciplinary Perinatal Practice Committee conducted a monthly review of all inductions that did not meet the criteria. The attending physician responsible for the induction was contacted and educated about the guidelines. Peer review was performed, and letters from the Medical Director of the Obstetrics and Gynecology department were sent to physicians who scheduled inductions that did not follow the guidelines. Outcomes included elective inductions less than 39 0/7 weeks, cesarean birth rate for elective inductions among nulliparas, the overall induction rate, special care nursery (SCN) admissions, and neonatal transports to a higher level III neonatal intensive care unit. At the same time, a quality improvement intervention was initiated by MHA in collaboration with the Institute for Healthcare Improvement (IHI) IMPACT Perinatal Community project. The IHI is an independent, not-for-profit organization spearheading the quality improvement movement in health care
Table 1. Reduction of Elective Induction Rates Total deliveries Total inductions Total inductions/total deliveries = total induction rate (%) Elective inductions b39 wk Elective inductions b39 wk/total deliveries = elective inductions rate (%) No. of nulliparas No. of nulliparas with cesarean delivery Rate of cesarean delivery for nulliparas (%)
NEWBORN
2005
2006
2007
1858 490 26.4%
1901 459 24.1%
1844 407 22.1% (P = .58)
225 12.1%
184 9.7%
712 266 37.4%
753 237 31.5%
& INFANT NURSING REVIEWS, JUNE 2011
8 1.97% (P b .001) 707 178 25%
53
Table 2. Elective Inductions, Unanticipated SCN Admissions, and Neonatal Transports to Level III Neonatal Intensive Care Unit Variable Elective inductions b39 wk Unanticipated SCN admissions 34 0/7–38 6/7 wk Neonatal transports to a level III facility
2005
2006
2007
34 0/7–38 6/7 wk 225 67 26
34 0/7–38 6/7 wk 184 51 20
34 0/7–38 6/7 wk 8 39 14
throughout the world. The IHI white paper “Idealized design of perinatal care” established an induction of labor bundle that was implemented. This included four criteria that had to be met before induction: (1) gestational age at least 39 0/7 weeks; (2) pelvic assessment documented in the medical record; (3) reassuring fetal status; and (4) tachysystole, if present, accurately identified and appropriately managed. When oxytocin was used to augment labor, the gestational age requirement was replaced with estimated fetal weight. All four components had to be met to achieve compliance with the bundle.30 Nursing and medical staff were held accountable to this newly established safety and quality measure. The implementation of an informed consent process was instituted for any woman receiving pitocin for induction or augmentation of labor. The compliance rate with the consent process was monitored. To simplify the process, the induction of labor assessment form was combined with the cervical ripening/ induction of labor order set; and a statement of informed consent was added. Estimated fetal weight was to be documented as small for gestational age, appropriate for gestational age, or large for gestational age. When medically indicated, approval for an elective induction less than 39 weeks' gestation had to be obtained from the medical director. Adherence by both nursing and medical staff members to this safety standard was established. This quality induction management program was aimed at improving outcomes and was therefore exempt from formal institutional review board approval. The overall induction rate and the elective induction rate were monitored throughout the quality initiative. Data collection sheets were entered electronically into a Web-based Excel database, and data were analyzed. Statistical analysis was performed by using χ2 and Yates continuity correction.
Results This study was a retrospective chart audit of all deliveries between January 2005 and December 2007. From 2005 to 2007, the overall induction rate dropped from 26.4% in 2005 to 24.1% in 2006 and 22.1% in 2007 (P = .59); and the percentage of elective inductions between 36 0/7 and 38 6/7 weeks' gestation dropped from 12.1% in 2005 to 9.7% in 2006% and 1.97% in 2007 (P b .001) (Table 1). The number of infants between 36 0/7 and 38 6/7 weeks' gestation that were electively induced and admitted to the SCN decreased from 67 in 2005 to 51 in 2006 and to 39 in 2007 (P b .001) (Table 2). Similarly, admissions to SCN following elective primary cesarean
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deliveries and elective repeat cesarean deliveries decreased; however, the decrease was not statistically significant. Neonatal transports to a higher level III facility went from 26 in 2005 to 20 in 2006 and 14 in 2007. Patient safety culture scores through the Agency for Healthcare Research and Quality were measured every 2 years in the Family Birth Center (FBC). In 2006, the FBC patient safety culture score was 74%; and in 2008, it increased to 91%. Compliance with the informed consenting process likewise improved from 40% in 2006 to 97% in 2007.
Conclusion Elective delivery before 39 weeks' gestation is associated with significant neonatal morbidity. The ACOG has advocated the restriction of elective term delivery to women with a confirmed gestational age of at least 39 weeks for more than 2 decades.31,32 Quality improvement efforts targeted at decreasing elective inductions at MHA have been successful, and the results sustained. To ensure that progress is being sustained, data collection and medical record review are ongoing; and direct feedback is provided to the nursing staff by their peers when deficiencies in documentation are identified. An engaged medical director reviews any questionable provider documentation and gives similar feedback to the physicians and nurse midwives. Ongoing education is provided to all new staff in the FBC, including medical staff and midwives. This education is not only clinically focused, but team focused.33 The entire staff has completed team training and simulation training; which have enhanced our teamwork and interdisciplinary professionalism. Simple interventions such as staff education and the implementation of elective induction guidelines at community hospitals can contribute toward decreasing the overall prematurity rate in this country. This improvement not only optimizes medical outcomes but can have a direct impact on minimizing health care resources and costs.
