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CONFIDENTIAL WSHA CQIP Peer Review and Quality Improvement Information Protected from disclosure or discovery under RCW 43-70-510. Reduction of Inappropriate Inductions It will take us all. Leasa Lowy BSN, MD, FACOG Medical Director Women’s Services PeaceHealth

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WSHA CQIP Peer Review and QualityImprovement InformationProtected from disclosure or discovery under RCW 43-70-510


Reduction of Inappropriate


It will take us all

Leasa Lowy BSN, MD, FACOG

Medical Director Women’s Services PeaceHealth

Washington State Perinatal Quality Improvement Collaborative

April 26, 2010


Reduction of Inappropriate Unplanned Primary Cesarean Delivery in the uncomplicated Primigavida

It will take us all


Medical Director Women’s Services PeaceHealth

Washington State Perinatal Quality Improvement Collaborative

inappropriate induction
Inappropriate Induction
  • Definition:
  • Elective induction less than 39 weeks
  • Unfavorable cervix
    • Bishop score of at least 8 for nulliparas and 6 for multiparas
  • WHY should we work on reducing/eliminating inappropriate inductions…decrease unplanned primary cesarean delivery…Decrease the need for VBAC’s
  • Share some commonly used TOOLS and STRATEGIES
  • Team
  • Deliveries of infants between 37 and 386/7 weeks has been increasing and now makes up 17.5% of live births in the US.
  • Up to 28% of elective inductions in some centers are between 37 and 38 6/7 weeks
washington state hospitals
Washington State Hospitals
  • Washington State Hospital Perinatal Quality Improvement and Data Survey Results 2 Draft Summary of Findings and Next Steps, June 15, 2009
  • 69 delivery hospitals
  • 35% track deliveries<39 weeks
  • 25% track elective inductions
  • 12% track C/S rate for low risk Primips
  • 10% track VBAC rate low risk
it will take us all
It will take us all…
  • Washington still scoring a “c” on premature births
  • 2005 1 in 8 babies born premature in the US (12.7%)
  • 2006 1 in 9 in Washington State (11 %)
  • 1996-2006 rate increased by 28%
  • Goal by 2010 in 7.6%
new economy
New Economy
  • Health care cost 2.2 trillion in 2007
  • Growth 10% per year
more support
More support…
  • ACOG and American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). Early inductions result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009) According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. AAFP (2000) also notes that elective induction doubles the cesarean delivery rate.
three published best practice quality initiatives
Three Published Best Practice Quality Initiatives
  • Oshiro et al 2009 IHC
    • Decrease elective deliveries before 39 weeks gestation
    • Monitor relevant clinical outcomes
  • Fisch,et al, Magee-Womens Hosp, University of Pittsburgh
    • Decrease inappropriate (elective<39 wk or unripe cervix) labor inductions through a new scheduling process and medical staff education
    • Decrease elective induction,39 weeks and c/s rate in nulliparous elective inductions
  • Reisner et al 2009 Swedish Hospital, Seattle
    • Decrease unplanned primary c/s by reducing elective inductions
    • Identify more clearly medical inductions decrease elective better patient education of risks/benefits
four outcome studies with increased morbidities for gestational age at birth 37 to 38 weeks
Four outcome studies with increased morbidities for gestational age at birth 37 to 38 weeks
  • Madar et al 1999 Respiratory distress, RDS mortality
  • Yee et al 2008 NICU admits/ Respiratory distress
  • Tita et al 2009 Neonatal death, Resp complications, Newborn sepsis, hypoglycemia, CPR, LOS
  • Clark et al 2009 NICU admits
evidence based
Evidence Based
  • Evidence based medicine DOES NOT mean:
    • Unless you can prove it with multiple prospective randomized double blind placebo controlled trials, it’s OK to engage in a clinical free-for-all
  • Evidence Based DOES mean:
    • Where there is clear evidence of superiority of one method over another, use it.
  • Develop 1 standardized way for the team to act in a given situation and get really good at it.
be specific
Be Specific
  • We have to get specific with respect to killer items !
  • Infants born at 37 weeks =7.5 fold greater rate of RDS than those born at 38 weeks
  • Infants born at 38 weeks= 7.5 fold greater rate of RDS than those born at 39-41 weeks
  • Increased neonatal morbidity
  • Increase admit to NICU
  • Increased c/s rate
  • Oxytocin was recently added to the Institute for Safe Medical Practices list of high risk medications which “bear a heightened risk of harm” and which warrants “special safeguards to reduce the risk of error”
  • This list includes only 11 other medications
obstetrics killer items
Obstetrics—Killer Items
  • Abnormal fetal heart rate tracing
  • Oxytocin
  • Misoprostol
  • MgSo4
  • VBAC
  • Forceps/Vacuum
  • Shoulder Dystocia
  • Prolonged second stage
help from acog
Help from ACOG
  • “Once an arrested disordered has been diagnosed”
    • P O:>2h,>3h with epidural
    • P>O:>1h, >2h with epidural #49 12/03
  • “The obstetrician has three choices:”
    • Continue to observe
    • Operative vaginal delivery
    • Cesarean delivery
more acog guidance
More ACOG Guidance
  • Oxytocin guidelines 2009
    • Any of the low or high dose oxytocin regimens outlined in table 2 are appropriate. (0.5-6mU/min q 15-40min)
    • Each hospital’s OB department should develop guidelines for preparation and administration of oxytocin
    • The uterine contractions and fetal heart rate should be monitored closely
guidelines for landing a 747 in extreme cross wind
Guidelines for landing a 747 in extreme cross wind…
  • Use any settings of the plane’s instruments you feel like
  • Every airline and pilot can do it differently
  • Be pretty darn careful
  • Cross your fingers if you want
shared baseline
Shared Baseline
  • We can be sensitive to traditional and philosophical factors and their effects on guideline/checklists. However, There should be no compromise regarding the critical “killer” items
all the papers used common strategies six steps
All the papers used common strategies: SIX STEPS

