- Email: [email protected]
Increasing Initiation and Exclusivity of Breastfeeding in the Hospitalized, Postpartum Dyad
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Implementation of an Evidence-Based Practice Project to Increase Hospital-Based Compliance Related to Cervical Cancer Screening Objective o improve the knowledge of the patient service coordinators (PSCs) to increase compliance related to cervical cancer screening.
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Lynn Anita Richards McDonald, DNP, RN, Johns Hopkins Hospital, Baltimore, MD Keywords cervical cancer screening cervical cancer knowledge and awareness education evidence-based practice cervical cancer screening compliance hospital based
Poster Presentation
Design Descriptive. Sample All patient service coordinators who conduct registration and screening when patients are admitted to the academic medical center. Methods Effectiveness of the education was measured by three assessments: a pre- and postknowledge survey of the patient service coordinator was used to measure knowledge about cervical cancer, the screening process, and the State of Maryland cervical cancer screening mandate; a calculation of screening rates was used to compare the number of women screened to the number of women admitted; and an assessment of the completeness of each screening form. Implementation Strategies Educational intervention that included cervical cancer screening, risk factors for cervical can-
cer, Maryland cervical cancer screening mandate, cervical cancer symptoms, and case studies of women screened within the program. Results A two-tailed paired samples t test indicated that the PSCs scored higher on the postsurvey (m7.68, s-2.52) than the presurvey (m-3.68, s-1.77), t (32) = 8.949, p ࣘ .0.5. A chi-squared test was used to compare categorical variables. During the 4 weeks before the educational intervention, 34% (543 of 1602) of eligible women were screened; 51% (279/543) of screening forms were completed. For the 4 weeks after the educational intervention, 54% (n = 735 of 1,373) of eligible women were screened; 89% (656/735) of screening forms were completed. Both tests were found to be significant p < .000. There was a significant improvement of the PSC’s knowledge, a 20% increase in the number of women screened, and completeness of the form increased by 38%. Conclusion/Implications for Nursing Practice These findings suggest that an educational intervention for registration staff can increase cervical cancer screening compliance and positively improve the ability of staff to screen inpatient women.
A Retrospective Analysis on the Effectiveness of a Maternal Hemorrhage Plan Objective n 2011, a multidisciplinary team at a 728-bed nonprofit Magnet hospital developed a standardized maternal hemorrhage plan (MHP) aimed at early identification and rapid treatment of excessive bleeding, with the ultimate goal of decreasing the incidence of massive maternal hemorrhage. The purpose of this study was to correlate the effectiveness of the MHP on maternal outcomes and blood utilization.
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Tammy J. Sincore, BSN, RN, RNC-OB, Baptist Hospital of Miami, Miami, FL
Design A pre- and postintervention retrospective data analysis to compare maternal outcomes and
blood utilization in women experiencing massive postpartum hemorrhage Sample All women at greater than 16-weeks gestation treated in the obstetrics unit requiring transfusion of ࣙ three units of blood products due to postpartum hemorrhage (n = 99). The sample was divided into two groups: pre-implementation (January 2009 – December 2011; n = 62) and postimplementation (January 2012 – June 2014; n = 37). Exclusion criteria included transfusions due to ectopic pregnancy, miscarriage, postsurgical hemoperitoneum, blood dyscrasias, and secondary postpartum hemorrhage following discharge.
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2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Keywords maternal hemorrhage blood transfusion INR labor and delivery postpartum hemorrhage
Poster Presentation
Method Retrospective chart reviews using obstetric transfusion records from transfusion services were performed. Data were extracted regarding estimated blood loss, quantitative blood transfusions, international normalized ratio (INR) results, intensive care unit (ICU) admissions, length of stay, disseminated intravascular coagulation (DIC) and hysterectomy rates. Preimplementation data from 2009 to 2011 were compared to postimplementation data from 2012 to 2014. Implementation Strategies Using an interdisciplinary approach, formal education on the unit inservices were conducted, followed by video recorded simulations, debriefings, and ongoing education. Results Since implementation of the MHP in 2011, there has been a notable decline in all outcomes. Sixty-
two women were transfused for massive hemorrhage prior to implementation, compared to 37 since implementation. There has been a steady decline in total obstetric transfusion rates from 1.5% in 2010 to 0.8% in 2014. Additionally, preimplementation blood product usage for massive hemorrhages totaled 561 units, compared to only 298 units postimplementation. Early identification and treatment of maternal hemorrhage has resulted in decreased instances of DIC (14 vs. 9), fewer hysterectomies (12 vs. 7), a reduction in hemorrhage related ICU admissions (26 vs. 16), and decrease in average length of stay (4.56 vs. 4.0 days).
Conclusion/Implications for Nursing Practice Early identification and treatment of hemorrhage with implementation of a MHP protocol resulted in improved maternal outcomes.
Quantifying Blood Loss at Birth Saves Lives Patricia Alvarez-Ramirez, MSN, CNS, Long Beach Memorial Medical Center/Miller’s Children’s Hospital, Long Beach, CA Janet L. Trial, EdD, CNM, MSN, Miller’s Children’s & Women’s Hospital, Long Beach, CA Brenna Hoff, BSN, Miller’s Children’s and Women’s Hospital, Long Beach, CA Amy Scott, MSN, WHNP-BC, RNC-OB, Miller’s Children’s & Women’s Hospital, Long Beach, CA Keywords quantification of blood loss staff training
Childbearing Poster Presentation
Objective o assess the effectiveness of a brief workshop designed to reinforce the clinical skills of labor and delivery staff and increase accurate documentation of quantification of blood loss (QBL) to enable staff to recognize significant hemorrhage and implement timely interventions.
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Design Postpartum hemorrhage is an obstetric emergency and is estimated to cause 25% of all maternal deaths in the United States. The accepted practice of estimating blood loss (EBL) has been demonstrated to be grossly inaccurate, and QBL has been determined to be the most accurate clinical assessment in the management of postpartum hemorrhage. Incorporating QBL into clinical management ensures that women receive appropriate care and helps prevent maternal mortality. Sample All 120 labor and delivery (L&D) registered nurses (RNs) in a tertiary care center with 6000 births annually. Methods Nurses participated in a 30-minute clinical skills QBL workshop. Sessions incorporated brief didactic instruction, clinical skill practice, including electronic medical record (EMR) documentation. A retrospective analysis of individual patient records (three before and three after workshop
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participation) was performed for all participating staff to assess workshop effectiveness. Implementation Strategies Workshops were held on the physical L&D unit during periods of low census. Standardized teaching tools were created and all assistant unit managers were oriented to teaching roles. Theses instructors were responsible for teaching workshops during a 6-month period. Results Nurses attending the workshops learned that their estimations of blood loss deviated significantly from actual QBL (range −2165 ml to +1597 ml). Efficacy in performing QBL was established (100%) for all learners. Retrospective chart analysis revealed a significant increase in EMR documentation from 77% to 87.6% for workshop participants. Compliance for QBL documentation in L&D as a whole increased from 67% to 88% during the course of the workshops. Conclusion/Implications for Nursing Practice The workshop was effective in teaching clinical skills and EMR documentation of QBL. The workshop allowed for an integrated learning experience that was well received by staff and could be implemented in an extended huddle format. This on-the-unit approach may have contributed to the overall increase in QBL documentation even for staff who did not attend the workshops.
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EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Obstetric-Based Advanced Cardiac Life Support Improves Performance and Self-Efficacy Objective o determine the effectiveness of an obstetricsbased advanced cardiac life support (ACLS OB) education program in enhancing the satisfaction, self-confidence, and abilities of labor and delivery (L&D) nurses to perform ACLS algorithms.
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Design Quasi-experimental study.
drills. Results were compared with the previous year’s scores. In the second study, pre- and postclass surveys were completed reflecting nurses’ satisfaction and self-confidence with successfully completing elements of AHA algorithms following attendance at traditional ACLS classes versus ACLS OB.
