No Fanning: Decreasing the Incidence of Surgical Site Infection

I N N O VAT I V E P R O G R A M S

Schaar, G. L.

Proceedings of the 2012 AWHONN Convention

Nurses Facilitate Change in Medical Practice: Unmasking Postpartum Depression Purpose for the Program hen one considers that every year in the United States approximately six million pregnancies occur and up to 20% of women develop postpartum depression, the far-reaching implications of this devastating illness are significant. Despite the many negative consequences associated with postpartum depression, the results from multiple studies that have addressed the screening practices of nurse practitioners, obsteGina L. Schaar, DNP, RN, tricians, and family physicians suggest postparUniversity of Southern Indiana, tum depression screening is not routine practice. Evansville, IN The program’s purpose was to increase postparKeywords tum depression awareness and identification.

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postpartum depression Edinburgh Postnatal Depression Scale

Paper Presentation

Proposed Change In a metropolitan area, prior to starting the program, only one obstetrician in a private practice and two primary care facilities offered postpartum depression screening. The change involved implementing routine postpartum depression screening at the 4- to 6-week postpartum visit in outpatient obstetric practices. The screening instrument used was the Edinburgh Postnatal Depression Scale, a 10-item self-report scale. The training of the outpatient obstetric practices’ registered nurses and office staff also was completed. The educational training focus was comprehensive and emphasized the nurse’s role in patient education, screening, and Edinburgh Postnatal Depression Scale scoring. Participating obstetricians agreed to initiate routine postpartum depression screening for 3 months and logging only the

patients’ Edinburgh Postnatal Depression Scale score. The goal was that by agreeing to screen for 3 months, routine screening would be so woven into the fabric of postpartum care that the obstetric providers would formally adopt this screening strategy. Implementation, Outcomes, and Evaluation Twenty-two obstetricians (82%) implemented routine postpartum depression screening using the Edinburgh Postnatal Depression Scale for 3 months. The percentage of women screened in each practice ranged from 39% to 100%. Five of the nine obstetric practices screened 100% of their postpartum patients. The other four fell below the targeted 90%. Over a 7-month period, a total of 415 women were screened. Of the 415 women screened, 38 (9.2%) had Edinburgh Postnatal Depression Scale scores greater than 13, suggesting postpartum depression. The highest documented Edinburgh Postnatal Depression Scale score was 26 and the lowest was 0. Twenty-one of the 22 obstetricians returned an evaluation letter and 71.4% indicated they planned to continue using the Edinburgh Postnatal Depression Scale as part of their routine postpartum care. Implications for Nursing Practice Nurse leaders caring for mothers and newborns should passionately advocate for care that is evidence-based and patient-centered. This project can serve as a model in which nurses can facilitate replication regionally, statewide, and nationally.

Implementing a New Initiative to Reduce Surgical Site Infections in Cesarean Birth Patients Janice Gries, DNP, APN, RNC, Purpose for the Program St. Alexius Medical Center, he Centers for Disease Control and PrevenBarrington, IL

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tion reports that in 2007, 32% of all deliveries were cesarean births. Along with the growing obesity and diabetic epidemic, these women have an increased risk of developing a surgical site infection. The program aim was to reduce the surgical site infection rate by developing a program to identify high-risk patients and implement a standardized risk assessment, order set, and patient education tools.

Proposed Change Changes included the development of a highrisk assessment form, incorporating all of the best practices to reduce the surgical site infection, initiating a new order set for high-risk patients, and implementing an education process for all patients having cesarean births. A unique new order for high-risk patients included the use of nanocrystalline silver rope dressing on the cesarean incision. Implementation, Outcomes, and Evaluation Implementation involved forming a committee, performing a literature review, and subsequently

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

incorporating evidence-based practices to reduce the surgical site infections. Some of these evidence-based practices included strict adherence to chlorhexidine gluconate application and dry time, monitoring the temperature of the operating room and the patient, careful antibiotic timing, maintaining strict glucose control of the patient, and ensuring that lab orders were consistent with clinical parameters. The new forms and processes were created and the education of the implementation of the program involved all health care providers. Follow-up involved creating

a form, which needed to be reviewed and completed before discharge, to document interventions on each patient who had a cesarean birth. The committee met monthly to review and analyze program outcomes and incorporated necessary changes as needed. A year after implementation, the surgical site infection rate has consistently been reduced. Implications for Nursing Practice Program changes have decreased the current surgical site infection rate consistently.

Keywords surgical site cesarean infection silver rope dressing nanocrystalline SSI education order set for SSI

Childbearing Paper Presentation

Postpartum Depression: A Multidisciplinary Initiative for Staff Education and Patient Management Purpose for the Program he program goal was to identify patients at risk of postpartum depression and bridge the gap between inpatient and outpatient care at Albert Einstein Medical Center. Three objectives were established to meet this goal:

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Educate multidisciplinary care providers about postpartum depression and identify patients at risk. Develop a management plan to link inpatient and outpatient care. Use advanced technology to screen and identify patients who are at risk of developing postpartum depression and provide education and appropriate follow-up care after discharge.

Implementation, Outcomes, and Evaluation This nurse-driven program, grounded in Watson’s Theory of Human Caring, involved other disciplines throughout the process: obstetric, psychiatric, and pediatric/neonatal physicians; social services; outpatient office staff; and community referral services. The Edinburgh Postnatal Depression Scale, which is the Association of Women’s Health, Obstetric and Neonatal Nurses’-

recommended screening tool, patient management algorithms, and staff scripts for patient screening were used to facilitate implementation that was initiated simultaneously with a new electronic medical record system. The intelligent electronic medical record was used to alert the nurses to screen all patients for postpartum depression, to track the outcomes of the program, and to audit all charts. The clinical outcomes revealed staff compliance with screening all women for postpartum depression. The education outcomes demonstrated significant participation from the multidisciplinary and multispecialty providers in the nurse-driven education program, which led to significant improvements in the identification and management of postpartum depression. The program resulted in clinical practice changes across disciplines. Implications for Nursing Practice Screening for postpartum depression is predominantly a nursing function. Nurses need to take the lead in screening all women for postpartum depression and to work with multidisciplinary and multispecialty providers to standardize and integrate the inpatient and outpatient management of postpartum depression.

Vicki A. Lucas, RNC, BSN, MNEd, WHNP, PhD, PeriGen, Inc. and Vicki Lucas, LLC, Phoenix, MD Agnes B. Fuentes, MA, BSN, RNC, Albert Einstein Medical Center, Philadelphia, PA Jane Lodise, BS, RNC, Albert Einstein Medical Center, Philadelphia, PA Anneliese W. Gualtieri, BSN, RN, Albert Einstein Medical Center, Philadelphia, PA Keywords multidisciplinary program for postpartum depression

Childbearing Paper Presentation

Placenta Accreta: A New Take on an Old Problem Purpose for the Program o disseminate information about a multidisciplinary approach to the management of patients with placenta accreta and its variants: increta and percreta. This program will define accreta and its variants and also identify the incidence of accreta in the population. The development of preoperative and intraoperative checklists will be presented along with an in-depth educational plan.

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The use of erythropoietin and iron sucrose injec- Patricia A. Heale, DNP, RN, CNS, Texas Children’s tion also will be discussed. Hospital, Houston, TX

Proposed Change To develop a multidisciplinary team, including physicians from the following specialties: obstetrics and gynecology, maternal–fetal medicine, gynecologic oncology, interventional radiology, and urology. Nursing specialties include

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

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Sommerness, S. A., Gams, B. L., Hirt, C. and Rauk, P.

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Keywords placenta previa placenta accreta placenta increta placenta percreta preoperative checklist patient education cesarean hysterectomy

Childbearing Paper Presentation

outpatient nursing and inpatient nursing from the antepartum, labor and delivery, and postpartum units. Nursing experts, such as the clinical nurse specialist, were essential to the team’s success. Implementation, Outcomes, and Evaluation The first case was scheduled for March with a scheduled patient admission 1-week prior. However, the patient came in before her scheduled admission date because of vaginal bleeding. The bleeding was moderate at the time of admission but became heavy through the night. The team was notified and an emergency cesarean hysterectomy was performed. The patient received 10 units of packed red blood cells. This case, though emergent, went well for this complex patient because of the briefing and preemptive work done by the assembled team of multidisciplinary professionals. To date, five other cases have been scheduled and performed with the use of preoperative and intraoperative checklists, which were developed by nurses. In total, only four units of packed red blood cells have been used subsequently.

Each of these cases has been carefully recorded, including timing of events throughout the case. Each case is briefed to the team to discuss pertinent findings peculiar to the case. Debriefing allows the opportunity for the multidisciplinary team to evaluate and perform a thorough review of the case and discuss what went well and what might be improved. Implications for Nursing Practice Consistent nursing practice among all of the nursing specialties was crucial, especially regarding the education plan, which was developed and implemented for each patient by taking into account the individual patient’s and family’s needs. Preoperative and intraoperative checklists, which were developed by nurses for safety and quality and also validated by the multidisciplinary team, were used for each case. Nurses proved to be critical members of the multidisciplinary team by providing education and quality and safety measures before and during the scheduled case.

To Push or Not to Push: An Evidenced-Based Guideline Shown to Improve Maternal and Neonatal Outcomes Samantha A. Sommerness, Purpose for the Program DNP, RN, CNM, Fairview he goal of the project was to reduce the numSouthdale Hospital, Edina, MN

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ber of preventable birth injuries within a health

Becky L. Gams, RN, MS, CNP, care system in Minneapolis, Minnesota, while imUniversity of Minnesota proving the quality of care during the second Medical Center, Fairview, stage of labor. Minneapolis, MN Charles Hirt, MD, Paul Larson Clinic, Edina, MN Phillip Rauk, MD, University of Minnesota Medical Center, Fairview, Minneapolis, MN Keywords second stage active pushing phase delaying pushing episiotomies operative vaginal birth third- and fourth-degree lacerations cesareans

Childbearing Paper Presentation

Proposed Change The project team developed and implemented a standardized evidence-based guideline for the second stage of labor after a careful review of the literature. The guideline set the following parameters: the duration of time a patient may remain in the second stage of labor, strategies to mitigate labor progress issues, confirmation measures to ensure that mother and fetus are not in jeopardy, and a process of determining the intervention steps if jeopardy is identified. Implementation, Outcomes, and Evaluation The implementation of a Second Stage of Labor Guideline builds on the Zero Birth Injury Initiative. The goal of reducing birth injuries to zero include preventing neonatal intensive care unit admissions, third and fourth degree lacerations, operative vaginal births (forceps and vacuum use), potentially avoidable cesarean births, and maternal and infant mortality.