References 1. http://www.who.int/fch/depts/rhr/en. [Accessed March 1, 2011]. 2. Main E, Oshiro B, Bingham D, Dang-Kiduff L, Kowalewski L. Elimination of non–medically indicated (elective) deliveries before 39 weeks gestational age. California Maternal Quality Care Collaborative toolkit to transform maternity Care–CMQCC). Developed under contract # 0886012 with the California Department of Public Health;
VOLUME 11, NUMBER 2, www.nainr.com
Maternal, Child and Adolescent Health Division; first edition published by March of Dimes, July, 2010. 3. Howson C, Merialdi M, Lawn J, Reavejo J, Say L, editors. March of Dimes White paper on preterm birth: the global and regional toll. New York: March of Dimes Foundation; White Plains; 2009. 4. Davidoff MJ, Dias T, Russell R, et al. The changing distribution of gestational age in the United States. White Plains, NY: March of Dimes Foundation; 2005. 5. McLaurin K, Hall C, Jackson A, Owens O, Mahadevia P. Persistence of morbidity and cost differences between latepreterm and term infants during the first year of life. Pediatrics. 2009;123:653-659. 6. Raju T, Higgins R, Stark A, Leveno K. Optimizing care and outcomes for late-preterm (near-term) infants: a summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics. 2006;118:1207-1214. 7. Prematurity task force initiative. www.preemievoices.com [Accessed April 25, 2011]. 8. Kramer MS, Demissie K, Yang H, Platt RW, Suave R, Liston R. The contribution of mild and moderate preterm birth to infant mortality. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. JAMA. 2000;284: 843-849. 9. Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, Barfield W, Weiss J, Evans S. Risk factors for neonatal morbidity and mortality among “healthy” late preterm newborns. Semin Perinatol. 2006;30:50-60. 10. Tomashek KM, Shapiro-Mendoza CK, Weiss J, et al. Early discharge among late preterm and term newborns and risk of neonatal morbidity. Semin Perinatol. 2006;30:61-68. 11. Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants. Pediatrics. 2004;114:372-376. 12. National vital statistics reports, vol 54, No 2, September 8, 2005. 13. http://marchofdimes.com. [Accessed January 15, 2011]. 14. http://www.savethechildren.org. [Accessed March 1, 2011]. 15. http://www.who.int/pmnch/en. [Accessed February 3, 2011]. 16. Beck S, Wojdyla D, Say L, et al. The worldwide incidence of preterm births: a systematic review of maternal mortality and morbidity. Bull World health Organ. 2010;88:31-38, doi:10.2471/BLT.08.062554. 17. Martin JA. United States vital statistics and the measurement of gestational age. Paediatr Perinat Epidemiol. 2007;21 (Suppl 2):13-21. 18. Luthy DA, Malmgren JA, Zingheim RW. Cesarean delivery after elective induction in nulliparous women: the physician effect. AM J Obstet Gynecol. 2004;191:1511-1515.
NEWBORN
19. Wing DA. Elective induction of labor in the USA. Curr Opin Obstet Gynecol. 2000;12:457-462. 20. Rayburn WF, Zhang J. Rising rates of labor induction: present concerns and future strategies. Obstet Gynecol. 2005;105:690-697. 21. Macer JA, Macer CL, Chan LS. Elective induction versus spontaneous labor: a retrospective study of complications and outcome. AM J Obstet Gynecol. 1992;166: 1690-1696. 22. Sorensen TK, Williams MA, Zingheim RW, Reisner DP, Luthy DA. Evaluation of a program to introduce active management of labor in a large urban hospital. Presented at the XIV Annual meeting of the American College of Obstetricians and Gynecologists District XIII, San Diego, CA; 1995. 23. Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean delivery: a review of 7001 consecutive inductions. Am J Obstet Gynecol. 1999;180: 628-633. 24. Cammu H, Martens G, Ruyssinck G, Amy J. Outcome after elective labor induction in nulliparous women: a matched cohort study. Am J Obstet Gynecol. 2002;186:240-244. 25. Kaufman KE, Bailit FJ, Grobman W. Elective induction: an analysis of economic and health consequences. Am J Obstet Gynecol. 2002;187:858-863. 26. Rayburn W. Minimizing the risks from elective induction of labor. J Reprod Med. 2007;52:671-676. 27. Batista L, Chung JH, Lagrew DC, Wing DA. Complications of labor induction among multiparous women in a community-based hospital system. Am J Obstet Gynecol. 2007;197:241.e1-241.e7. 28. Simpson K, Knox E. Quality analysis of the Mercy Hospital Anderson Family Birth Center. Private Consultation; 2005. 29. Cherouny PH, Federico FA, Haraden C, Leavitt Gullo S, Resar R. Idealized design of perinatal care. IHI innovation series white paper. Cambridge (Mass): Institute for Healthcare Improvement; 2005. Available at http://www. ihi.org. [Accessed March 1, 2010]. 30. Straub S. Implementing best practice safety initiatives to diminish patient harm in a hospital-based family birth center. Newborn in Infant Nursing Reviews. 2010;10:151-156. 31. American College of Obstetricians and Gynecologists. Induction of labor. Washington, DC: The College; 1999. Practice Bulletin no 10. 32. American College of Obstetricians and Gynecologists. Assessment of fetal lung maturity. Washington: DCL The College; 1996. Technical bulletin no.230. 33. TeamSTEPPS. Available at:http://teamstepps.ahrq.gov/ index.htm. [Accessed April 1, 2011].
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