Sheryl Parfitt, MSN, RNC-OB, Scottsdale Healthcare, Shea Campus, Scottsdale, AZ Cheryl Roth, PhD, RNC-OB, WHNP-BC, RNFA, Scottsdale Healthcare, Phoenix, AZ Keywords maternal cardiac arrest
Sample Ninety-six L&D nurses from a community hospital system. Method Pre- and postsurvey of nurses completing ACLS OB class and concurrent individual scoring of mock code scenario using American Heart Association (AHA) ACLS algorithms. Implementation Strategies Nurses rotated through an ACLS OB course after ACLS recertification. Two studies were done. Prior to the class, nurses participated in a maternal mock code drill during annual skills review and performances were scored. One year later, nurses again participated in maternal mock code
Results labor and delivery nurses Nurses who completed the ACLS OB course had ACLS significantly higher scores overall when performing ACLS MegaCode algorithms (z = −6.08, p < .001) and for 18 of 21 individual elements of the Childbearing algorithm. Nurses reported statistically significant increases (p < .001) in all 13 elements of satis- Poster Presentation faction and self-confidence following completion of ACLS OB instead of traditional ACLS courses. Conclusion/Implications for Nursing Practice Emphasizing changes in ACLS for obstetric patients during preconference and using patient scenarios encountered in obstetric settings improved nurses’ performance in maternal MegaCode scenarios. The course also increased self-satisfaction and self-confidence in obstetric nurses’ abilities to perform ACLS algorithms.
Team Engagement and Improvement Through Huddles Objective o reduce the rate of postpartum hemorrhage (PPH) at an academic health center.
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Design The innovative format of the multidisciplinary team debriefing supports immediate review and evaluation of the PPH event and interventions. Sample All women who gave birth. Methods PPH is tracked over time through a standardized measurement system, and results are disseminated back to the team. Implementation Strategies The team huddle is facilitated by the charge nurse with team members immediately following PPH resolution. A standardized form frames the conversation and focuses on the identification and feedback related to risk awareness, treatment,
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and outcomes. The debrief highlights what went well and what opportunities exist through the lens of the participants. Frequently, potential solutions are generated directly at the point of care. Debrief forms are reviewed by the clinical nurse specialist (CNS) and nurse manager within 24 to 48 hours to provide further assessment, evaluate systems issues, and support rapid improvement. The CNS and nurse manager track the strengths and opportunities as a measure of progress. This process design also offers time to celebrate positive team response and growth.
Kerista Hansell, MSN, RN, CNS-BC, C-EFM, IBCLC, Indiana University Health, Indianapolis, IN
Results During 10 quarters, the rate of PPH was reduced by 49% using a standard national metric; current data show the rate continuing to decline. Through team debriefing, opportunities and solutions are identified. Implementation of team-based solutions enhances team engagement in practices and outcomes, placing the patient at the center of care.
Childbearing Poster Presentation
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
Erin M. Kirby, MSN, MBA, RNC-OB, Indiana University Health Methodist Hospital, Indianapolis, IN Keywords postpartum hemorrhage quality implementation science
http://jognn.awhonn.org
Hansell, K. and Kirby, E. M.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Conclusion/Implications for Nursing Practice Clinical nurse expertise is influenced by education level, experience level, nursing staff composition, and practice environment. Leveraging team talent and decreasing the power gradient via team hud-
dles has changed the practice environment. In a recent emergent event unrelated to PPH, the team huddled to debrief, and a novice registered nurse (RN) captured all elements of the huddle including opportunities for growth, demonstrating increased team resilience in emergent situations.
An Evidence-Based Preoperative Bundle to Reduce Infection Rates Among Women with Cesarean Births Paula R Brooks, BSN, RN, Missouri Baptist Medical Center, St. Louis, MO Keywords cesarean patients surgical site infection evidence-based practice
Childbearing Poster Presentation
Objective o address the following clinical questions: For women with cesarean births, does the use of a standardized antibiotic and timing reduce the incidence of postoperative infection? For women with cesarean births, does the use of a chlorhexidine-alcohol based combination reduce the incidence of postoperative infection compared with a betadine-alcohol based combination?
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Design The evidence-based project was designed to create guidelines for the selection of antibiotics with weight-based dosing and timing of administration and for the selection and standardized use of an intraoperative surgical skin preparation.
as the antibiotic for use. Another schedule was created for patients allergic to penicillin that included clindamycin and gentamicin. Implementation Strategies The chief of obstetrics communicated the practice changes to all associated physicians. Nurses were educated through a joint effort by the unit clinical educator, the nurse manager, and a nurse representative from the product company. Written and verbal communications from the project leader and management announced the implementation date. Nurses from infection prevention and control monitored the incidence of surgical site infection post implementation.
Sample Preintervention data consisted of infection rates for 12 months prior to the new practice and postintervention data consisted of infection rates following the practice change.
Results Data obtained for the 12 months following the practice change demonstrated a significant decrease in the rate of surgical site infections for women with cesarean births.
Methods Following an extensive literature search and appraisal of the evidence, a multidisciplinary committee was formed consisting of nurses, physicians, and pharmacists. Decisions based on the evidence were made to implement the use of a chlorhexidine product, and cefazolin was chosen
Conclusion/Implications for Nursing Practice Application of current evidence is needed to establish a guideline designed to improve patient care. A multidisciplinary team is needed to effect a practice change that is sustained. Further work is needed to address surgical site infection rates among obese women.
Improving Antibiotic Prophylaxis Prior to Cesarean Birth Carol Spruill, MSN, APRN, CPHQ, Children’s Memorial Hermann Hospital, Houston, TX
Objective o ensure that antibiotic prophylaxis will occur 100% of the time within the one-hour window prior to incision for women with scheduled cesarean births at Children’s Memorial Hermann Hospital Women’s Services by July 30, 2014.
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Design A quality-improvement team of anesthesiologists, nurses, and pharmacists used qualityimprovement methods to understand the problem and develop a new process for antibiotic delivery.
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Sample Women with scheduled cesareans at Children’s Memorial Hermann Hospital Women’s Services comprised the sample. Methods Baseline data were collected to define the scope of the problem of antibiotics being delivered according to evidence-based guidelines. A fishbone diagram was developed to understand the potential causes of antibiotic delivery failure in 18% of patients from anesthesiologist and nursing staff
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perspectives. A waste walk was performed to identify inefficiencies. A map of the current process was created to detect potential stages at which interventions might improve the ability to give antibiotics on time. A spaghetti map was drawn after a nurse wearing a pedometer walked to all areas where nurses must travel to gather intravenous tubing and antibiotics to make a packet for anesthesia. A test of change in one pod was tested with positive results and then the new process was implemented in the entire unit. Postimplementation data were collected. Implementation Strategies Anesthesia, medicine, and nursing leaders approved the project. The new process was taught to all nurses and anesthesiologists with the goal to reduce surgical site infections by delivering antibiotics within one hour prior to incision. Specific resources and supplies needed for the process to work smoothly and efficiently were also implemented. Pyxix MedStations were purchased
for operating rooms (ORs). The pharmacy supplied antibiotics and altered practice to support the new process. Information systems collaborated on the implementation of Power Chart Maternity Care4 (PCM), a new electronic charting method, to reduce the incidence of charting in different software and to support the convenience of charting medications in the ORs for the anesthesiologists. Results The goal of 100% compliance was not met, although at 99%, the goal is within reach. The new process is in place and Power Chart Maternity has been implemented.
Kendra Folh, BSN, RN, Children’s Memorial Hermann Hospital, Houston, TX Keywords cesarean antibiotic prophylaxis surgical site infection
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice A control plan to maintain gains will need to be in place. Implications for nursing practice include the elimination of time wasted in finding tubing and antibiotics and the ability of the nursing staff to focus on laboring women without leaving the bedside.
Meeting the 30-Minute Decision to Incision Rule in the Community Hospital Objective o develop a multidisciplinary process whereby St. Joseph Hospital can consistently meet or exceed the 30-minute time frame from the decision to perform an unscheduled emergency cesarean to the time the surgical incision is made.
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Design A retrospective audit of unscheduled cesareans from January 2012 through May 2013 was used to identify 118 cases. The reasons for the cesareans were reviewed and the most emergent cases were identified: nonreassuring fetal heart rate tracing and maternal complications. Sample A total of 23 cases met these criteria and were reviewed for decision to incision time and time of day performed. Response time ranged from 49 to 170 minutes from 7 am to 3 pm, 53 to 66 minutes from 3 pm to 11 pm, and 51 to 82 minutes from 11 pm to 7 am with an overall mean response time of 80.8 minutes. Methods Quality improvement, plan, do, study, act (PDSA).