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This guideline was piloted at a 13-bed labor and delivery unit within a community hospital in the upper Midwest from April to July 2011. During this period, the delivery outcomes for 428 women were evaluated and compared with a baseline retrospective chart review of 403 deliveries. When the guideline was used, a woman was half as likely to have a vacuum-assisted birth (OR = 0.44, 95% CI [.24, .78], p = .006). Those for whom the guideline was used also had a significantly shorter active pushing duration than those for whom the guideline was not used (median = 25 minutes, range 0-185 vs. 35 minutes, range 2-18, p < .001). The total length of the second stage, 5-minute Apgar score, number of third and fourth degree lacerations, and cesarean births were similar. If a woman had a vacuum-assisted birth, she was almost twice as likely to have an episiotomy (OR = 1.7, 95% CI [1.1, 3.7], p = .01) and if she had an episiotomy she was 5.6 times more likely to experience a third-degree laceration (95% CI [2.8, 11.1], p < .001). Implications for Nursing Practice A guideline for the second stage of labor can be developed within any labor and delivery unit. We hope to show these benefits and discuss how this process can be implemented.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Cesarean Birth Safety Care Improvement: Preventing Adverse Outcomes Purpose for the Program: o share the current evidence and the best practice methods regarding the prevention of complications, such as infection and thromboembolism, to improve the outcomes of women having cesarean births.

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Proposed Change Beginning in 2007, changes were implemented in a large tertiary center to improve safety of cesarean births by implementing knee-high sequential compression devices and changing the timing of preoperative antibiotics for women having cesarean births. Subsequent to this, preoperative skin preparation with chlorhexidine gluconate was implemented for all cesarean births as well as an algorithm for the use of silver wound dressings for at risk populations (e.g., women who are morbidly obese, diabetic, and methicillin-resistant Staphylococcus aureus-positive). Implementation, Outcomes, and Evaluation As evidence emerges to improve the outcomes by preventing complications, a multidisciplinary group of nurses and physicians have sought to translate these practices to optimize care and outcomes for women having cesarean births. In 2007, order sets were updated in a large multihospital

system to ensure the use of mechanical thromboprophylaxis and optimal antibiotic timing for women having cesarean births. As a result, postoperative infections decreased 50% in 2008-2009, and there were no incidences of venous thrombosis postoperatively for patients who had cesarean births in 2009. Because the use of chlorhexidine gluconate preoperative skin preparation has become common practice in other areas of the hospital to decrease postoperative infection rates, this intervention also was implemented for obstetrics. An algorithm for at risk populations was created to change wound dressings to further reduce the possibility of infection. Data will be evaluated to determine the success of these additional measures to reduce postoperative cesarean infections.

Sandra Hoffman, MS, RN, CNS-BC, Abbott Northwestern Hospital, Minneapolis, MN Keywords cesarean infection thromboembolism surgical care improvement

Childbearing Poster Presentation

Implications for Nursing Practice Cesarean births have increased by 53% from 1996 to 2007, with approximately one third of births in the United States now delivered by cesarean. As with any major surgery, serious complications may result, such as infection and thromboembolism. Nurses are in a key position to improve patient safety by implementing prevention strategies aimed at reducing postoperative cesarean complications.

Addressing Maternal Death Prevention Through Nursing Education Purpose for the Program n January 2010, the Joint Commission issued a Sentinel Event Alert addressing maternal death prevention. The Centers for Disease Control and Prevention states that current trends indicate maternal mortality rates may be increasing. The latest published statistics from 2006 cite 13.3 maternal deaths per 100,000 live births, far from the Healthy People 2010 target of no more than 3.3 deaths per 100,000 live births. Near misses (defined as maternal complications severe enough to endanger a woman’s life) also have increased to approximately 34,000 per year. Analysis of negative outcomes calls for improvement in patient safety. Education utilizing evidence-based practice can be a key in providing quality patient care.

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Proposed Change Recognizing the impact and great personal loss, The Memorial Hermann Healthcare System took the initiative in addressing maternal death prevention through an aggressive educational program. The initial goal was to develop evidence-based guidelines for nurses to follow when they identified changes in their patient’s condition and to improve communication between the health care team. Implementation, Outcomes, and Evaluation A team of perinatal educators developed core content related to three leading causes of maternal death: postpartum hemorrhage, hypertensive disorders, and venous thrombotic events. Pharmacology was covered within each section as it pertained to the disease and treatment.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

Linda Schoene, RNC, MSN, Memorial Hermann Southwest Hospital, Houston, TX Carole Kanusky, RN, MSN, CNS, Memorial Hermann Southwest Hospital, Houston, TX Keywords maternal death prevention perinatal education patient safety

Childbearing Poster Presentation

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I N N O VAT I V E P R O G R A M S

Dudas, L. and Pedaline, S. H.

Proceedings of the 2012 AWHONN Convention

After collaboration with obstetricians, the content was offered as a systemwide mandatory class presented by hospital perinatal educators. During May and June 2011, approximately 350 nurses from the labor and delivery and postpartum departments from four hospitals attended with a 95% compliance rate. The remaining hospitals in the system are currently implementing the program. Evaluations were overwhelmingly positive with many nurses expressing satisfaction with the content, guidelines, case studies, and use of Situation-Background-AssessmentRecommendation (SBAR) for communicating with physicians. Originally, it was thought the core content could be taught as three separate 1hour offerings but the vast majority of hospitals chose to do one 3-hour session. This de-

cision actually facilitated scheduling the classes and tracking attendees. Nursing contact hours were provided. Registration and completion of the course was entered on a system web site. Implications for Nursing Practice With education comes empowerment, and with evidence-based guidelines to support their assessment nurses can respond quickly to changes in their patient’s condition. SBAR promotes clear communication between the nurse and the physician. As a result of this first educational program, physicians and nurses will soon be required to take additional self-study modules aimed at reducing negative maternal outcomes and improving patient safety.

Stop the Bleeding: A Postpartum Hemorrhage Protocol Linda Dudas, RNC, MSN, Purpose for the Program CNL, Magee-Womens Hospital woman dies somewhere in the world every of University of Pittsburgh 4 minutes from postpartum hemorrhage. SeMedical Center, Pittsburgh, PA

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vere bleeding is the number one cause of maternal Susan H. Pedaline, RNC, DNP, death and it is estimated that 75% of those deaths MS, BSN, Magee-Womens are preventable. Statistics have shown a signifiHospital of University of cant increase in the national incidence of postparPittsburgh Medical Center, tum hemorrhage over the past 5 years. A multidisPittsburgh, PA ciplinary task force was established to review the Keywords literature and develop and implement a protocol postpartum hemorrhage to decrease the incidence of postpartum hemorpostpartum hemorrhage risk rhage in a large, university hospital birth center. factors The key focus of the protocol is recognition of risk postpartum hemorrhage factors, anticipation, and mobilization of personinterventions nel.

Childbearing Poster Presentation

Proposed Change Postpartum hemorrhage by traditional definition is a blood loss greater than 500 ml following a vaginal birth or greater than 1,000 ml following a cesarean birth. A protocol was developed that defines postpartum hemorrhage as any blood loss that causes a life-threatening physiological change (e.g., change in vital signs or loss of consciousness). The protocol identifies prenatal assessment and planning, admission hemorrhage risk factor evaluation, ongoing risk assessment, and four stages of hemorrhage (based on estimated blood loss, vital sign stability, need for blood products, and surgical intervention). Implementation, Outcomes, and Evaluation A multidisciplinary team consisting of nursing, physicians, pharmacy, anesthesia, quality, and blood bank/lab personnel was established to pro-

JOGNN 2012; Vol. 41, Supplement 1

pose a protocol to improve the assessment and management of postpartum hemorrhage. Hospital staff were educated so that protocol implementation would be standardized no matter where the patient was located in the hospital. The overall outcome was to decrease the incidence of the rate of postpartum hemorrhage. To implement the protocol, the following were created: a postpartum hemorrhage kit in the automated medication cabinets, laminated algorithms for patient care units in table form and flow chart form, computerized physician order set for postpartum hemorrhage, photograph examples for the estimation of blood loss, and four separate staff education presentations on patient care units were posted and sent via e-mail. Since initiation of the project, a decrease in the incidence of the rate of postpartum hemorrhage, within 24 hours of delivery, has been demonstrated through cumulative statistics based on diagnosis coding. Statistics reveal a 5% rate of postpartum hemorrhage since the implementation of the project (down from 6% in June 2009). Implications for Nursing Practice The implementation of the protocol has helped staff to recognize the importance of assessing each patient for the risk of postpartum hemorrhage and the need to maintain current blood work. In addition, the protocol has given all members of the health care team tools for recognizing the need for and implementing timely and well-coordinated interventions when faced with this life-threatening and increasingly common complication.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Improving Labor Support for Patients in an Urban, Academic Medical Center: An Evidence-Based Practice Project Purpose for the Program o improve the labor support provided for women in active labor by nurses in an urban, academic medical center.

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Proposed Change All registered nurses who work in labor and delivery will participate in a 4-hour workshop about labor support techniques. This workshop will provide every nurse with a similar skill set and should increase nurse confidence with the use of these various techniques in clinical practice. Implementation, Outcomes, and Evaluation In 2010, the labor and delivery senior clinical nurse staff recognized inconsistent practice among nurses in the provision of labor support. A committee of five registered nurses, four labor and delivery nurses, and one international board certified lactation consultant conducted an extensive literature review about continuous labor support and recognized a potential gap between current practice and best practice. To quantify this gap, the committee developed two surveys, one for the nurses and one for the patients. The nurse survey assessed the nurses’ attitudes about current labor support practices. The patient survey targeted labor and delivery patients and sought to identify specific support practices that patients expected during labor. Survey results confirmed that there were gaps between patient expectations and nurses’ attitudes and behaviors.

Based on these results, the committee developed an interactive, 4-hour workshop for all labor and delivery nurses. The workshop reviewed the survey results, as well as the importance of providing continuous labor support. The history of childbirth education also was reviewed, which provided context for the physiological and psychological mechanisms of pain and pain mitigation during childbirth. The majority of the workshop was spent conducting interactive simulations of breathing techniques, birth bag tools, hydrotherapy, Reiki, intermittent fetal monitoring, comfort measures for patients with an occiput posterior fetus, comfort measures for patients with an epidural, and an update about breastfeeding initiation within the first hour postpartum. To date, five workshops have been offered, 88% of the nursing staff has participated, and evaluations have been positive. Staff currently uses information learned in this workshop to improve practice and improve the patient experience. The committee is now conducting a follow-up survey with nurses to determine the perceived effectiveness of the workshop.

