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Decreasing elective deliveries Prior to 39 weeks. Melanie Hermann, MSN, RNC-OB, CNS-BC Perinatal Clinical Nurse Specialist Iowa Health Des Moines. objectives. Discuss the history of the Perinatal Safety Team at Iowa Health Des Moines

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decreasing elective deliveries prior to 39 weeks

Decreasing elective deliveries Prior to 39 weeks

Melanie Hermann, MSN, RNC-OB, CNS-BC

Perinatal Clinical Nurse Specialist

Iowa Health Des Moines

objectives
objectives
  • Discuss the history of the Perinatal Safety Team at Iowa Health Des Moines
  • Describe steps taken to help decrease the rate of elective deliveries prior to 39 weeks gestation
  • Outline barriers identified during implementation
  • Discuss recommendations for implementing a 39 week elective delivery policy
ihs ihdm perinatal safety teams
IHS & IHDM Perinatal safety teams
  • Began in Nov 2006
  • Iowa Health System Board defined perinatal safety as a quality initiative
  • IHS joined the Institute of Healthcare Improvement Program
  • Multidisciplinary group involving obstetricians, nurses, quality, pediatricians, anesthesia, family practice, and hospital leadership
  • Goal of decreasing the number of elective deliveries < 39 weeks was identified on the charter
  • Other areas of safety also addressed on the charter annually
    • Bundles (induction/augmentation/vacuum), PPH education, medication safety, etc
steps taken
Steps taken
  • 2006 – Baseline data for meeting elective induction bundles and number of elective inductions and Cesarean sections <39 weeks
    • The elective induction bundle includes:
      • Gestation age > 39 weeks
      • Reassuring fetal status
      • All pelvic exam elements documented
      • No tachysystole and if there was tachysystole the appropriate treatment was done
steps taken1
Steps taken
  • March 2007 – City wide policy and labor analysis form created
    • Meetings held with all 4 area hospitals providing OB care
    • All in agreement of developing a policy to not allow elective deliveries < 39 weeks
    • Helped to all be consistent – patient/provider couldn’t use it against the hospital
    • Piloted the labor analysis form in 2007
    • Communicated to providers to begin using Feb 2008
    • The form helped the nurse scheduling the induction to know criteria has been met
    • If there was no form on the chart there was no induction until the information was obtained
steps taken2
Steps taken
  • Oct 2009 – Hired a procedure scheduler
    • This helped to streamline the process of screening and ensuring the induction/c-section was appropriate
    • She now schedules all procedures for all 3 hospitals
    • A change in how c/sections were scheduled at ILH helped to decrease the number of <39 week scheduled c/sections
          • Percent of scheduled “elective” c/sections prior to 39 weeks:
steps taken3
Steps taken
  • 2010 – Letter to providers discouraging use of cervical ripening agents for elective inductions
    • Significant correlation between the use of cervical ripening with elective inductions and increased risk of Cesarean delivery
        • Baseline use of cervical ripening and elective inductions
steps taken4
Steps taken
  • March 2012 – Brochure created to hand out to patients for education, additional information added to the website and other forms of patient education
  • Discussion in childbirth education classes regarding elective deliveries
barriers encountered
Barriers encountered
  • Resistance from providers
  • Persistence from patients
  • Nurses put in difficult situations – “hard stop”
  • Noticed a decrease in elective inductions but an increase in “medical” inductions – difficult to achieve agreement among providers on what should be listed a medical indications
    • Quality audit conducted to validate the documentation

to support medical inductions

recommendations
recommendations
  • Strong buy-in from a physician champion
  • Support from administration
  • Provide education to staff, providers, and patients
  • Persistence
  • Plan in place for peer review for those cases that “fall out”