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Implementation Strategies A multidisciplinary team comprised of nursing and medical leaders from maternal child health, anesthesia, the operating room, and representatives from ancillary support departments convened to identify processes currently in place and ways to improve workflow efficiencies to reduce the response times with the goal of meeting or exceeding the 30-minute decision to incision time for unscheduled emergency cesareans. The team implemented a structured response for all cesareans so in instances of true emergencies, the staff would be well drilled. Results Heightened awareness reduced mean response time to 61.5 minutes by October 2013. A structured response team Code OBERT (Obstetrical Emergency Response Team) was implemented in November 2013, and by February 2014 mean response time was reduced to 40.4 minutes.
Jennifer Pedley, BSN, MS, RNC-OB, St. Joseph Hospital, Nashua, NH Nora C. Fortin, BSN, RNC-OB, St. Joseph Hospital, Nashua, NH Keywords cesarean decision to incision response time
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice Significant progress has been made in meeting or exceeding the timeframe, however, we continue to work toward consistency in all cases. Nurses in community hospitals with limited resources can still navigate the complexities of obstetric care.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
http://jognn.awhonn.org
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
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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%.
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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.
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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
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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.
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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-
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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
von Kohler, C. et al.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Using Best Evidence to Reduce the Rate of Surgical Site Infection Lynda A. Tyer-Viola, PhD, RNC, FAAN, Texas Children’s Hospital, Houston, TX Frances C. Kelly, MSN, RNC-OB, NEA-BC, CPHQ, Texas Children’s Hospital, Pavilion for Women, Houston, TX Keywords surgical site infection cesarean quality improvement nursing practice
Childbearing Poster Presentation
Objective o create a surgical site infection prevention bundle by examining population characteristics, context of care, and prioritization of evidencebased interventions.
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Design Quality improvement plan-do-study-act (PDSA) methodology with a small-scale iterative approach to three cycles of improvement was used to create a surgical site infection (SSI) prevention bundle. Sample All women with cesarean births in scheduled day surgery operating suites and labor room operating suites at an academic medical center with 5500 births annually. Methods Care improvement process consisting of a common cause analysis of our readmission cases to determine the characteristics of our population. Next, we examined the literature on SSI prevention and treatment related to these characteristics. Three areas with significant variation from evidence-based practice were identified: antibiotic prophylaxis, skin preparation, and education. Implementation Strategies To plan cycle one, we assessed antibiotic stewardship of participants. Overall 32% of participants and 31% of readmission participants did not adhere to guidelines To act, a forcing function in our
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order sets yielded a 100% compliance rate, and none of the participants in the test of change cycle (N = 20) was readmitted. In the second cycle, we assessed skin preparation and found significant variation in processes. After education and implementation of new interventions, we found 100% compliance. The last cycle focused on patient education. To plan, we called 20 participants to assess their knowledge, what they were taught, and their current wound status. We found that we were teaching patients the signs and symptoms of infection but not prevention. Participants reported variation in care, limited education on wound care, and no education on hand hygiene; 20% reported wound deviation. Interventions applied included focused nursing education on wound care and hand hygiene when caring for infants, including a care package with materials to support the education at home. Reassessment revealed increased knowledge and wound care and no reports of wound deviations. Results SSI rates decreased during 10 months from 2.41% to 0.61% to zero. Days between SSI readmissions increased from 2 days to 68 days at present. Conclusion/Implications for Nursing Practice Developing a context and population focused evidence-based prioritized care bundle can result in improved patient outcomes. Nursing interventions based on knowing the patient can yield sustainable results.
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Nurses Improving the Health of Mothers and Infants by Dancing the 10 Steps to Successful Breastfeeding Newborn Care
Marianne Allen, MN, RNC-OB, CNS, Pinnacle Health System, Harrisburg, PA
Objective o implement practices that promote optimal infant feeding for all mothers and infants at our organization. Our organization had implemented some components of the Ten Steps to Successful Breastfeeding, but the breastfeeding initiation rate was 62% and the formula supplementation rate was 70%.
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Design The following guidelines were followed: The BabyFriendly Hospital Initiative Guidelines and EvaluaDeborah J. Schafer, MSN, tion Criteria for Facilities Seeking Baby-Friendly RNC-OB, Pinnacle Health Designation, AWHONN’s Breastfeeding Support System, Harrisburg, PA through First Two Years Evidence-Based Practice Keywords Guideline, and AWHONN’s Assessment and Care breastfeeding evidence-based practice change of the Late Preterm Infant Evidence-Based Practice Guideline. education
Poster Presentation
Sample Pregnant women, postpartum mothers and their infants, health care providers, and the health care organization. Methods Participation in 89-hospital national quality improvement initiative to help improve maternity care and increase the number of Baby Friendly designated hospitals. An interdisciplinary team collaborated to move the organization through the discovery, development, dissemination, and designation phases for a 2-year process improvement. Implementation Strategies Implementation strategies included assessment of current practice, identification of barriers and opportunities, and strategies to support significant changes that encompass the continuum of care; development and implementation of a staff
teaching plan of knowledge and practical skills necessary to implement practices that support the Ten Steps to Successful Breastfeeding; review of materials across the organization and private practices; development of patient education materials and a comprehensive teaching plan; monthly quantitative and qualitative audits; rapid cycle testing; collaboration and communication with stakeholders at all levels of organization; and community partnerships. Integral to the success of the quality initiative were weekly interdisciplinary team meetings, presentations at obstetrics and pediatric department meetings, role development of breastfeeding champions, incremental phasein of practice changes, education roll-outs and celebrations, and monthly tracking of our progress in meeting the Ten Steps with communication to staff, physicians, and administration. Results Results included heightened professional environment of competence, enhanced delivery of patient centered care, improved health of mothers and infants, increased patient satisfaction, and achievement of regulatory compliance benchmarks. The implementation of the Ten Steps to Successful Breastfeeding resulted in improved rates of breastfeeding as well as reduced ethnic, racial, and socioeconomic disparities related to infant feeding. Conclusion/Implications for Nursing Practice This presentation demonstrates the effect of a nurse-led, quality initiative that improved the continuum of care for mothers and infants from the prenatal period, to delivery, and through postdischarge community care. The steps to implementation can be a model for other organizations that want to improve the quality of health care to support optimum infant feeding.
Use of Dextrose Gel Reverses Neonatal Hypoglycemia and Decreases Admissions to the NICU Catherine Bennett, APN, CNS, Advocate Lutheran General Hospital, Park Ridge, IL
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Objective o reduce newborn admission to the neonatal intensive care unit (NICU) for the diagnosis of neonatal hypoglycemia by using 40% dextrose gel rather than intravenous (IV) dextrose.
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Design A retrospective chart review of more than 700 charts from 2013 was performed prior to implementation, and approximately 60 charts per month were reviewed postimplementation.
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http://jognn.awhonn.org
Bennett, C., Headtke, E., and Rowe-Telow, M.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Elyse Headtke, MSN, Northwestern Memorial Hospital, Palos Hills, IL Meg Rowe-Telow, BS, RNC, Advocate Lutheran General Hospital, Park Ridge, IL Keywords neonatal hypoglycemia 40% dextrose gel NICU admission rates
Newborn Care Poster Presentation
Sample The sample included infants at risk for neonatal hypoglycemia born at a tertiary teaching institution. Inclusion criteria were 35 0/7- to 42 0/7-weeks gestation with one of the following conditions: small for gestational age, large for gestational age, an infant of a diabetic mother, late preterm infant, or an Apgar score of <7 at 5 minutes. Methods A protocol was developed for the treatment of infants at risk for hypoglycemia. Newborns were fed within the first hour of life. A bedside blood glucose (BG) level was obtained 30 minutes after the feeding was completed. If the BG was < 35, the registered nurse (RN) administered dextrose gel per syringe to the buccal cavity of the infant and placed the infant with the mother to feed. A BG level was then repeated after one hour. If the BG level was < 35 a second dose of the gel was administered. If hypoglycemia was not reversed following the second dose, the physician was contacted for further orders. Implementation Strategies After review of a randomized controlled study our multidisciplinary newborn advisory committee
(NAC) added glucose gel to the neonatal hypoglycemia protocol. The NAC collaborated with the pharmacy to establish weight base dosing of dextrose gel. Mandatory educational sessions were provided to all RNs that focused on the rationale for change, use of the new algorithm, and the technique to administer the gel. Once all was in place a go live date was set of May 15. Data collection began in June 2014. Results Following the implementation of the protocol, admission to the NICU for the diagnosis of neonatal hypoglycemia decreased from a mean of 11% to 2%. Conclusion/Implications for Nursing Practice The utilization of dextrose gel along with oral feeding resulted in a decrease in the incidence of neonatal hypoglycemia with a corresponding decrease in the admission rates to the NICU for the primary diagnosis of neonatal hypoglycemia. This inexpensive, noninvasive intervention can be adopted by other institutions to decrease NICU admissions for the primary diagnosis of neonatal hypoglycemia.