Suzanne Margaret Alton, BSN, RNC-OB, University of Maryland Medical Center, Baltimore, MD Jennifer L. MacHamer, BA, BSN, RN, CCE, University of Maryland Medical Center, Baltimore, MD Christine Kirk Shippen, MS, RNC-OB, IBCLC, RLC, University of Maryland Medical Center and University of Maryland School of Nursing, Baltimore, MD Maria Nicole Mayzel, MPIA, BSN, RN, SNM, University of Maryland Medical Center, Baltimore, MD Deborah M. Grau, MS, RNC-OB, University of Maryland Medical Center and University of Maryland School of Nursing, Baltimore, MD

Keywords labor support techniques Implications for Nursing Practice birth bag tools In an urban, academic medical center, there are comfort measures barriers to providing quality labor support. All la- hydrotherapy bor and delivery nurses, however, including the breastfeeding

novice nurse and the most expert senior nurse, must be educated about evidence-based labor support techniques and empowered to incorporate these techniques into clinical practice.

Childbearing Poster Presentation

Fall Risk Prevention in Postpartum Patients Purpose for the Program alls are recognized as an important patient safety issue for hospitalized patients of all ages. Obstetric patients, many of whom receive epidural analgesia, can be at high risk of falls. A literature search yielded limited research that addressed falls taken by obstetric patients. The search found Dionne’s EGRESS Test, which was developed to address falls taken by bariatric patients, and a postepidural fall risk assessment score to address falls of obstetric patients after receiving epidural analgesia. Neither tool had been validated for use within the obstetric community.

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A review of our institutional records showed that 42 postpartum patients fell from 2004 to 2010. Primary reasons for the falls included the follow-

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ing: 57% were due to weak legs, 19% were due to fainting/dizziness, 10% were due to slipping or tripping, and 14% were due to unknown causes. Of the reported falls, 64% were due to patients trying to get to the bathroom, with and without assistance. To date, there has not been a standardized tool used to assess a postpartum patient’s ability to ambulate. Proposed Change Our institutional fall risk assessment protocol does not adequately assess the postpartum patient. Using Dionne’s EGRESS Test, this study will evaluate a postpartum patient’s ability to safely ambulate. Dionne’s EGRESS Test is a three-step process that evaluates a patient’s mobility to go from a sitting position to a standing one, march in place, and

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

Joanne Elaine Auger, MSN, RNC, Hartford Hospital, Hartford, CT Deborah A. Gingras, MS, RN, CNS, Hartford Hospital, Hartford, CT Keywords postpartum patients falls Dionne’s Egress Test (DET)

Childbearing Poster Presentation

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I N N O VAT I V E P R O G R A M S

Schneiderman, E.

Proceedings of the 2012 AWHONN Convention

step forward and back. Patients must successfully complete all three steps to ambulate independently. Implementation of the Dionne’s EGRESS Test began July 5, 2011.

will take place over a 24-month period. It is hypothesized that postpartum patients that have undergone the Dionne’s EGRESS Test will experience a clinically significant reduction in falls.

Implementation, Outcomes, and Evaluation This study will utilize a retrospective design using data collected from all obstetric postpartum patients meeting criteria. All nurses caring for postpartum patients will be educated on how to perform the Dionne’s EGRESS Test. If the patient does not successfully pass the Dionne’s EGRESS Test, it will be repeated until successfully completed. Results of the Dionne’s EGRESS Test will be documented in the patient’s electronic chart. The study

Implications for Nursing Practice This study embodies the philosophy and core values of our institution. Positive results would significantly affect the safety of patients and have widespread application. The success of this study aligns with the National Patient Safety goal of reducing falls of patients. It promotes further nursing research, heightens nursing awareness of falls of postpartum patients, and improves the patient experience.

Epidural and Urinary Catheters: You Can Have One Without The Other Ellen Schneiderman, MS, RNC-OB, CNS-BC, Banner Desert Medical Center, Mesa, AZ Keywords indwelling urinary catheter labor epidural intermittent catheterization

Childbearing Poster Presentation

Purpose for the Program he purpose of this initiative is to reduce the use of indwelling urinary catheters as a routine intervention for patients in labor who have had an epidural. This has been a common practice throughout a major southwestern hospital system. However, there is no evidence that this process improves patient care. Studies indicate that a patient’s perception and satisfaction of labor are improved with less intervention. Likewise, there is no evidence to suggest that the use of an indwelling catheter will shorten labor. Therefore, the use of an indwelling urinary catheter should not be dependent upon a patient receiving an epidural during labor but rather upon her clinical need.

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Clinical indications for the necessity of a urinary catheter may include Category III fetal heart rate tracing or arrest of labor, where an operative or cesarean birth is likely to occur; closer monitoring of intake and output, as in a patient receiving magnesium sulfate; or obese patients where bladder assessment is unobtainable. The greatest risk for urinary tract infections is via indwelling urinary catheters. This practice change will align labor and delivery units with national initiatives to decrease catheter-acquired urinary tract infections. Proposed Change The proposed changes of this initiative are the following:

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To eliminate the use of indwelling catheters from labor order sets.

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Order an indwelling catheter for a patient in labor only when it is clinically appropriate. A patient should be encouraged to void prior to an epidural placement and subsequently every 2 to 4 hours. Nurses should assess the bladder and perform perinatal care every 2 hours for every patient in labor. If a patient is unable to void, proceed with straight catheterization, using sterile technique, and record volume.

Implementation, Outcomes, and Evaluation This initiative was instituted in April 2011 at one facility. The clinical nurse specialist provided evidence-based information to the nursing staff and physicians to support the proposed change. In the first 3 months, indwelling catheter use decreased from 66% to 25%. These data were presented to the system’s Clinical Consensus Group by the clinical nurse specialist and approved as an expected system practice. At the time of submission, the initiative was in the design phase of the project, with a projected roll-out date of October 2011. Implications for Nursing Practice Nurses will have the opportunity to improve patient care by assessing the evidence, considering patient preference, and using critical thinking skills to make sound clinical decisions. The clinical nurse specialist’s role as a facilitator of change also is illustrated through the advancement of evidencebased practice.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Journey to Zero Birth Injury: Improving Outcomes, Sustaining Gains Purpose for the Program dverse outcomes in perinatal settings are a relatively rare occurrence but may have devastating consequences. To mitigate adverse outcomes, key strategies generally include standardization of care, communication and teamwork, physician engagement on multidisciplinary teams, and metrics. Initiatives incorporating bundle science to standardize daily operations have been successful in reducing birth trauma.

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Proposed Change Key nursing and medical leadership proposed a system-wide multidisciplinary strategy to change the culture of safety by incorporating the Institute for Healthcare Improvement (IHI) perinatal bundles at all six hospitals in the health care system. Advanced practice nurse leaders directed the process of standardizing evidence-based practices related to induction and augmentation of labor and the use of the vacuum extractor, including order sets, policies, criteria for induction of labor, management of oxytocin, and patient education. A sustainable infrastructure set the teams on a trajectory for further initiatives, including the Management of Second Stage of Labor Guideline and the Management of Diabetes in Pregnancy and Postpartum Consensus Guideline. Implementation, Outcomes, and Evaluation Physician and nursing engagement is supported by leadership, which affirms the importance of

partnerships in dialogue and decision making, professional autonomy and accountability for improving outcomes, and commitment to continued learning. Data are collected monthly to measure process compliance with all three IHI perinatal bundles. Clinical outcomes are measured quarterly by the perinatal adverse outcome index. Overall, all six hospitals are experiencing an annual decrease in the adverse outcome index since the implementation of standardized practices in 2009. The Zero Birth Injury multidisciplinary team engages in transparency by sharing their experiences from in situ simulation training debriefs or adverse events. Data are shared with all disciplines and are posted on the hospital web site. Action plans to address upward trending, in particular adverse outcomes, are developed and implemented.

Samantha A. Sommerness, DNP, RN, CNM, Fairview Southdale Hospital, Edina, MN Becky Gams, RN, MS, CNP, University of Minnesota Medical Center, Fairview, Minneapolis, MN Keywords birth trauma birth injury perinatal bundle team building high reliability team in situ simulation perinatal safety multidisciplinary team

Childbearing Poster Presentation

Implications for Nursing Practice Birth injury, though infrequent, is traumatic for the family and the health care team. Nurses are often at the forefront of safety initiatives and are often the last defense to prevent harm to the patient. However, changing organizational culture to focus on patient safety is difficult without a multidisciplinary team approach. At any level, nurses incorporating evidence-based care, standardized communication, and teamwork concepts are integral to high reliability teams and reap the rewards of improved outcomes.

Entrance Into the World by EXIT (Ex Utero Intrapartum Treatment) Purpose for the Program o provide information on the Ex Utero Intrapartum Treatment (EXIT) procedure and develop standards of care to ensure that the multidisciplinary perioperative team provides excellent patient care during the EXIT procedure by using the TEAM approach:

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T-Multidisciplinary team using the latest technology. E-Evidence-based practice. A-Utilization of Association of Perioperative Registered Nurses standards. M-Highest quality of care for mother and infant.

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Proposed Change Because the EXIT procedure was a new procedure, a plan of care had to be created. Each procedure has a unique set of patient-specific, clinical needs. The role of each multidisciplinary member needed to be defined. Perioperative nurses collaborated with members of the multidisciplinary team to define the role of each member. This included staff nurses from the departments of labor and delivery, surgery, and neonatal intensive care unit (NICU). There was also a need to develop clinical guidelines and protocols and to educate the staff. Preprocedure briefing and postprocedure briefing were planned.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

Kristy Simmons, RN, BSN, Woman’s Hospital, Baton Rouge, LA Cynthia Thomas, RN, BSN, CNOR, Woman’s Hospital, Baton Rouge, LA

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Conrad, C.

Proceedings of the 2012 AWHONN Convention

Keywords EXIT algorithm of care multidisciplinary team members EXIT checklist

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Implementation, Outcomes, and Evaluation r A preprocedure briefing was held 1 to 2 hours prior to the start of the procedure. r All the representatives from each discipline were in attendance. r A perioperative EXIT supply checklist was developed by the team for ensuring that all the necessary supplies were available at the time of the procedure. r All members of the EXIT team were briefed and educated on the preprocedure checklist and how it is utilized. Furthermore, the members were informed that scrutiny of this checklist will be ongoing. All the equipment was readily available for use during the actual procedure. Through the process of team building and education, the perioperative

team members had an increased understanding of other team members’ roles. A postprocedure debriefing was held to review the supplies used and add additional information as needed for future cases. Implications for Nursing Practice Each EXIT procedure performed provides the opportunity to improve patient care and provide new information to our colleagues regarding our increased knowledge in this unique area. The algorithm of care established was hysterectomy, fetal airway assessment, direct laryngoscope, airway suctioning, view of vocal cords, rigid or flexible bronchoscope, intubation or tracheostomy, application of pulse oximeter, and fetal heart monitor or electrocardiogram.