1. Baseline establish rates

2. Guidelines/Process change

3. Leadership/organizational support

4. Create a new culture

5. Patient centered

6. Indicator Measurement Monitor and Reporting

1 baselines
1. Baselines
  • Establish your baseline:
    • Elective inductions less than 39 weeks…use the ACOG practice bulletin for definition of medical and create an advisory board for the grey areas
    • Elective inductions by Bishop score and outcome
baseline we need agreed upon measures
Baseline: We need agreed upon measures
  • Two easy measures are tracking elective inductions
  • Tracking primary low risk c/s rates
  • Tracking nursery admits of babies >2500 grams
best to track
Best to track…
  • Cesarean rate for uncomplicated elective inductions in nulliparas…not born by Cesarean section.
2 guidelines process change
2. Guidelines/Process change
  • New Policy
    • Induction and Augmentation
    • Standard Oxytocin concentration and dosing
    • Standard Fetal monitoring term-NICHD
    • Algorithm/Guidelines for Tachysystole
  • New Augmentation and Induction Orders
  • Labor induction check list
  • New standard L&D admit note
  • New standard H&P with prenatal care
  • New standard H&P no prenatal care
leadership and culture
Leadership and Culture
  • Find a champion
    • Pay them
  • Create a Multi Disciplinary team
  • Join Local and National OB safety/Quality collaborative
    • PAC-New group Quality
    • JC alerts
    • IHC-Brent James
    • ACPE
    • ACOG Quality/Safety meeting
3 leadership organizational support 4 create a new culture
3. Leadership/organizational support4. Create a new culture
  • IOM reports
  • ACOG
  • Premier
  • Outside review
  • CME
  • OB advisory
great early team members
Great early team members…
  • CEO
  • Hospital insurance
  • Hospital risk management
  • Secondary insurance especially for OB
  • Private practice insurance
  • Docs
  • Nurses
  • Patient
5 patient centered
5. Patient centered
  • Patient on our OB advisory team
  • Patient on our Hospital Board Quality Committee
where do you start
Where do you start ?
  • Participate in the Washington State Perinatal Quality collaborative
  • No hospital is to small
  • Build a team
  • Build a common shared goal of no inappropriate inductions
  • Go talk with your Administration including your CEO first
how can washington ob providers work together
How can Washington OB providers work together?
  • Share resources
  • Elective induction reduction at all hospital sizes across the state
  • Learn from Utah, Swedish, PeaceHealth and others
  • Share

WSHA CQIP Peer Review and QualityImprovement InformationProtected from disclosure or discovery under RCW 43-70-510