Incorporating Evidence-Based Practice for Skin-to-Skin Care in the Operating Room to Increase in-Hospital Exclusive Breastfeeding Rates Melaney L. Stricklin, BSN, Objective RN-C, CCE, UC Davis Medical o initiate skin-to-skin contact in the operating Center, Sacramento, CA
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Kandice L. Duns, BSN, RN, CLE, UC Davis Medical Center, Sacramento, CA Keywords skin-to-skin cesarean breastfeeding
Newborn Care Poster Presentation
room after cesarean birth.
Design Nurse- led quality improvement project based on the define, measure, analyze, improve and control (DMAIC) model.
Sample UC Davis Medical Center has a cesarean rate of 30% and this rate was targeted for change. Prior to project implementation, skin-to-skin care was initiated in the postanesthesia care unit (PACU) sometimes an hour or more following birth. Our proposal was to initiate skin-to-skin care in the operating room. Initially low-risk women with scheduled cesareans at greater than 39 weeks gestation were included, but the practice was expanded to include mothers of stable neonates who were at least 37-weeks gestational age. Mothers with gestational diabetes were included.
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Methods A retrospective chart review was performed to evaluate the rates of in-hospital exclusive breastfeeding for neonates born via cesarean. Implementation Strategies Staff education was provided to address concerns and elicit support from key stakeholders. Mothers identified as candidates were provided with education about the benefits of skin-to-skin care, and consent was obtained. After an initial assessment by the NICU team at fewer than 10 minutes, the diapered neonate was placed directly on the bare chest of the mother in a transverse position. The neonate remained skin-to-skin until skin closure or request of cessation by mother. Limiting factors included unstable neonates, instability of mother, and mother’s lack of interest in doing skin-to-skin contact. Results A baseline was established with a sample size of 33 neonates; 33% were exclusively breastfeeding at discharge. Subsequent chart reviews at 12 months (n = 33) and 18 months (n = 26) after
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implementation showed an increase in exclusive breastfeeding rates at discharge to 53% and 69% respectively.
terdisciplinary collaborative model, the practice of skin-to-skin care in the operating room can be achieved and help to improve exclusive breastfeeding rates.
Conclusion/Implications for Nursing Practice Improving the rates of exclusive breastfeeding has become a national health priority. Through an in-
Improvement in Rates of Preterm Infant Hypothermia by the Implementation of a Best Practice Bundle Objective o decrease the number of preterm infants with hypothermia on admission to the NICU by improving delivery room management.
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Design A best practice bundle was developed for preterm infants. This included the use of heated mattress pads for all infants 36-weeks gestational age or less and polyethylene bags for infants 28-weeks gestational age or fewer. Additionally, to prevent convective and conductive heat loss, preterm infants were not weighed in the delivery room, and operating room temperatures were set to 25 degrees C. Sample Data were collected for 300 preterm neonates admitted to the NICU between January 2013 and June 2014. Methods Using plan-do-check-act (PDCA) methodology, an interprofessional team reviewed the literature, developed and implemented an evidence-based protocol, and evaluated outcomes. Normal admission temperature was defined as 36.5 degrees C or greater within one hour of birth. Implementation Strategies All nursing and physician staff who attended births were educated on the significance of infant hypothermia and the bundle components. Following implementation of the bundle, outcomes were tracked and disseminated on a monthly basis.
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Outliers were analyzed and debriefs with the nurs- Donna S. Bowman, DNP, FNP-BC, RNC-OB, EFM-C, ing and physician staff were conducted. Results The retrospective baseline data included 45 infants: 10 (22%) had admission temperatures of 36.5 degrees C or greater. Postimplementation, there was a steady improvement in admission temperatures. By the third quarter of 2014, 68% of infants in had admission temperatures of 36.5 degrees C or greater. For the low-birth-weight infants tracked in the Vermont Oxford Network (VON) database, for the 3 years prior to the bundle implementation, we performed at 3.8%, 3.10%, and 14.3%. The year postimplementation, of 12 VLBW neonates, 75% met the standard for temperature on admission to NICU.
Stamford Hospital, Stamford, CT Kathy LiVolsi, MHA, BSN, RNC, Stamford Hospital, Stamford, CT Keywords infant hypothermia delivery room quality improvement
Newborn Care Poster Presentation
Conclusion/Implications for Nursing Practice Successful implementation of this project required a commitment from the obstetric and neonatal teams. Although it is clearly our responsibility to take admission temperatures and monitor various physiologic parameters in individual neonates, it is equally incumbent on the team to analyze aggregate data indicators to monitor overall performance. Data dissemination has been a crucial factor in maintaining awareness of this problem and providing the impetus for continued use of the bundle elements. In addition, conducting a case by case analysis of outliers is essential for ensuring that any gaps in performance are recognized and rectified by providing feedback to individual providers.
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Stagg, J. and Ustianov, J.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Improving and Sustaining Breastfeeding Practices through a Statewide Learning Collaborative Julie Stagg, MSN, RN, IBCLC, Objective RLC, Texas Department of he aim of the Texas Breastfeeding LearnState Health Services, Austin, ing Collaborative (TBLC) is to increase inTX
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Jennifer Ustianov, MS, RN, IBCLC, National Institute for Children’s Health Quality, Boston, MA Keywords breastfeeding Ten Steps learning collaborative quality improvement adaptability
Newborn Care Poster Presentation
hospital exclusive breastfeeding rates by 35% across three, sequential, regional, quality improvement, learning collaborative cohorts of as many as 81 birthing facilities.
Design Use of the Institute for Healthcare Improvement’s Breakthrough Series (BTS) and Model for Improvement (MFI) to facilitate uptake of the Ten Steps to Successful Breastfeeding (Ten Steps). Sample Cohorts A and B included 41 hospital improvement teams in two geographic regions cumulatively accounting for 99,000 births (26% of Texas births and 2.5% U.S. births) annually. Participating facilities included a diverse mix of urban/rural, large/midsized/small, and public, private, and academic center settings at varying stages of Ten Steps implementation. Methods The TBLC utilizes the BTS, MFI, and complementary support to facilitate implementation of the Ten Steps within participating facilities. Implementation Strategies Twenty hospital teams (Cohort A) were guided through a BTS Learning Collaborative with compo-
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nents including data collection, self-assessment surveys, discussion forums, support calls, leadership events, face-to-face learning sessions (LS), and virtual action periods (AP) calls. Components work to accelerate plan-do-study-act cycles for improvement and to facilitate sharing of best practices among teams. Learning sessions included didactic lectures to communicate the evidence base of the Ten Steps and interactive workshops focused on sharing strategies to overcome common and special cause barriers. Teams were linked to breastfeeding support resources of the Department of Health and Human Services. Cohort B built upon Cohort A successes, and collective learning was spread to hospital teams through cross-cohort collaborative mentorship and continuous quality improvement within the project structure. Results Cohort A’s quality data indicated aggregate improvements from February 2013 to April 2014 for multiple outcome and process measures. Conclusion/Implications for Nursing Practice Multidisciplinary teams engaged in a quality improvement learning collaborative to accelerate adaptation of recommended maternity practices across diverse hospital settings to achieve improved process- and outcome measures. Improvement strategies and lessons learned are transferable to other projects and settings.