Supporting the Survivor: Creating an Evidence-Based Program That Helps Survivors of Sexual Abuse Plan for Labor and Birth Christine Conrad, BSN, RNC-OB, Mission Hospital, Asheville, NC Keywords childhood sexual abuse birth survivor services program birth plan

Childbearing Poster Presentation

Purpose for the Program he Survivor Services program is designed to facilitate a positive birth experience for survivors of childhood sexual abuse. These survivors are at increased risk of a traumatic birth experience, which has been documented to increase the risk of postpartum depression and posttraumatic stress disorder in new mothers. Women who experience postpartum depression and posttraumatic stress disorder have an increased risk of costly postpartum care, hospital readmissions, and increased rates of perpetrating child abuse and neglect. They also may avoid or delay medical care for themselves and their children. Prenatal counseling and planning for labor can have a positive impact on how women perceive childbirth.

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Proposed Change To create a nursing intervention with the goal of helping to facilitate a positive birth experience for this population. Participants come to the unit during their pregnancies and receive a tour, verbal education about labor and birth, and a written resource list. The participant fills out a brief intake form that asks about her fears/concerns about childbirth and her typical ways of coping with stress. Common posttraumatic stress disorder triggers are reviewed and coping strategies are discussed. The resource nurse creates a nurs-

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ing care plan that addresses each woman’s specific concerns and outlines planned strategies. The plan is reviewed/revised by the patient and distributed to her provider and her labor nurse. Implementation, Outcomes, and Evaluation Current literature was reviewed and a need identified. A proposal that included the risks for this population, the desired outcomes, and projected costs of the program was presented to leadership. It was agreed that the opportunity for increased quality and patient satisfaction justified the need for this program. Education in the region about this high-risk population was facilitated by securing a grant to fund a regional conference with nationally recognized experts in the field. Focus then shifted to educating individual providers about the program. A dedicated phone line and an intake and interview process were established. Patient, physician, and nurse feedback about the intervention have been very positive. Still in process is a quantitative and qualitative evaluation system to track outcomes and a formal education program for the resource nurses. Implications for Nursing Practice This program is an example of how nurses can implement an evidence-based program for a highrisk population with the potential to improve patient satisfaction.

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Food Matters: A Quality Improvement Initiative on Healthy Foods in Pregnancy for a Clinic Population Purpose for the Program linic populations often face multiple barriers to the acquisition of healthy, affordable foods during pregnancy. These barriers include lack of knowledge about optimal nutrition as well as access to whole foods. Clinic nurses are challenged to teach health information in short periods of time during the clients’ visits to the clinic.

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Proposed Change Provide nurses with tools that allow them to teach effectively in short periods of time and provide clients with easy to use, understandable resources about healthy, affordable foods to consume during pregnancy. Implementation, Outcomes, and Evaluation Nurses were provided with Food Matters calendars to review and utilize as teaching tools in the clinic setting. Nurses were asked to perform a short pretest at the initial obstetric visit. In the initial visit, nurses reviewed the calendar and used it as a tool to begin the discussion about healthy, affordable foods to consume during pregnancy.

In the month of July 2011, this program was implemented and 105 calendars were provided to newly pregnant patients. Nurses performed a short pretest with each client. Questions were asked to assess the clients’ evaluation of their diet, desire to improve diet, and intention to utilize the foods calendar to improve diet. Post tests will be performed at the next monthly appointment and will assess any improvements in diet, especially those directly related to calendar usage. This program will continue until 400 calendars are distributed and post tests are complete. Nurses will be surveyed to assess comfort level and ease of use with the calendars. This initiative will be evaluated from the caregivers’ and the clients’ point of view. Implications for Nursing Practice Nurses who work with childbearing families, particularly in clinic settings, need effective and efficient teaching tools. The Food Matters calendar could serve as a prototype for nurses who are searching for tested tools to utilize in multiple settings.

Judith Focareta, RN, BA, MEd, LCCE, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA Margaret Brady, RN, BSN, MSN, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA Keywords clinic healthy affordable nutrition

Childbearing Poster Presentation

Implementation of the 5As Prenatal Smoking Cessation Education Program Among Rural Women Purpose for the Program he aim of the program is for midwives caring for pregnant women in three counties in West Virginia to implement and evaluate the 5As smoking cessation program to promote smoking reduction and cessation and, thereby, decrease fetal exposure to smoking.

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Proposed Change Midwives in three West Virginia counties attended the American College of Obstetricians and Gynecologists’ 5As training program to learn to incorporate the recommendations into their care of pregnant smokers. Midwives were provided education and referral information to present to their clients and were encouraged to give messages regarding smoking reduction and cessation at each prenatal visit. Telephone follow-up and support calls to pregnant women between prenatal visits help provide pregnant women with encouragement and resources to further promote smoking reduction and cessation.

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Implementation, Outcomes, and Evaluation Evaluation methods will include assessing changes in the midwives’ knowledge of the 5As program and changes in the pregnant women’s reported smoking behaviors, including use of smoking cessation resources, changes in behavior as evidenced by a decrease in prenatal smoking doses (reported number of cigarettes smoked), and a decrease in smoking rates compared with baseline levels.

Implications for Nursing Practice Nurses and nurse–midwives play a crucial role in health promotion for their pregnant clients because they care for them on a frequent and regular schedule. Women are highly motivated to engage in healthy lifestyle changes during pregnancy. Nurses should capitalize on this motivational period by using the 5As evidence-based program for guiding and supporting women in reducing fetal exposure to smoking.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

Adrienne Duckworth, BSN, student, West Virginia University, Morgantown, WV Ilana R. Azulay Chertok, PhD, RN, IBCLC, West Virginia University, Morgantown, WV Keywords prenatal smoking cessation

Childbearing Poster Presentation

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I N N O VAT I V E P R O G R A M S

Swift, C., Scott K. L. and Harvey, D.

Proceedings of the 2012 AWHONN Convention

Implementing New Guidelines: How to Make It Happen Successfully Cheryl Swift, BS, RNC, MSN, Purpose for the Program Christiana Care Health System, nductions are the reality of labor and delivery Newark, DE

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units across the country. Concerns over the cur-

rent induction process, available resources, and Katherine L. Scott, BSN, RN, Christiana Care Health System, the communication of patients, physicians, and Newark, DE nurses within a busy labor and delivery unit provided an opportunity to formulate ideas to improve Deborah Harvey, RNC, Christiana Care Health System, safety, quality, and efficiency with patient care. Boothwyn, PA One identified goal was to minimize day-to-day Keywords induction collaboration safety success

Childbearing Poster Presentation

volume fluctuations in scheduled procedures. Any multifaceted, complex issue requires the oversight and guidance of a special committee to evaluate problems, create solutions, and implement successful change. Proposed Change The labor and delivery room process improvement team, a selected collaborative group of obstetrician and anesthesia physicians, nurses, labor and delivery room management, and hospital operational excellence personnel began bimonthly meetings in November 2010. Identified concerns were compiled and prioritized. Potential solutions were discussed using evidenced-based criteria to formulate new induction guidelines. The proposed guidelines consisted of capping the number of daily scheduled inductions, unless a medical necessity occurred, and staggering patient arrival times between 1:00 and 7:30 a.m. Furthermore, the proposed guidelines offered weekend induction opportunities and promoted active labor management by ordering oxytocin initiation within 2 hours of patient admission or postcervical ripen-

ing. Significant proposed changes consisted of eliminating elective cervical ripening and extending post dates (a medical diagnosis for induction) from 40 1/7 weeks, currently used at our facility, to 41 weeks. The final key to successful initiation was the appointment of a gatekeeper, who was a unit-specific scheduler with clinical knowledge. Implementation, Outcomes, and Evaluation A 3-month pilot plan was designed with a “go live” date and established measurable goals. Prior to implementation, physicians and their office staff were educated on the impending changes. The nurses from the labor and delivery unit were informed via a slide presentation, staff meeting, and bulletin board display. Members from the labor and delivery room process improvement team were available resources during the start of the trial process. The team had frequent meetings to discuss and address procedural problems. Implications for Nursing Practice Preliminary data indicate patient volume is being spread more evenly throughout the week, with an increase in spontaneous labors and a decrease in the induction rate. Further data are being analyzed regarding an impact on scheduled and nonscheduled cesarean birth rates. Patient, physician, office staff, and nursing satisfaction are currently being assessed with positive feedback. Renewed commitment to delivering superior health care to women and newborns often requires change that can ignite passion to move forward on the path of continuous improvement.

Coping/Not Coping Algorithm Implementation of a Labor Pain Tool Martha Kathy Dwight, RNC-OB, BSN, Baylor University Medical Center, Dallas, TX Keywords Coping/Not Coping algorithm labor pain tool implementation evaluation

Childbearing Poster Presentation

Purpose for the Program t the 2007 Association of Women’s Health, Obstetrics, and Neonatal Nurses Convention, Brenda Gulliver, RN, Labor and Delivery, University Hospital University of Utah and Leissa Roberts, MS, CNM, Associate Professor, College of Nursing, University of Utah delivered a presentation entitled “Assessing Pain in Labor.” The presentation was an algorithm they developed for the evaluation of labor pain using the Coping/Not Coping clues and actions to help the patient cope with labor. Permission was obtained to bring this Coping/Not Coping algorithm (with the copyright infor-

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mation of the University of Utah Hospital and Clinics printed at the bottom of the algorithm) to Baylor Health Care System. A project was designed to implement this algorithm in the labor and delivery units of Baylor Health Care System. Proposed Change The need for an improved method to evaluate and chart labor pain was a driving force for bringing the Coping/Not Coping algorithm to the bedside at Baylor Health Care System. The proposed change was to enable nurses to evaluate labor pain in the Baylor Health Care System through evaluation

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

rather than assigning labor pain a number 0 to 10. Implementation, Outcomes, and Evaluation After obtaining permission to bring the tool to the Baylor Health Care System, the process of modifying the algorithm to Baylor Health Care System was started, including how the algorithm fits the Joint Commission standards for pain. It was agreed by all who reviewed the algorithm that a pilot needed to be designed in order for the nurses to evaluate the tool prior to the implementation. At the end of the pilot, many positive responses were obtained with no recommendations for change in the algorithm. The only suggested change was to place the charting information on the pain and contraction tabs of the computer charting system.

A booklet for patients also was written, which explained the terminology of the Coping/Not Coping algorithm to labor patients. Education of nurses in Baylor’s labor and delivery units was developed and the algorithm was implemented. The nurses have positively stated that the algorithm is an effective tool in the evaluation of labor pain through observation of behaviors.

Implications for Nursing Practice The use of the Coping/Not Coping algorithm gives the nurses of the labor and delivery units the tools to evaluate a patient’s labor pain through the evaluation of labor clues. It also gives the patient control over the perception of her labor pain by not assigning a number of 0 to 10.