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Implementation of an Evidence-Based Practice Project to Increase Hospital-Based Compliance Related to Cervical Cancer Screening Objective o improve the knowledge of the patient service coordinators (PSCs) to increase compliance related to cervical cancer screening.
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Lynn Anita Richards McDonald, DNP, RN, Johns Hopkins Hospital, Baltimore, MD Keywords cervical cancer screening cervical cancer knowledge and awareness education evidence-based practice cervical cancer screening compliance hospital based
Poster Presentation
Design Descriptive. Sample All patient service coordinators who conduct registration and screening when patients are admitted to the academic medical center. Methods Effectiveness of the education was measured by three assessments: a pre- and postknowledge survey of the patient service coordinator was used to measure knowledge about cervical cancer, the screening process, and the State of Maryland cervical cancer screening mandate; a calculation of screening rates was used to compare the number of women screened to the number of women admitted; and an assessment of the completeness of each screening form. Implementation Strategies Educational intervention that included cervical cancer screening, risk factors for cervical can-
cer, Maryland cervical cancer screening mandate, cervical cancer symptoms, and case studies of women screened within the program. Results A two-tailed paired samples t test indicated that the PSCs scored higher on the postsurvey (m7.68, s-2.52) than the presurvey (m-3.68, s-1.77), t (32) = 8.949, p ࣘ .0.5. A chi-squared test was used to compare categorical variables. During the 4 weeks before the educational intervention, 34% (543 of 1602) of eligible women were screened; 51% (279/543) of screening forms were completed. For the 4 weeks after the educational intervention, 54% (n = 735 of 1,373) of eligible women were screened; 89% (656/735) of screening forms were completed. Both tests were found to be significant p < .000. There was a significant improvement of the PSC’s knowledge, a 20% increase in the number of women screened, and completeness of the form increased by 38%. Conclusion/Implications for Nursing Practice These findings suggest that an educational intervention for registration staff can increase cervical cancer screening compliance and positively improve the ability of staff to screen inpatient women.
A Retrospective Analysis on the Effectiveness of a Maternal Hemorrhage Plan Objective n 2011, a multidisciplinary team at a 728-bed nonprofit Magnet hospital developed a standardized maternal hemorrhage plan (MHP) aimed at early identification and rapid treatment of excessive bleeding, with the ultimate goal of decreasing the incidence of massive maternal hemorrhage. The purpose of this study was to correlate the effectiveness of the MHP on maternal outcomes and blood utilization.
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Tammy J. Sincore, BSN, RN, RNC-OB, Baptist Hospital of Miami, Miami, FL
Design A pre- and postintervention retrospective data analysis to compare maternal outcomes and
blood utilization in women experiencing massive postpartum hemorrhage Sample All women at greater than 16-weeks gestation treated in the obstetrics unit requiring transfusion of ࣙ three units of blood products due to postpartum hemorrhage (n = 99). The sample was divided into two groups: pre-implementation (January 2009 – December 2011; n = 62) and postimplementation (January 2012 – June 2014; n = 37). Exclusion criteria included transfusions due to ectopic pregnancy, miscarriage, postsurgical hemoperitoneum, blood dyscrasias, and secondary postpartum hemorrhage following discharge.
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2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
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EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Keywords maternal hemorrhage blood transfusion INR labor and delivery postpartum hemorrhage
Poster Presentation
Method Retrospective chart reviews using obstetric transfusion records from transfusion services were performed. Data were extracted regarding estimated blood loss, quantitative blood transfusions, international normalized ratio (INR) results, intensive care unit (ICU) admissions, length of stay, disseminated intravascular coagulation (DIC) and hysterectomy rates. Preimplementation data from 2009 to 2011 were compared to postimplementation data from 2012 to 2014. Implementation Strategies Using an interdisciplinary approach, formal education on the unit inservices were conducted, followed by video recorded simulations, debriefings, and ongoing education. Results Since implementation of the MHP in 2011, there has been a notable decline in all outcomes. Sixty-
two women were transfused for massive hemorrhage prior to implementation, compared to 37 since implementation. There has been a steady decline in total obstetric transfusion rates from 1.5% in 2010 to 0.8% in 2014. Additionally, preimplementation blood product usage for massive hemorrhages totaled 561 units, compared to only 298 units postimplementation. Early identification and treatment of maternal hemorrhage has resulted in decreased instances of DIC (14 vs. 9), fewer hysterectomies (12 vs. 7), a reduction in hemorrhage related ICU admissions (26 vs. 16), and decrease in average length of stay (4.56 vs. 4.0 days).
Conclusion/Implications for Nursing Practice Early identification and treatment of hemorrhage with implementation of a MHP protocol resulted in improved maternal outcomes.
Quantifying Blood Loss at Birth Saves Lives Patricia Alvarez-Ramirez, MSN, CNS, Long Beach Memorial Medical Center/Miller’s Children’s Hospital, Long Beach, CA Janet L. Trial, EdD, CNM, MSN, Miller’s Children’s & Women’s Hospital, Long Beach, CA Brenna Hoff, BSN, Miller’s Children’s and Women’s Hospital, Long Beach, CA Amy Scott, MSN, WHNP-BC, RNC-OB, Miller’s Children’s & Women’s Hospital, Long Beach, CA Keywords quantification of blood loss staff training
Childbearing Poster Presentation
Objective o assess the effectiveness of a brief workshop designed to reinforce the clinical skills of labor and delivery staff and increase accurate documentation of quantification of blood loss (QBL) to enable staff to recognize significant hemorrhage and implement timely interventions.
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Design Postpartum hemorrhage is an obstetric emergency and is estimated to cause 25% of all maternal deaths in the United States. The accepted practice of estimating blood loss (EBL) has been demonstrated to be grossly inaccurate, and QBL has been determined to be the most accurate clinical assessment in the management of postpartum hemorrhage. Incorporating QBL into clinical management ensures that women receive appropriate care and helps prevent maternal mortality. Sample All 120 labor and delivery (L&D) registered nurses (RNs) in a tertiary care center with 6000 births annually. Methods Nurses participated in a 30-minute clinical skills QBL workshop. Sessions incorporated brief didactic instruction, clinical skill practice, including electronic medical record (EMR) documentation. A retrospective analysis of individual patient records (three before and three after workshop
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participation) was performed for all participating staff to assess workshop effectiveness. Implementation Strategies Workshops were held on the physical L&D unit during periods of low census. Standardized teaching tools were created and all assistant unit managers were oriented to teaching roles. Theses instructors were responsible for teaching workshops during a 6-month period. Results Nurses attending the workshops learned that their estimations of blood loss deviated significantly from actual QBL (range −2165 ml to +1597 ml). Efficacy in performing QBL was established (100%) for all learners. Retrospective chart analysis revealed a significant increase in EMR documentation from 77% to 87.6% for workshop participants. Compliance for QBL documentation in L&D as a whole increased from 67% to 88% during the course of the workshops. Conclusion/Implications for Nursing Practice The workshop was effective in teaching clinical skills and EMR documentation of QBL. The workshop allowed for an integrated learning experience that was well received by staff and could be implemented in an extended huddle format. This on-the-unit approach may have contributed to the overall increase in QBL documentation even for staff who did not attend the workshops.
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Obstetric-Based Advanced Cardiac Life Support Improves Performance and Self-Efficacy Objective o determine the effectiveness of an obstetricsbased advanced cardiac life support (ACLS OB) education program in enhancing the satisfaction, self-confidence, and abilities of labor and delivery (L&D) nurses to perform ACLS algorithms.
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Design Quasi-experimental study.
drills. Results were compared with the previous year’s scores. In the second study, pre- and postclass surveys were completed reflecting nurses’ satisfaction and self-confidence with successfully completing elements of AHA algorithms following attendance at traditional ACLS classes versus ACLS OB.
Sheryl Parfitt, MSN, RNC-OB, Scottsdale Healthcare, Shea Campus, Scottsdale, AZ Cheryl Roth, PhD, RNC-OB, WHNP-BC, RNFA, Scottsdale Healthcare, Phoenix, AZ Keywords maternal cardiac arrest
Sample Ninety-six L&D nurses from a community hospital system. Method Pre- and postsurvey of nurses completing ACLS OB class and concurrent individual scoring of mock code scenario using American Heart Association (AHA) ACLS algorithms. Implementation Strategies Nurses rotated through an ACLS OB course after ACLS recertification. Two studies were done. Prior to the class, nurses participated in a maternal mock code drill during annual skills review and performances were scored. One year later, nurses again participated in maternal mock code
Results labor and delivery nurses Nurses who completed the ACLS OB course had ACLS significantly higher scores overall when performing ACLS MegaCode algorithms (z = −6.08, p < .001) and for 18 of 21 individual elements of the Childbearing algorithm. Nurses reported statistically significant increases (p < .001) in all 13 elements of satis- Poster Presentation faction and self-confidence following completion of ACLS OB instead of traditional ACLS courses. Conclusion/Implications for Nursing Practice Emphasizing changes in ACLS for obstetric patients during preconference and using patient scenarios encountered in obstetric settings improved nurses’ performance in maternal MegaCode scenarios. The course also increased self-satisfaction and self-confidence in obstetric nurses’ abilities to perform ACLS algorithms.
Team Engagement and Improvement Through Huddles Objective o reduce the rate of postpartum hemorrhage (PPH) at an academic health center.
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Design The innovative format of the multidisciplinary team debriefing supports immediate review and evaluation of the PPH event and interventions. Sample All women who gave birth. Methods PPH is tracked over time through a standardized measurement system, and results are disseminated back to the team. Implementation Strategies The team huddle is facilitated by the charge nurse with team members immediately following PPH resolution. A standardized form frames the conversation and focuses on the identification and feedback related to risk awareness, treatment,
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and outcomes. The debrief highlights what went well and what opportunities exist through the lens of the participants. Frequently, potential solutions are generated directly at the point of care. Debrief forms are reviewed by the clinical nurse specialist (CNS) and nurse manager within 24 to 48 hours to provide further assessment, evaluate systems issues, and support rapid improvement. The CNS and nurse manager track the strengths and opportunities as a measure of progress. This process design also offers time to celebrate positive team response and growth.
Kerista Hansell, MSN, RN, CNS-BC, C-EFM, IBCLC, Indiana University Health, Indianapolis, IN
Results During 10 quarters, the rate of PPH was reduced by 49% using a standard national metric; current data show the rate continuing to decline. Through team debriefing, opportunities and solutions are identified. Implementation of team-based solutions enhances team engagement in practices and outcomes, placing the patient at the center of care.
Childbearing Poster Presentation
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Erin M. Kirby, MSN, MBA, RNC-OB, Indiana University Health Methodist Hospital, Indianapolis, IN Keywords postpartum hemorrhage quality implementation science
http://jognn.awhonn.org
Hansell, K. and Kirby, E. M.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Conclusion/Implications for Nursing Practice Clinical nurse expertise is influenced by education level, experience level, nursing staff composition, and practice environment. Leveraging team talent and decreasing the power gradient via team hud-
dles has changed the practice environment. In a recent emergent event unrelated to PPH, the team huddled to debrief, and a novice registered nurse (RN) captured all elements of the huddle including opportunities for growth, demonstrating increased team resilience in emergent situations.
An Evidence-Based Preoperative Bundle to Reduce Infection Rates Among Women with Cesarean Births Paula R Brooks, BSN, RN, Missouri Baptist Medical Center, St. Louis, MO Keywords cesarean patients surgical site infection evidence-based practice
Childbearing Poster Presentation
Objective o address the following clinical questions: For women with cesarean births, does the use of a standardized antibiotic and timing reduce the incidence of postoperative infection? For women with cesarean births, does the use of a chlorhexidine-alcohol based combination reduce the incidence of postoperative infection compared with a betadine-alcohol based combination?
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Design The evidence-based project was designed to create guidelines for the selection of antibiotics with weight-based dosing and timing of administration and for the selection and standardized use of an intraoperative surgical skin preparation.
as the antibiotic for use. Another schedule was created for patients allergic to penicillin that included clindamycin and gentamicin. Implementation Strategies The chief of obstetrics communicated the practice changes to all associated physicians. Nurses were educated through a joint effort by the unit clinical educator, the nurse manager, and a nurse representative from the product company. Written and verbal communications from the project leader and management announced the implementation date. Nurses from infection prevention and control monitored the incidence of surgical site infection post implementation.
Sample Preintervention data consisted of infection rates for 12 months prior to the new practice and postintervention data consisted of infection rates following the practice change.
Results Data obtained for the 12 months following the practice change demonstrated a significant decrease in the rate of surgical site infections for women with cesarean births.
Methods Following an extensive literature search and appraisal of the evidence, a multidisciplinary committee was formed consisting of nurses, physicians, and pharmacists. Decisions based on the evidence were made to implement the use of a chlorhexidine product, and cefazolin was chosen
Conclusion/Implications for Nursing Practice Application of current evidence is needed to establish a guideline designed to improve patient care. A multidisciplinary team is needed to effect a practice change that is sustained. Further work is needed to address surgical site infection rates among obese women.
Improving Antibiotic Prophylaxis Prior to Cesarean Birth Carol Spruill, MSN, APRN, CPHQ, Children’s Memorial Hermann Hospital, Houston, TX
Objective o ensure that antibiotic prophylaxis will occur 100% of the time within the one-hour window prior to incision for women with scheduled cesarean births at Children’s Memorial Hermann Hospital Women’s Services by July 30, 2014.
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Design A quality-improvement team of anesthesiologists, nurses, and pharmacists used qualityimprovement methods to understand the problem and develop a new process for antibiotic delivery.
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Sample Women with scheduled cesareans at Children’s Memorial Hermann Hospital Women’s Services comprised the sample. Methods Baseline data were collected to define the scope of the problem of antibiotics being delivered according to evidence-based guidelines. A fishbone diagram was developed to understand the potential causes of antibiotic delivery failure in 18% of patients from anesthesiologist and nursing staff
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perspectives. A waste walk was performed to identify inefficiencies. A map of the current process was created to detect potential stages at which interventions might improve the ability to give antibiotics on time. A spaghetti map was drawn after a nurse wearing a pedometer walked to all areas where nurses must travel to gather intravenous tubing and antibiotics to make a packet for anesthesia. A test of change in one pod was tested with positive results and then the new process was implemented in the entire unit. Postimplementation data were collected. Implementation Strategies Anesthesia, medicine, and nursing leaders approved the project. The new process was taught to all nurses and anesthesiologists with the goal to reduce surgical site infections by delivering antibiotics within one hour prior to incision. Specific resources and supplies needed for the process to work smoothly and efficiently were also implemented. Pyxix MedStations were purchased
for operating rooms (ORs). The pharmacy supplied antibiotics and altered practice to support the new process. Information systems collaborated on the implementation of Power Chart Maternity Care4 (PCM), a new electronic charting method, to reduce the incidence of charting in different software and to support the convenience of charting medications in the ORs for the anesthesiologists. Results The goal of 100% compliance was not met, although at 99%, the goal is within reach. The new process is in place and Power Chart Maternity has been implemented.
Kendra Folh, BSN, RN, Children’s Memorial Hermann Hospital, Houston, TX Keywords cesarean antibiotic prophylaxis surgical site infection
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice A control plan to maintain gains will need to be in place. Implications for nursing practice include the elimination of time wasted in finding tubing and antibiotics and the ability of the nursing staff to focus on laboring women without leaving the bedside.
Meeting the 30-Minute Decision to Incision Rule in the Community Hospital Objective o develop a multidisciplinary process whereby St. Joseph Hospital can consistently meet or exceed the 30-minute time frame from the decision to perform an unscheduled emergency cesarean to the time the surgical incision is made.
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Design A retrospective audit of unscheduled cesareans from January 2012 through May 2013 was used to identify 118 cases. The reasons for the cesareans were reviewed and the most emergent cases were identified: nonreassuring fetal heart rate tracing and maternal complications. Sample A total of 23 cases met these criteria and were reviewed for decision to incision time and time of day performed. Response time ranged from 49 to 170 minutes from 7 am to 3 pm, 53 to 66 minutes from 3 pm to 11 pm, and 51 to 82 minutes from 11 pm to 7 am with an overall mean response time of 80.8 minutes. Methods Quality improvement, plan, do, study, act (PDSA).