39 is Fine: Ending Elective Deliveries Prior to 39 Weeks Purpose for the Program or more than 30 years, the American College of Obstetricians (ACOG), the American Academy of Pediatrics (AAP), and the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN) have recommended that elective deliveries prior to 39 weeks gestation without a medical indication be avoided. According to ACOG, one third of all infants are electively delivered in the United States contrary to the aforementioned recommendations. Research supports that performing deliveries prior to 39 weeks gestation without a medical indication leads to increased perinatal and neonatal morbidity. Furthermore, the AAP has published that elective induction of labor doubles the cesarean birth rate. The purpose of the 39 is Fine program is to decrease the number of elective deliveries performed before 39 weeks gestation at a community hospital in southern California.

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Proposed Change To decrease the overall number of elective deliveries prior to 39 weeks gestation by 20% (to make an achievable goal) from the current baseline rate of 39.6% (n = 19/48); however, the national benchmark is less than 5%. Implementation, Outcomes, and Evaluation An interdisciplinary taskforce composed of nurses and physicians worked in conjunction with a regional collaborative to achieve a community stan-

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dard. Goals and interventions were established using the ACOG and AWHONN recommendations. The hospital policies and procedures were updated and created to list elective deliveries less than 39 weeks gestation as a contraindication for delivery. The scheduling process was streamlined for inductions and cesarean births to incorporate a standard form that would require a reason for delivery if the patients were less than 39 weeks gestation, verification of gestational age, and informed consent. Physicians and staff were educated on the importance of the initiative and the implementation process. Data were abstracted using computerized software and were analyzed by a labor and delivery nurse for accuracy. Confidential results were provided to each physician to inform them of their data and progress. The results exceeded the original goal and demonstrated a dramatic decline in the number of elective deliveries from 14.2% (n = 32/143) in the first quarter after implementation to 24% (n = 19/123) in the second quarter. Future plans include implementation of a peer review process and a hard stop to prevent elective deliveries less than 39 weeks gestation.

Jacqueline B. Hiner, MSN/Ed, RNC-OB, Sharp Grossmont Hospital, La Mesa, CA Lisa Delong, RNC-OB, BSN, Sharp Grossmont Hospital, La Mesa, CA Lily Pisegna, BSN, MBA, Sharp Grossmont Hospital, La Mesa, CA Colleen Burks, RNC-OB, C-EFM, Sharp Grossmont Hospital, La Mesa, CA Sharon White, RNC-OB, MSN, Sharp Grossmont Hospital, La Mesa, CA Keywords elective deliveries 39 weeks process improvement

Childbearing Poster Presentation

Implications for Nursing Practice With the establishment of value-based medicine, nursing and physicians will need to collaborate to improve quality initiatives and patient outcomes. Nurses should educate their patients of the importance of waiting until completing 39 weeks gestation before giving birth.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

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I N N O VAT I V E P R O G R A M S

Andrews, B. and Petrosino, S. M.

Proceedings of the 2012 AWHONN Convention

No Fanning: Decreasing the Incidence of Surgical Site Infection Betsy Andrews, BSN, MEd, RNC-OB, C-EFM, Winchester Hospital, Winchester, MA Susan Marie Petrosino, MSN, RNC-OB, NE-BC, Winchester Hospital, Winchester, MA Keywords surgical site infection wound infection decreasing infection rates

Childbearing Poster Presentation

Purpose for the Program o increase knowledge and implement changes in clinical practice that reduces the incidence of preventable surgical site infections in our obstetric unit.

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from staff nurses, surgical technicians, nurse managers, the director of maternal child health, the chair of the department of obstetrics and gynecology, and the infection prevention specialists.

Proposed Change To reduce the incidence of preventable surgical site infections.

As a result of our efforts, we have seen a dramatic reduction in the number of preventable surgical site infections. The incidence of surgical site infections continues to be monitored and each case is reviewed by an interdisciplinary team of clinicians.

Implementation, Outcomes, and Evaluation Evidence-based resources were used to develop a program that focused on staff and patient education and specific changes in clinical practice. Our strategies for implementation included the use of several venues for education; techniques to ensure effective communications related to the practice changes; and the securing of support

Implications for Nursing Practice Prevention of infection is an important aspect of the care we provide for our surgical patients. Maintaining a low surgical site infection rate ensures a decrease in pain and discomfort, a reduced risk of long-term sequelae, and a lowered financial strain for the patient and her family.

Great Expectations: A Personalized Prenatal Nurse Visit Marianna Volodarskiy, RN, MSN, Kaiser Permanente, Woodland Hills, CA DiAne Cabanne, RN, Kaiser Permanente, Woodland Hills, CA Keywords prenatal nurse visit patient satisfaction Great Expectations birthing experience

Childbearing Poster Presentation

Purpose for the Program he Great Expectations prenatal visit strives to increase patient awareness and knowledge of the labor process and, thereby, decrease her anxiety level about the birthing process and postpartum period.

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Proposed Change To create a positive birthing experience for families through education regarding topics such as pain management, breastfeeding, time for skin-to-skin contact, family bonding, family-centered services, environmental awareness, and support staff. The goal of the prenatal visit is to increase the number of patients receiving prenatal information through an innovative and alternative method that individually addresses different adult learning needs. Implementation, Outcomes, and Evaluation To execute the goal, prenatal patients who were 32 weeks gestation and beyond were scheduled for a 1-hour visit with a perinatal nurse. The visit was an extraordinary platform for the education of patients, and they were given a personalized tour of the facility and the opportunity to have their questions and concerns addressed. The visit, which

JOGNN 2012; Vol. 41, Supplement 1

was scheduled through the obstetric clinic, became an integral part of the prenatal care and the input and support from providers was vital to the success of the program. Continuous evaluation of the program has illustrated that overall patient satisfaction has increased. Evaluation methods include the following: patient feedback during management rounds, patient survey scores, results from exclusive breastfeeding audits, discharge phone calls, and pain management scores. The success of the program is underscored when patients verbalize that they feel more knowledgeable and confident as a result of the education they received. Implications for Nursing Practice When nurses perform one-on-one education with patients, they advance nursing practice. The nurses are able to use their unique skills to implement an individualized and psychosocial assessment as well as recognize key education and knowledge gaps that may exist in patients. Additionally, by working together with providers, nurses become a key contributor to the multidisciplinary approach to care.

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

Making Kicks Count: Delaware’s Consumer and Provider Education Tool to Promote Fetal Movement Tracking Purpose for the Program very year, more than 25,000 families nationwide experience the stillbirth of an infant with more than 50% of those deaths occurring during the third trimester. In Delaware, 70% of the women who participated in maternal interviews through the fetal infant mortality review, reported that they had not been educated on fetal movement, nor was there documentation of education on fetal movement in their medical records.

Implementation, Outcomes, and Evaluation Kicks Count is a statewide awareness campaign dedicated to improving the chances of delivering a healthy infant by reducing stillbirth rates, which occur in approximately 1 of every 150 pregnancies nationwide. The toolkit contains multilingual low-literacy materials that help patients learn to track kick counts. These materials include patient education brochures, a tracker picture booklet for recording a fetus’s daily movement, and educational information for medical providers and practices that distribute the materials.

Proposed Change Counting and tracking significant changes in a fetus’s movement patterns may help identify potential problems with a pregnancy.

Implications for Nursing Practice Nurses who interact with pregnant women and their families will have new resources to share with their patients that can improve outcomes.

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Michele K. Savin, MSN, NNP, Christiana Care Health Services, Wilmington, DE Susan Smith Noyes, MSN, RN, Delaware Healthy Mothers and Infants Consortium, Hockessin, DE Keywords stillbirth kick counting fetal infant mortality review (FIMR) patient education

Childbearing Poster Presentation

Caring for the Bariatric Obstetric Patient Purpose for the Program ody mass index has been increasing at epidemic proportions in the United States and internationally, with no states reaching the Healthy People 2010 obesity goal of 15% or lower. This same trend holds true in women of childbearing age. Among women aged 20 to 44 years, 24.5% are overweight, 12.7% are obese (body mass index 30%-34.9%), and 10.3% are severely or morbidly obese (body mass index greater than 35%), with the highest rate among nonHispanic black women. Obesity places women of childbearing age and pregnant women at increased risk of diabetes, hypertension, sleep apnea, arthritis, chronic back pain, coronary heart disease, infertility, and depression. Additional intrapartum and postpartum risks include increased cesarean birth, gestational diabetes, preeclampsia, eclampsia, HELLP syndrome, prolonged labor, dystocia of labor, inadequate pain control, thromboembolic event, hemorrhage, bowel obstruction, wound infections, seizures or stroke, and pneumonia.

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Proposed Change In an effort to appropriately care for pregnant women with higher body mass indexes, our institution initiated an evidence-based systematized approach to care.

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Implementation, Outcomes, and Evaluation Key elements of the evidence-based approach included a review of standards of care, a CINAHL and MEDLINE literature search, attendance at the national Association of Women’s Health, Obstetric and Neonatal Nurses conference, and a multidisciplinary team assessment of internal resources. As a result, a process guideline was developed and is being implemented. The guideline includes definitions, quality and safety standards, risk considerations, equipment and supply needs, clinical considerations, and psychosocial considerations. The guideline is expected to enhance the care team’s ability to provide safe, effective, and efficient care to pregnant women with higher body mass index. Data collection and outcomes evaluations are ongoing with changes being made as relevant.

Melinda Panzarella, MSN, MBA, RNC, Edward Hospital, Naperville, IL Keywords bariatric Class 1 obesity/obese Class 11 obesity/severe obesity Class 111 obesity/morbid obesity body mass index process guidelines

Childbearing Poster Presentation

Implications for Nursing Practice The implications for nursing practice include an evidence-based systematized approach to care for patients with higher body mass index during the antepartum, intrapartum, postpartum, and recovery periods and the utilization of the multidisciplinary team to provide safe, effective, and efficient care to pregnant women with a higher body mass index presenting in the labor and delivery department.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

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I N N O VAT I V E P R O G R A M S

Brumley, J. and Jevitt, C.