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Implementation Strategies A multidisciplinary team comprised of nursing and medical leaders from maternal child health, anesthesia, the operating room, and representatives from ancillary support departments convened to identify processes currently in place and ways to improve workflow efficiencies to reduce the response times with the goal of meeting or exceeding the 30-minute decision to incision time for unscheduled emergency cesareans. The team implemented a structured response for all cesareans so in instances of true emergencies, the staff would be well drilled. Results Heightened awareness reduced mean response time to 61.5 minutes by October 2013. A structured response team Code OBERT (Obstetrical Emergency Response Team) was implemented in November 2013, and by February 2014 mean response time was reduced to 40.4 minutes.
Jennifer Pedley, BSN, MS, RNC-OB, St. Joseph Hospital, Nashua, NH Nora C. Fortin, BSN, RNC-OB, St. Joseph Hospital, Nashua, NH Keywords cesarean decision to incision response time
Childbearing Poster Presentation
Conclusion/Implications for Nursing Practice Significant progress has been made in meeting or exceeding the timeframe, however, we continue to work toward consistency in all cases. Nurses in community hospitals with limited resources can still navigate the complexities of obstetric care.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
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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
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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%.
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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.
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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
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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.
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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-
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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
von Kohler, C. et al.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Using Best Evidence to Reduce the Rate of Surgical Site Infection Lynda A. Tyer-Viola, PhD, RNC, FAAN, Texas Children’s Hospital, Houston, TX Frances C. Kelly, MSN, RNC-OB, NEA-BC, CPHQ, Texas Children’s Hospital, Pavilion for Women, Houston, TX Keywords surgical site infection cesarean quality improvement nursing practice
Childbearing Poster Presentation
Objective o create a surgical site infection prevention bundle by examining population characteristics, context of care, and prioritization of evidencebased interventions.
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Design Quality improvement plan-do-study-act (PDSA) methodology with a small-scale iterative approach to three cycles of improvement was used to create a surgical site infection (SSI) prevention bundle. Sample All women with cesarean births in scheduled day surgery operating suites and labor room operating suites at an academic medical center with 5500 births annually. Methods Care improvement process consisting of a common cause analysis of our readmission cases to determine the characteristics of our population. Next, we examined the literature on SSI prevention and treatment related to these characteristics. Three areas with significant variation from evidence-based practice were identified: antibiotic prophylaxis, skin preparation, and education. Implementation Strategies To plan cycle one, we assessed antibiotic stewardship of participants. Overall 32% of participants and 31% of readmission participants did not adhere to guidelines To act, a forcing function in our
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order sets yielded a 100% compliance rate, and none of the participants in the test of change cycle (N = 20) was readmitted. In the second cycle, we assessed skin preparation and found significant variation in processes. After education and implementation of new interventions, we found 100% compliance. The last cycle focused on patient education. To plan, we called 20 participants to assess their knowledge, what they were taught, and their current wound status. We found that we were teaching patients the signs and symptoms of infection but not prevention. Participants reported variation in care, limited education on wound care, and no education on hand hygiene; 20% reported wound deviation. Interventions applied included focused nursing education on wound care and hand hygiene when caring for infants, including a care package with materials to support the education at home. Reassessment revealed increased knowledge and wound care and no reports of wound deviations. Results SSI rates decreased during 10 months from 2.41% to 0.61% to zero. Days between SSI readmissions increased from 2 days to 68 days at present. Conclusion/Implications for Nursing Practice Developing a context and population focused evidence-based prioritized care bundle can result in improved patient outcomes. Nursing interventions based on knowing the patient can yield sustainable results.
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EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Nurses Improving the Health of Mothers and Infants by Dancing the 10 Steps to Successful Breastfeeding Newborn Care
Marianne Allen, MN, RNC-OB, CNS, Pinnacle Health System, Harrisburg, PA
Objective o implement practices that promote optimal infant feeding for all mothers and infants at our organization. Our organization had implemented some components of the Ten Steps to Successful Breastfeeding, but the breastfeeding initiation rate was 62% and the formula supplementation rate was 70%.
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Design The following guidelines were followed: The BabyFriendly Hospital Initiative Guidelines and EvaluaDeborah J. Schafer, MSN, tion Criteria for Facilities Seeking Baby-Friendly RNC-OB, Pinnacle Health Designation, AWHONN’s Breastfeeding Support System, Harrisburg, PA through First Two Years Evidence-Based Practice Keywords Guideline, and AWHONN’s Assessment and Care breastfeeding evidence-based practice change of the Late Preterm Infant Evidence-Based Practice Guideline. education
Poster Presentation
Sample Pregnant women, postpartum mothers and their infants, health care providers, and the health care organization. Methods Participation in 89-hospital national quality improvement initiative to help improve maternity care and increase the number of Baby Friendly designated hospitals. An interdisciplinary team collaborated to move the organization through the discovery, development, dissemination, and designation phases for a 2-year process improvement. Implementation Strategies Implementation strategies included assessment of current practice, identification of barriers and opportunities, and strategies to support significant changes that encompass the continuum of care; development and implementation of a staff
teaching plan of knowledge and practical skills necessary to implement practices that support the Ten Steps to Successful Breastfeeding; review of materials across the organization and private practices; development of patient education materials and a comprehensive teaching plan; monthly quantitative and qualitative audits; rapid cycle testing; collaboration and communication with stakeholders at all levels of organization; and community partnerships. Integral to the success of the quality initiative were weekly interdisciplinary team meetings, presentations at obstetrics and pediatric department meetings, role development of breastfeeding champions, incremental phasein of practice changes, education roll-outs and celebrations, and monthly tracking of our progress in meeting the Ten Steps with communication to staff, physicians, and administration. Results Results included heightened professional environment of competence, enhanced delivery of patient centered care, improved health of mothers and infants, increased patient satisfaction, and achievement of regulatory compliance benchmarks. The implementation of the Ten Steps to Successful Breastfeeding resulted in improved rates of breastfeeding as well as reduced ethnic, racial, and socioeconomic disparities related to infant feeding. Conclusion/Implications for Nursing Practice This presentation demonstrates the effect of a nurse-led, quality initiative that improved the continuum of care for mothers and infants from the prenatal period, to delivery, and through postdischarge community care. The steps to implementation can be a model for other organizations that want to improve the quality of health care to support optimum infant feeding.
Use of Dextrose Gel Reverses Neonatal Hypoglycemia and Decreases Admissions to the NICU Catherine Bennett, APN, CNS, Advocate Lutheran General Hospital, Park Ridge, IL
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Objective o reduce newborn admission to the neonatal intensive care unit (NICU) for the diagnosis of neonatal hypoglycemia by using 40% dextrose gel rather than intravenous (IV) dextrose.
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Design A retrospective chart review of more than 700 charts from 2013 was performed prior to implementation, and approximately 60 charts per month were reviewed postimplementation.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
http://jognn.awhonn.org
Bennett, C., Headtke, E., and Rowe-Telow, M.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Elyse Headtke, MSN, Northwestern Memorial Hospital, Palos Hills, IL Meg Rowe-Telow, BS, RNC, Advocate Lutheran General Hospital, Park Ridge, IL Keywords neonatal hypoglycemia 40% dextrose gel NICU admission rates
Newborn Care Poster Presentation
Sample The sample included infants at risk for neonatal hypoglycemia born at a tertiary teaching institution. Inclusion criteria were 35 0/7- to 42 0/7-weeks gestation with one of the following conditions: small for gestational age, large for gestational age, an infant of a diabetic mother, late preterm infant, or an Apgar score of <7 at 5 minutes. Methods A protocol was developed for the treatment of infants at risk for hypoglycemia. Newborns were fed within the first hour of life. A bedside blood glucose (BG) level was obtained 30 minutes after the feeding was completed. If the BG was < 35, the registered nurse (RN) administered dextrose gel per syringe to the buccal cavity of the infant and placed the infant with the mother to feed. A BG level was then repeated after one hour. If the BG level was < 35 a second dose of the gel was administered. If hypoglycemia was not reversed following the second dose, the physician was contacted for further orders. Implementation Strategies After review of a randomized controlled study our multidisciplinary newborn advisory committee
(NAC) added glucose gel to the neonatal hypoglycemia protocol. The NAC collaborated with the pharmacy to establish weight base dosing of dextrose gel. Mandatory educational sessions were provided to all RNs that focused on the rationale for change, use of the new algorithm, and the technique to administer the gel. Once all was in place a go live date was set of May 15. Data collection began in June 2014. Results Following the implementation of the protocol, admission to the NICU for the diagnosis of neonatal hypoglycemia decreased from a mean of 11% to 2%. Conclusion/Implications for Nursing Practice The utilization of dextrose gel along with oral feeding resulted in a decrease in the incidence of neonatal hypoglycemia with a corresponding decrease in the admission rates to the NICU for the primary diagnosis of neonatal hypoglycemia. This inexpensive, noninvasive intervention can be adopted by other institutions to decrease NICU admissions for the primary diagnosis of neonatal hypoglycemia.