Proceedings of the 2012 AWHONN Convention

Optimizing Prenatal Weight Gain Through Group Prenatal Care Jessica Brumley, CNM, MA, University of South Florida, Tampa, FL Cecilia Jevitt, CNM, PhD, University of South Florida, Tampa, FL Keywords obesity pregnancy group prenatal care

Childbearing Poster Presentation

Purpose for the Program omen who gain excessive weight during pregnancy have an increased risk of macrosomia, gestational diabetes, hypertension, prolonged labor, instrumental birth, shoulder dystocia, cesarean birth, lactation complications, and giving birth to infants prone to developing childhood obesity. Weight gain within the Institute of Medicine’s Prenatal Weight Gain guidelines lowers risk of complications and postpartum weight retention. Typical prenatal care provides limited opportunity and time to offer the counseling and support many require to encourage the behavioral changes needed to optimize prenatal weight gain.

visits. Referrals come from nurse–midwives and obstetricians. A certified nurse–midwife organizes and facilitates the group. Women of any pregravid weight, without chronic disease and less than 20 weeks gestation are eligible for group participation. Women are given a detailed personalized nutrition plan from the www.choosemyplate.gov web site. The women plot their weight gain at each visit and set a goal for the next month. A physical therapist discusses physical activity during pregnancy and a lactation consultant presents the benefits of breastfeeding while attempting to return to pregravid weight. Group size is limited to eight women with similar due dates.

Proposed Change Group prenatal care is a model of care in which women of similar gestational ages are scheduled for prenatal care at the same time for 11/2 to 2 hours. This model provides the opportunity for individual exam and group counseling. It encourages active engagement in health care and social support from the group. This model was adapted to assist women in maintaining weight gain within the 2009 Institute of Medicine Prenatal Weight Gain guidelines.

Ten groups are currently in progress or have completed the program with an average of five participants. We are continuously recruiting for new groups. Members have used techniques that they have learned in the group, though weight management is still challenging. Group members have gained weight within the Institute of Medicine recommendations or have slowed their weight gain when excessive.

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Implementation, Outcomes, and Evaluation Over a period of four meetings, registration and scheduling for group meetings was developed, group meeting space was reserved, and medical assistants were prepared for group prenatal

Implications for Nursing Practice Advanced practice nurses offering prenatal care should consider the feasibility of offering prenatal care in a group setting. This model promotes social support, active engagement, and educational counseling. Some of the tools utilized also may be applied to the typical prenatal care setting.

Stork Support: A Hospital-Based Program to Navigate Women Through Pregnancy Emily Hirsch, MSN, MHA, RNC-NIC, UPMC Hamot Medical Center, Erie, PA Keywords prenatal education pregnancy navigation and support postpartum care relationship-based care

Childbearing Poster Presentation

Purpose for the Program tork Support is a pregnancy navigation program established to provide women with evidence-based resources and information to assist them in achieving healthy outcomes for themselves and their infants. This innovative program provides comprehensive perinatal education and postpartum follow-up care. The one-on-one relationship between the nurse and the client establishes a personal bond. After participating in the Stork Program, women are able to make informed decisions about labor management, breastfeeding, infant care, and self-care.

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Proposed Change The Stork Support program has changed the way women gain knowledge about pregnancy, the postpartum period, and infant care. Implementation, Outcomes, and Evaluation A March of Dimes grant supported the implementation of the program. Enrollment in the program is voluntary and can begin at any time during the pregnancy. Mother–baby nurses make an initial phone call at the time of enrollment to explain the program and obtain information about the pregnancy. Additional contacts are made during and

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I N N O VAT I V E P R O G R A M S Proceedings of the 2012 AWHONN Convention

after the pregnancy and consist of one-on-one conversations and support. Pregnancy outcomes are collected in a database and a patient survey is provided to all patients in the program during the postpartum hospital stay. Analyses of behavior changes, number of elective inductions prior to 39 weeks gestation, smoking cessation success, and breastfeeding at time of discharge are key components of the evaluation of the program.

Implications for Nursing Practice The Stork Support program has demonstrated that nurses can impact pregnancy outcomes by providing women with evidence-based knowledge to improve decision making, to change behaviors, and to take an active role in attaining healthy outcomes for themselves and their newborns.

Not Just the Blues: A Collaborative Program of Postpartum Depression Risk Assessment, Screening, Follow-Up, and Referrals Purpose for the Program ostpartum depression occurs during pregnancy and the first 12 months following birth. It affects at least 1 in 10 new mothers (20%-22%). Prior to our postpartum depression program, women received written materials and education about signs and symptoms of postpartum depression. None of these patients received follow-up from our organization after discharge. The immediate, long-term, and sometimes tragic effects of postpartum depression on families made an evidence-based initiative to provide seamless care and follow-up for these families a priority.

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Proposed Change A comprehensive program of postpartum depression risk assessment; education; screening; timesequenced follow-up; and referral during pregnancy, postpartum, and after discharge for all mothers giving birth at our hospital. Implementation, Outcomes, and Evaluation An interdisciplinary team reviewed the literature and identified opportunities to develop postpartum depression services. Feedback from our clients identified needs and supported screening all mothers for postpartum depression. We chose the Edinburgh Postnatal Depression Scale for screening. Our program included education about postpartum depression, Edinburgh Postnatal Depression Scale, and patient follow-up for nurses, physicians, and office staff. Patient education materials and discharge instructions were revised. All mothers were screened before discharge, with repeat screenings by a registered nurse 2 weeks later during follow-up calls. We established direct links with our organiza-

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tion’s behavioral health department for antepartum/postpartum assessments and interventions and obtained grant funding for services. Outpatient emergent and follow-up behavioral health care was a priority. The results of the initial/followup screenings were shared with the physicians.

Marianne Allen, MN, RNC-OB, Pinnacle Health System, Harrisburg, PA Kelly Lesh, RN, Pinnacle Health System, Harrisburg, PA Keywords

In the first year of the program, all mothers were postpartum depression screened for risk of postpartum depression while EPDS in the hospital and received either a follow-up phone call by a registered nurse after discharge or a visit by a clinical nurse specialist. This has Childbearing resulted in early identification of risk and ac- Poster Presentation cess to behavioral health services that may prevent/reduce symptoms of postpartum depression. This program has strengthened the relationships among maternal and child health departments, behavioral services, and private physician offices and improved the early identification/referral of women at risk. Physician practices that previously had not done formal screenings at postpartum follow-up visits are now using the Edinburgh Postnatal Depression Scale. Weekly antepartum support groups are led by a therapist, who also provides individual counseling through grant funding. Implications for Nursing Practice Comprehensive maternity care must include postpartum depression screening, assessment, and referral. Seamless care during the antepartum and postpartum periods, and sequential followup has had a positive impact on families through education, early identification, and referrals for treatment/support. The development of interdisciplinary collaboration is essential and strengthens the care offered to families. Our program provides a seamless model that hospitals may replicate.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

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I N N O VAT I V E P R O G R A M S

Smith, T. E.

Proceedings of the 2012 AWHONN Convention

Implementation of a Perinatal Mood and Anxiety Disorder Screening Program in Northern Arizona Terry E. Smith, RN, MS, RNC-OB, Northern Arizona Healthcare, Flagstaff, AZ Keywords perinatal mood and anxiety disorders (PMADs) postpartum depression support group depression screening

Childbearing Poster Presentation

Purpose for the Program he purpose of this program was to develop a process for screening, educating, and offering referral resources to mothers identified as suffering from perinatal mood and anxiety disorders.

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Proposed Change With 400,000 infants born in the United States every year to mothers who are depressed, perinatal mood and anxiety disorders are the most underdiagnosed, underreported, and undertreated complications of childbirth. Universal screening has not yet been mandated within the United States, which leaves many organizations struggling to meet the recognized needs of this vulnerable population with little guidance. In an effort to provide education, screening, and referral resources to pregnant women in rural, northern Arizona, a community-centered, interdisciplinary program was developed in a hospital setting that initiated perinatal mood and anxiety disorder screening.

Implementation, Outcomes, and Evaluation This was achieved by first gathering a nurse-lead multidisciplinary team to evaluate current screening, education, and referral practices as well as financial resources. This information was compared with current evidence-based practice and a plan was developed that would facilitate the availability of screening for all newly delivered mothers, education for mothers and staff, and improved availability of referral resources, including a grantfunded support group. In the first 4 months of the program, 300 mothers were screened, nearly 60 women were found to be at risk of the perinatal mood and anxiety disorder, and the support group was thriving.

Implications for Nursing Practice This presentation demonstrates that hospital nurses who act as leaders can be change agents by collaborating with other members of the health care team to initiate innovative, evidence-based programs.

Know Before They Go: A Time/Cost Analysis of an Early Screening and Referral Pilot Program for Postpartum Depression Jennifer B. Rousseau, MSN, ARNP-BC, Rush University College of Nursing, Chicago, IL Robin L. Jones, MD, Rush University Medical Center, Chicago, IL Keywords postpartum depression early screening postpartum depression treatment

Childbearing Poster Presentation

Purpose for the Program here are missed opportunities to screen women for postpartum depression and refer them for appropriate follow-up care. This pilot program, Know Before They Go, evaluated the feasibility of establishing a standardized screening and referral process in the immediate postpartum period. We describe how the process was implemented and provide a cost-benefit analysis. Nurse managers can use this information to develop a similar interprofessional program at their institutions to improve patient safety and optimize the level of service they provide women during the postpartum period.

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Proposed Change To implement early screening and referral for postpartum depression. Implementation, Outcomes, and Evaluation Forty-eight patients consented during their pregnancies to be screened for depression at 12-36

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hours after giving birth. Two prelicensure nursing students, who served as research assistants, measured the length of time to distribute, collect, and score the screening results. The nurses reviewed and discussed the results with the patients and documented the findings into the medical record. As per the early screening protocol developed for this pilot, those women who had a positive screening result (more than 12 on the Edinburgh Postnatal Depressive Scale) for severe depression were offered social work and behavioral health consults. When patients in the pilot returned for their 6-week postpartum visits, they were given a survey about their participation in the program. From a process standpoint, the pilot ran smoothly. Consistent with the literature, 6.25% of women had a positive screening result for major depression. Patients willingly completed the screening test in a timely manner; the response of the various disciplines was prompt; there were no delayed discharges as a result of a positive screening result; and there was support from patients, nurses, and

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physicians. The cost per patient with a negative screening result was $3.23 and the cost per patient with a positive screening result was $4.98 based on a nurse’s salary of $35.00 per hour. As part of the pilot, nurses and physicians were invited to educational sessions on postpartum depression. Outcomes show that screening in the immediate postpartum period is feasible and relatively inexpensive for the department of nursing. One of the three women with a positive screening result sought follow-up mental health treatment while another cited transportation issues as a barrier to treatment.

Implications for Nursing Practice The Association of Women’s Health, Obstetric and Neonatal Nurses believes that nurses are in a key position to assess new mothers for symptoms of depression and provide education and appropriate referral information for the treatment of postpartum depression. Improved marketing, identification of barriers to treatment, and universal implementation are recommendations to improve access to mental health follow-up for this vulnerable population.