Incorporating Evidence-Based Practice for Skin-to-Skin Care in the Operating Room to Increase in-Hospital Exclusive Breastfeeding Rates Melaney L. Stricklin, BSN, Objective RN-C, CCE, UC Davis Medical o initiate skin-to-skin contact in the operating Center, Sacramento, CA
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Kandice L. Duns, BSN, RN, CLE, UC Davis Medical Center, Sacramento, CA Keywords skin-to-skin cesarean breastfeeding
Newborn Care Poster Presentation
room after cesarean birth.
Design Nurse- led quality improvement project based on the define, measure, analyze, improve and control (DMAIC) model.
Sample UC Davis Medical Center has a cesarean rate of 30% and this rate was targeted for change. Prior to project implementation, skin-to-skin care was initiated in the postanesthesia care unit (PACU) sometimes an hour or more following birth. Our proposal was to initiate skin-to-skin care in the operating room. Initially low-risk women with scheduled cesareans at greater than 39 weeks gestation were included, but the practice was expanded to include mothers of stable neonates who were at least 37-weeks gestational age. Mothers with gestational diabetes were included.
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Methods A retrospective chart review was performed to evaluate the rates of in-hospital exclusive breastfeeding for neonates born via cesarean. Implementation Strategies Staff education was provided to address concerns and elicit support from key stakeholders. Mothers identified as candidates were provided with education about the benefits of skin-to-skin care, and consent was obtained. After an initial assessment by the NICU team at fewer than 10 minutes, the diapered neonate was placed directly on the bare chest of the mother in a transverse position. The neonate remained skin-to-skin until skin closure or request of cessation by mother. Limiting factors included unstable neonates, instability of mother, and mother’s lack of interest in doing skin-to-skin contact. Results A baseline was established with a sample size of 33 neonates; 33% were exclusively breastfeeding at discharge. Subsequent chart reviews at 12 months (n = 33) and 18 months (n = 26) after
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EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
implementation showed an increase in exclusive breastfeeding rates at discharge to 53% and 69% respectively.
terdisciplinary collaborative model, the practice of skin-to-skin care in the operating room can be achieved and help to improve exclusive breastfeeding rates.
Conclusion/Implications for Nursing Practice Improving the rates of exclusive breastfeeding has become a national health priority. Through an in-
Improvement in Rates of Preterm Infant Hypothermia by the Implementation of a Best Practice Bundle Objective o decrease the number of preterm infants with hypothermia on admission to the NICU by improving delivery room management.
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Design A best practice bundle was developed for preterm infants. This included the use of heated mattress pads for all infants 36-weeks gestational age or less and polyethylene bags for infants 28-weeks gestational age or fewer. Additionally, to prevent convective and conductive heat loss, preterm infants were not weighed in the delivery room, and operating room temperatures were set to 25 degrees C. Sample Data were collected for 300 preterm neonates admitted to the NICU between January 2013 and June 2014. Methods Using plan-do-check-act (PDCA) methodology, an interprofessional team reviewed the literature, developed and implemented an evidence-based protocol, and evaluated outcomes. Normal admission temperature was defined as 36.5 degrees C or greater within one hour of birth. Implementation Strategies All nursing and physician staff who attended births were educated on the significance of infant hypothermia and the bundle components. Following implementation of the bundle, outcomes were tracked and disseminated on a monthly basis.
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Outliers were analyzed and debriefs with the nurs- Donna S. Bowman, DNP, FNP-BC, RNC-OB, EFM-C, ing and physician staff were conducted. Results The retrospective baseline data included 45 infants: 10 (22%) had admission temperatures of 36.5 degrees C or greater. Postimplementation, there was a steady improvement in admission temperatures. By the third quarter of 2014, 68% of infants in had admission temperatures of 36.5 degrees C or greater. For the low-birth-weight infants tracked in the Vermont Oxford Network (VON) database, for the 3 years prior to the bundle implementation, we performed at 3.8%, 3.10%, and 14.3%. The year postimplementation, of 12 VLBW neonates, 75% met the standard for temperature on admission to NICU.
Stamford Hospital, Stamford, CT Kathy LiVolsi, MHA, BSN, RNC, Stamford Hospital, Stamford, CT Keywords infant hypothermia delivery room quality improvement
Newborn Care Poster Presentation
Conclusion/Implications for Nursing Practice Successful implementation of this project required a commitment from the obstetric and neonatal teams. Although it is clearly our responsibility to take admission temperatures and monitor various physiologic parameters in individual neonates, it is equally incumbent on the team to analyze aggregate data indicators to monitor overall performance. Data dissemination has been a crucial factor in maintaining awareness of this problem and providing the impetus for continued use of the bundle elements. In addition, conducting a case by case analysis of outliers is essential for ensuring that any gaps in performance are recognized and rectified by providing feedback to individual providers.
JOGNN, 44, S44-S55; 2015. DOI: 10.1111/1552-6909.12600
http://jognn.awhonn.org
Stagg, J. and Ustianov, J.
EVIDENCE-BASED Q UALITY IMPROVEMENT PROJECTS Proceedings of the 2015 AWHONN Convention
Improving and Sustaining Breastfeeding Practices through a Statewide Learning Collaborative Julie Stagg, MSN, RN, IBCLC, Objective RLC, Texas Department of he aim of the Texas Breastfeeding LearnState Health Services, Austin, ing Collaborative (TBLC) is to increase inTX
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Jennifer Ustianov, MS, RN, IBCLC, National Institute for Children’s Health Quality, Boston, MA Keywords breastfeeding Ten Steps learning collaborative quality improvement adaptability
Newborn Care Poster Presentation
hospital exclusive breastfeeding rates by 35% across three, sequential, regional, quality improvement, learning collaborative cohorts of as many as 81 birthing facilities.
Design Use of the Institute for Healthcare Improvement’s Breakthrough Series (BTS) and Model for Improvement (MFI) to facilitate uptake of the Ten Steps to Successful Breastfeeding (Ten Steps). Sample Cohorts A and B included 41 hospital improvement teams in two geographic regions cumulatively accounting for 99,000 births (26% of Texas births and 2.5% U.S. births) annually. Participating facilities included a diverse mix of urban/rural, large/midsized/small, and public, private, and academic center settings at varying stages of Ten Steps implementation. Methods The TBLC utilizes the BTS, MFI, and complementary support to facilitate implementation of the Ten Steps within participating facilities. Implementation Strategies Twenty hospital teams (Cohort A) were guided through a BTS Learning Collaborative with compo-
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nents including data collection, self-assessment surveys, discussion forums, support calls, leadership events, face-to-face learning sessions (LS), and virtual action periods (AP) calls. Components work to accelerate plan-do-study-act cycles for improvement and to facilitate sharing of best practices among teams. Learning sessions included didactic lectures to communicate the evidence base of the Ten Steps and interactive workshops focused on sharing strategies to overcome common and special cause barriers. Teams were linked to breastfeeding support resources of the Department of Health and Human Services. Cohort B built upon Cohort A successes, and collective learning was spread to hospital teams through cross-cohort collaborative mentorship and continuous quality improvement within the project structure. Results Cohort A’s quality data indicated aggregate improvements from February 2013 to April 2014 for multiple outcome and process measures. Conclusion/Implications for Nursing Practice Multidisciplinary teams engaged in a quality improvement learning collaborative to accelerate adaptation of recommended maternity practices across diverse hospital settings to achieve improved process- and outcome measures. Improvement strategies and lessons learned are transferable to other projects and settings.
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