Sepsis Screening in the Perinatal Patient Purpose for the Program here are 18 million cases of sepsis annually throughout the world. An estimated 75,000 maternal deaths worldwide are associated with sepsis. The rate of sepsis in developed countries is lower, but it is among the leading causes of preventable maternal mortality. The Surviving Sepsis Campaign is a national program focused on reducing sepsis-related morbidity and mortality. This program will review the physiology of sepsis and how it affects the perinatal patient. Early recognition and evidence-based management are keys to reducing morbidity and mortality. Implementation of a screening and management program for the perinatal patient will improve outcomes as it has in the nonperinatal population nationwide.

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Proposed Change To implement a standardized sepsis screening tool that includes the unique physiology of pregnancy and to implement the Surviving Sepsis management bundle. Implementation, Outcomes, and Evaluation Sepsis screening and standard management was initially implemented for the adult non-obstetric population throughout the Sutter Healthcare System. Consequently, a reduction in overall mortality

has been associated with this program at Sutter Healthcare System. It soon became obvious that the perinatal population would benefit from this program. We adopted the Surviving Sepsis bundle elements but made changes to the screening tool to account for the changes in physiology in the pregnant and postpartum population. Implementation of this program required a multidisciplinary team of obstetrician and intensive care unit physicians; obstetric, intensive care unit, and emergency department registered nurses; a rapid response team; a laboratory, and a pharmacy. Patients are screened on admission and then again on every shift. If a sepsis screening result is positive, the rapid response nurse is called to immediately evaluate the patient. The standard, evidence-based order set is initiated. This process has improved the collaboration between the perinatal and intensive care teams. There has been an increase in admissions to the intensive care unit; however, compared to our intensive care unit admissions before the screening, the duration of time spent in the intensive care unit is shorter.

Beth M. Stephens-Hennessy, RNC-OB, EFM, MS, CNS, Sutter Memorial Hospital, Sacramento, CA Keywords sepsis perinatal

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Implications for Nursing Practice There is an increased awareness of sepsis and how it presents in the perinatal patient.

Ambulation Readiness for the Post Obstetric Delivered Patient Purpose for the Program n increase in nurse injuries related to falls of postpartum patients resulted in an increase in worker’s compensation and overtime expenditures. Young healthy women with full cognitive capabilities are not viewed as a high-risk population; however, this postpartum patient population becomes high risk for falls because of two prominent

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factors: motor nerve block postepidural and ortho- Jo Annette Cooksey, BSN, RNC-OB, Baylor Regional static hypotension related to blood loss.

Medical Center at Grapevine, Grapevine, TX

Proposed Change A comprehensive search of online databases revealed only one article to guide a standardized approach to fall assessment in the postepidural obstetric patient. It had not been tested

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Ludden, E. and Wood, N.

Proceedings of the 2012 AWHONN Convention

for reliability or validity. A trial was conducted using the assessment tool. Keywords ambulation readiness postobstetric delivered patient

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Implementation, Outcomes, and Evaluation The rate of falls in the labor and delivery unit decreased from 11 to 0 in fiscal year 2010 because the problem areas were identified. Patients still fainted in the bathroom, though by definition this was not classified as a fall. Nurses transferred the patient from the toilet via wheelchair back to bed, yet the risk of injury to the patient and the nurse remained. Though the tool was not ideal, we did find that it had an impact on the rate of falls, rate of nurse injury, and worker’s compensation dollars.

Implications for Nursing Practice Problems identified with the tool were corrected, and it was changed to accommodate all obstetric patients after delivery. The tool was transformed into the Cooksey-Post Obstetric Delivery Fall Risk Assessment and presented to the Baylor Healthcare Perinatal Educator Group to meet the needs of all Baylor perinatal facilities. It was then presented to the Baylor Healthcare Perinatal Counsel. Permission was given to test the Cooksey-Post Obstetric Delivery Fall Risk Assessment in electronic recovery charting. Implementation of the trial started June 2011.

Never Alone Perinatal Palliative Care Program Eileen Ludden, RNC, BSN, Holy Cross Hospital, Silver Spring, MD Nancy Wood, BSN, RNC, CDE, Holy Cross Hospital, Silver Spring, MD Keywords Never Alone perinatal palliative care

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Purpose for the Program he Never Alone Perinatal Palliative Care program will provide support for the patient and family with a prenatal diagnosis (any serious or lethal diagnosis to the fetus or pregnant patient) while providing support to nursing and medical staff.

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Proposed Change The Perinatal Palliative Care Program was an underutilized program and there was a lack of knowledge of what support could be provided. Implementation, Outcomes, and Evaluation A knowledge survey was conducted about the program and the results were evaluated. An ed-

ucation program was developed for the nursing and medical staff, and the community. A brochure was created with a name to describe the program. A fact sheet was developed for physicians along with birth plans for the patients and their families. Within 2 months, referrals to the program increased from 0 to 5. Implications for Nursing Practice Increased knowledge about the Never Alone Perinatal Palliative Care program and the support it will provide will allow the nursing and medical staff to be better prepared to care for and support patients and their families at a very vulnerable time in their lives.

Reducing Postpartum Smoking Relapse Through the Use of Incentives Julia Greenawalt, PhD, RNC, Indiana University of Pennsylvania, Indiana, PA Meri Christine Orinko, BSN, RN, Dubois Regional Medical Center, Dubois, PA Keywords smoking cessation pregnancy incentives diapers relapse

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Purpose for the Program pproximately 40% of women who smoke tobacco quit smoking during pregnancy, yet up to 85% relapse after birth. The risks for mother and infant are well known, during the pregnancy and through secondhand smoke postpartum. The implementation of monthly counseling sessions and the incentive of a free case of diapers can drastically reduce relapse rates.

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Proposed Change Introduce programs that offer incentives to participants to make healthy lifestyle choices. Implementation, Outcomes, and Evaluation A cessation program was offered to all smokers during their prenatal care in three counties in

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western Pennsylvania. One hundred fifty pregnant women self-selected as participants and were enrolled in the Healthy Living: Keeping Me Smoke Free program. Three to six prenatal counseling sessions were offered in addition to the monthly counseling sessions, and CO2 monitoring and distribution of diapers were scheduled during the 12 months following birth. Implications for Nursing Practice The use of an incentive, such as a case of diapers, has been shown to decrease the relapse rate to 47% in the 12-month postpartum time frame. However, as the sample population was self-selected, bias may be pervasive. Further research is warranted to see if the findings of this study are generalizable to a population of nonidentified smokers.

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With budget issues in the forefront, incentives can often take various forms, such as diapers, baby goods, or other staple items. Further research is

warranted to reveal alternative incentives that are appealing and beneficial to mothers, infants, and management.

Could This Get Any More Complicated? Supporting Adoptions and Surrogates in the Birth Place Purpose for the Program he families in our communities are often told by adoption agencies and surrogate companies that hospitals do not understand their unique situations. They are told to prepare themselves for insensitive comments and challenging attitudes. Sadly, the level of care and understanding offered during these hospital stays is largely reliant upon the staff’s education about adoption and surrogate protocol. Because only 12% of adoptions are closed adoptions, the challenge of serving the birth family and the adoptive family within the Parker Adventist Hospital’s BirthPlace delivery unit is ever present. In surrogacy, families have a business agreement surrounding the pregnancy and birth, so there are multiple families involved in the hospital stay. Adoption and surrogacy can create unexpected challenges in the hospital setting. As a hospital we owe all families who come through our delivery unit a high level of respect and we must ensure that we care for these families appropriately.

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Proposed Change Our hospital has developed a program to support the special needs of our unique families. The Family to Family Adoption Support program began in 2005 at Parker Adventist Hospital and has grown to include mandatory staff education, adoption-

sensitive materials, and supportive guidelines for all parties involved in the adoption process. We have found in the past 3 years that this program also serves our surrogate population. There are many similarities in the hospital dynamics for surrogate and adoption placements. Each hospital can take the top five initiatives out of our established program and begin changing the culture in their facility.

Dixie K. Weber, MS, RNC, Eastern Idaho Regional Medical Center (HCA), Idaho Falls, ID Rebecca Vahle, MA, Parker Adventist Hospital, Parker, CO

Keywords adoption surrogacy nursing families hospital based Implementation, Outcomes, and Evaluation In our facility, we identified an area of weakness Birth Place

and developed a support role and curriculum to support staff development. The position of adoption liaison was created to support families and implement this program. The program utilizes the Infant Adoption Initiative Training for all staff in the Birth Place. We also partner with pregnancy centers and clinics throughout the Denver area. This outreach also impacts those considering utilizing a surrogate and thus delivering a child surrounded by a sensitive and educated staff.

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Implications for Nursing Practice The very heart of the program is the transition support in the Birth Place. During a unique delivery situation, the program supports all families involved to encourage healing and empowerment for all parties.

Bridging the Gaps Across the Continuum for Pregnant Women at Risk for Preterm Birth Purpose for the Program reterm birth is the leading cause of newborn death in the United States. In Colorado, one in eight infants is born prematurely. Preterm birth accounts for 70% of neonatal mortality, morbidity, and health care dollars spent on newborns, with national annual costs totaling more than $26.2 billion. St. Anthony North Hospital is collaborating with community stakeholders to identify strategies that can be implemented across the continuum of care to positively affect women at risk of preterm birth.

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Proposed Change To increase quality, decrease cost, and increase satisfaction for patients at risk of preterm labor, nursing staff, and physicians across the continuum. Implementation, Outcomes, and Evaluation Community stakeholders were gathered to work on the project. Process mapping from nursing, clinic, and patient perspectives was completed to evaluate risk or failure points as the patient traveled through the continuum of care. Clinician satisfaction surveys also were collected. Clinical

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

Kathy Pehanich, BSN, RNC-OB, C-EFM, Centura Health, St. Anthony North Hospital, Westminster, CO Debra Dieme, MBA, HCM, RN, Centura Health, St. Anthony North Hospital, Westminster, CO

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I N N O VAT I V E P R O G R A M S

LaBossiere, M.

Proceedings of the 2012 AWHONN Convention

Keywords preterm labor preterm birth cervical length

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variances were identified with regard to assessment and treatment of preterm labor as well as patient education and coordination of care. Standardized definitions, guidelines, and orders are being developed to aid in early identification and treatment of preterm labor. Patient educational materials were designed for utilization across the continuum. Teach-back was implemented to assess patient knowledge of the care plan. Coordination of care and communication between providers were streamlined to convey assessment findings, interventions, and medications; pending tests; care needs; follow-up appointments; and resources to aid in the coordination of care between providers. A process also was developed for the safe transport of patients at greatest risk

of preterm delivery to more appropriate levels of neonatal care. Data collection is currently underway. Anticipated results include a decreased triage time; decreased observation admissions for preterm labor; decreased cost triage and hospital costs; increased patient, nurse, and physician satisfaction; and an improved rate of antenatal steroid administration. Implications for Nursing Practice Coordination of care with community stakeholders across the continuum of care can improve outcomes for women at risk of preterm birth by early identification of risk, improved handoff communication, and decreased utilization of health care resources.

Operation Red Flag: Igniting a Passion and Commitment to Improving Patient Outcomes: An Interdisciplinary Approach to Prevention and Management of Postpartum Hemorrhage Marci LaBossiere, MSN, RN, U.S. Navy, San Diego, CA Keywords Operation Red Flag postpartum hemorrhage (PPH)

Childbearing Poster Presentation

Purpose for the Program peration Red Flag was developed to ignite and renew our interdisciplinary team approach to the prevention and management of postpartum hemorrhage. The purpose was to provide the opportunity for all disciplines involved in responding to a postpartum hemorrhage to review research and cases and collaborate to develop evidence-based guidelines for the prevention and management of postpartum hemorrhage.

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Proposed Change Operation Red Flag was developed to allow an interdisciplinary team to provide input in the development of evidence-based guidelines, training, and order set and to provide role clarification. Implementation, Outcomes, and Evaluation Operation Red Flag was initiated in early 2011. The team has conducted case reviews and modified our guideline as needed. We will continue to review cases as they arise and plan to implement simulation-based training for ongoing evaluation and training. Implications for Nursing Practice Nurses play a critical role in the assessment, communication, and implementation of a plan to prevent and manage postpartum hemorrhage. It is critical that nurses identify risk factors that increase the patient’s risk of postpartum hemorrhage and are familiar with nursing interventions that are key to the assessment, prevention, and

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management of postpartum hemorrhage. It is the responsibility of our medical facility teams to establish an interdisciplinary approach to ensure we are all working together to improve patient outcomes. Postpartum hemorrhage is a leading cause of maternal mortality and is increasing in incidence. Severe bleeding is the most significant cause of maternal death within the first 24 hours of delivery. Deaths from hemorrhage consistently rank at the top of the most preventable list, with 70 to 92% of deaths judged preventable. Hemodynamic changes that occur in the postpartum period may fluctuate significantly as they reflect results of blood loss sustained at delivery and the body’s compensation to peripartum hemorrhage. Postpartum hemorrhage is a potentially lifethreatening event that can occur with little warning and may be unrecognized until the patient is symptomatic. Our obstetrics and gynecology team identified the need to initiate a collaborative working group to establish policies, procedures, and education for the assessment, management, and prevention of postpartum hemorrhage. Early recognition and response to postpartum hemorrhage are critical for optimal management and stabilization of a patient with postpartum hemorrhage. Our interdisciplinary team focused on assessment, communication, and establishing a guideline and order set to be initiated immediately following assessment of postpartum hemorrhage.

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Committing to Excellence in Antenatal Steroid Administration: Applying the Plan-Do-Check-Act Continuous Performance Improvement Model Purpose for the Program o ignite a passion in nurses to actively engage and participate in performance improvement initiatives that advance evidence-based practices.

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Proposed Change Nurses will commit to participate in ongoing performance improvement initiatives with renewed confidence from gained knowledge. Implementation, Outcomes, and Evaluation In 2006, concern was raised by our neonatology department that all women at risk of preterm delivery were not receiving antenatal steroids. A team of nurses, physicians, and system analysts routinely met to evaluate performance and assess for improvement opportunities. Since 2005, findings from our neonatal information system showed that 77.8% of the women who gave birth between 24 and 32 weeks gestation received at least one dose of antenatal steroids. Staff was educated and protocols established with some improvement realized (83.9% in the year 2008). Efforts to develop a key performance indicator to facilitate concurrent review of missed opportunities were initiated. In 2009, the National Quality Forum released the Perinatal Consensus Standard (PC03) supporting the National Institutes of Health recommendations to give a full course of corticosteroids to all expectant women between 24 and 32 weeks gestation. On further evaluation, numerous challenges surfaced, including the collection and accurate

reporting of data (due to definitional issues of successful treatment), identification of barriers to treatment, and the need to clarify reporting parameters. The need to refine the definition of success to accurately measure quality within the constraints of controllable variables also was identified. In October 2010, the key performance indicator was operationalized, facilitating concurrent review of identified cases of failed treatment. Staff education and awareness of the need for timely administration (within 2 hours of admission/order) was established. Utilizing the Plan-Do-Check-Act continuous performance improvement model, the percentage of mothers receiving antenatal steroids prior to giving birth to a premature newborn improved 19%, from 78% to 93% between 2005 and 2010 (per the neonatal information system data base). Additional improvements were realized with the use of the key performance indicator, correcting and supplementing the system’s reporting capabilities specific to the National Quality Forum definition (successful treatment defined as administration of both doses). Monthly rates improved from 61.5% in October 2010 to 100% in July 2011 representing a 38.5% increase.

Linda Daniel, MSN, RN, CPHQ, Christiana Care Health Services, Newark, DE Keywords antenatal steroids perinatal quality indicators PDCA empowering nurses performance improvement

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Implications for Nursing Practice It is essential to set clear expectations and involve front line staff in promoting evidence-based practices. Plan-Do-Check-Act is a valuable tool to guide and sustain quality improvement endeavors.

Hot Mommas! Prewarming of Maternity Patients Undergoing Cesareans Purpose for the Program he purpose of this presentation is to share an evidence-based practice process to meet the Surgical Care Improvement Project criteria of the patient temperature on admission to the postanesthesia care unit (PACU) of 36◦ C. This practice also shows a reduction in nursing interventions to treat hypothermia in the PACU and a significant reduction in surgical site infections after cesarean birth.

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Proposed Change To warm the maternal-surgical patient with a forced air warmer prior to entering the operating room.

Megan Parsons, MSN, RNC-OB, Banner Thunderbird Medical Center, Glendale, AZ

Sherry Stott, MSN, RNC-OB, C-EFM, ACNS-BC, Banner Thunderbird Medical Center, Implementation, Outcomes, and Evaluation All maternity patients are warmed during the pre- Glendale, AZ

operative period for 30 minutes. This preoperative warming occurs while the admitting nurse is doing other tasks, such as taking the patient history,

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I N N O VAT I V E P R O G R A M S

Provost, C. and Rines, N. C.

Proceedings of the 2012 AWHONN Convention

Keywords preoperational warming prior to cesarean section Surgical Care Improvement Project (SCIP) surgical site infection forced air warmer

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starting the intravenous line, and monitoring the fetal heart tones. The outcome of this project shows that the surgical site infection rate after cesarean dropped from 2.6% to 1.5% during the quarter in which the project was implemented. Because of the reduced infection rate, costs are reduced for patient readmissions to the hospital and repeat visits to a physician’s office for surgical site care.

Implications for Nursing Practice Implications for nursing practice involve a onestep preoperational warming process that takes place during the preoperative period with a forced air warmer for scheduled cesareans. This practice takes place during the time the nurse is doing other tasks to prepare the patient for surgery. On admission to the PACU, fewer nursing interventions are required to treat hypothermia after the surgery.

A Postpartum Pertussis Vaccination Program: A Celebration of the Baystate Experience Carla Provost, RNC, Baystate Medical Center, Springfield, MA Nancy Rines, BSN, RN, Baystate Medical Center, Springfield, MA Keywords pertussis Tdap postpartum vaccination

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Purpose for the Program o share the process, strategies, and metrics of a successful postpartum vaccination program. Pertussis is on the rise. In 2010, localized outbreaks were reported in Michigan, Ohio, and California. California’s outbreak included 10 infant deaths. The fatality rate in newborns younger than 3 months is 1.4%; however, 55% of infant pertussis is caused by an infected parent. Proposed Change To implement a postpartum vaccination program.

Practice and the American College of Obstetricians and Gynecologists, the Perinatal Committee agreed to implement a postpartum pertussis vaccination program. This presentation will provide the steps taken to initialize and mobilize the process followed by educational strategies, including timelines and metrics. Nurse and patient perceptions related to immunizations will be shared. Discussion continues regarding cocooning and immunizing the family unit, including the operational challenges this particular initiative presents. An update will be provided.

Implementation, Outcomes, and Evaluation Our goal was to protect our newborns while educating the new family regarding pertussis and highlighting the public health challenges that this initiative presents. Challenged by a visit from our regional immunization nurse highlighting public safety concerns along with the recommendations of the Advisory Committee on Immunization

Implications for Nursing Practice We will present the process and metrics and document why the vaccine has not been widely administered. In 2011, our goal was to immunize 80% of all postpartum mothers. By July 2011, we had successfully administered vaccinations to 79% of postpartum women—a true cause for celebration!

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“Aye, Aye Captain!” Implementing an Induction Initiative to Improve Safety and Outcomes Jennifer L. Doyle, MSN, WHNP, Summa Health System, Wadsworth, OH Keywords cervical ripening IHI intrapartum safety PPSI premature delivery 39 weeks gestation

Childbearing Poster Presentation

Purpose for the Program abor inductions have become routine in modern society and are one of the most common procedures in obstetrics. Women undergoing induction of labor are at increased risk of cesarean birth. Additionally, a concerning number of elective labor inductions are performed earlier than 39 weeks gestation, often when the woman’s cervix is not yet mature. Therefore, the risks to the dyad not only include cesarean birth, but also morbidity from premature delivery. When it comes to induction, there are questions of “if and when and how.” Inappropriate use of oxytocin is one of the top five areas of preventable perinatal harm. The Institute

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for Healthcare Improvement and Premier Perinatal Safety Initiative have addressed the avoidance and proper management of uterine tachysystole as part of their evidence-based bundles. Finally, elective induction and cervical favorability are becoming forefront issues. Some facilities across the nation are disallowing cervical ripening for elective inductions and/or requiring a prespecified Bishop score to proceed with elective induction. Proposed Change To ignite passion, renew commitment, and promote professional excellence to enhance intrapartum safety.

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Implementation, Outcomes, and Evaluation As part of the Premier Perinatal Safety Initiative, our level III perinatal center addressed safety in obstetrics, particularly induction of labor. The strategy was multifaceted, but two issues are covered in this talk: elective induction of labor and induction medication safety. After 3 years of developing projects to improve the quality of elective inductions, our facility was able to virtually eliminate inductions at less than 39 weeks gestation and maintain greater than 90% compliance with tachysystole recognition and treatment. The next step will be to address the issue of cervical fa-

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vorability. Consistent with the literature, we have noted at our institution a significant difference in elective delivery outcomes in patients with favorable cervices when compared to unfavorable cervices. Such differences include longer induction times, more cesarean births, neonatal admissions to special care nursery, and length of hospital stay. Implications for Practice Induction safety is of paramount importance to Association of Women’s Health, Obstetric and Neonatal Nurses.

JOGNN, 41, S1-S118; 2012. DOI: 10.1111/j.1552-6909.2012.01359.x

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