algorithm checklist pdsa trials n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Algorithm & Checklist PDSA Trials PowerPoint Presentation
Download Presentation
Algorithm & Checklist PDSA Trials

Loading in 2 Seconds...

play fullscreen
1 / 7

Algorithm & Checklist PDSA Trials - PowerPoint PPT Presentation


  • 162 Views
  • Uploaded on

Algorithm & Checklist PDSA Trials. Dale Reisner , MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries Roadmap November 19, 2013. Presented at Washington State Hospital Association Safe Table 11/19/2013. Induction

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Algorithm & Checklist PDSA Trials' - walter


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
algorithm checklist pdsa trials

Algorithm & Checklist PDSA Trials

Dale Reisner, MD

Medical Director of Obstetrics Quality and Safety

Swedish Medical Center

WSHA Safe Table

Safe Deliveries Roadmap

November 19, 2013

Presented at Washington State Hospital Association Safe Table 11/19/2013

slide2

Induction

Fetal and Maternal Assessment Appropriate

for Induction

Draft

Medically Indicated Only

Favorable Cervix

(Bishop Score > 8)

Unfavorable Cervix

(Bishop Score < 8)

Initiate Oxytocin

Mechanical or Pharmacological

Cervical Ripening

DRAFT

Cervical

Change

No Cervical

Change

No Cervical

Change

Continue Oxytocin

or AROM

Repeat with

Different Method

Cervix < 6 cm, Unable

to AROM, or no Cervical

Change with 24 Hours

Oxytocin

Cervix > 6 cm*

*may observe for

spontaneous labor

No Response

Oxytocin Trial?

If Elective, Consider Home

Home or

Cesarean

See Spontaneous Labor Algorithm

Assess

Cervical Change

  • No Change
  • Adequate contractions
  • for > 4 hours
  • Inadequate contractions
  • for 6 hours

Cervical Change

Failed Induction

Second Stage

Arrest

Proceed to Cesarean

Presented at Washington State Hospital Association Safe Table 11/19/2013

slide3

Labor Induction Checklist - DRAFT

  • Type of Induction:
  • Medical ___________________________
  • Non-medical/Elective
  • Pre-procedure:
  • Consent form discussed with patient and signed, and on chart (medical and non-medical)
  • Non-medical Induction:
  • Not done prior to 39 weeks gestation. Gestational age: wks_________ days__________
  • Between 39 – 40 6/7 weeks gestation, Bishop score is 8 or greater confirmed by 2 examiners (no cervical ripening)
  • Medical Induction:
  • Done for accepted medical inductions w/i evidenced-based or National association guidelines (ACOG, SMFM, etc) for definition and most appropriate gestational age for delivery.
  • Consultation for indication not on above lists
  • Cervical ripening for unfavorable cervix
  • Failed Induction (assuming stable mother and fetus) – parameters to use when not entering active labor (> 6 cms):
  • Either: failure to achieve uterine contractions every 3 minutes with cervical change after 24 hrs of Pitocin and with AROM (if no contraindications), or, uterine contractions every 3 min x 24 hrs without entering active phase if initial Bishop score was less than 8 or if cervical ripening was used.
  • Inadequate response to a needed, clinically appropriate, second cervical ripening agent
  • Membranes have ben ruptured with inadequate progress (assuming feasible and no contraindications to AROM)
  • Pitocin has been given per hospital protocol if inadequate frequency and/or intensity of contractions occur after cervical ripening alone
  • If ROM, Pitocin given x 12 hrs without regular contractions resulting in cervical change
  • If Failed Induction:
  • Options discussed regarding further management: consideration of risks, benefits, and alternatives of all options (i.e. discharge home with plan to return versus Caesarean Section, depending on clinical situation)

DRAFT

Presented at Washington State Hospital Association Safe Table 11/19/2013

slide4

Maternal or Fetal Indication

for Admission

TRIAGE

Induction Algorithm

Draft

Spontaneous Labor

> 37 wks and < 41 wks

Stable Mother and Baby

Cervix < 4 cm

Cervix 4 cm or More

DRAFT

Inadequate

Progress

First Stage

Walk and Reassess

Admit to L&D

Home

Adequate

Progress

First Stage

First Stage Arrest

Operative Vaginal

or Cesarean

Depending on assessment;

Home, AROM and/or Oxytocin,

or Cesarean

Vaginal Delivery

Adequate Progress Second Stage

Inadequate Progress Second Stage

Adequate

Progress

Second Stage

Inadequate

Progress

Second Stage

Second Stage Arrest

Presented at Washington State Hospital Association Safe Table 11/19/2013

slide5

Spontaneous Labor Checklist - DRAFT

  • First Stage:
  • Admission delayed for (all conditions met for discharge):
    • Cervix less than 4 cm
    • Membranes intact
    • Reactive NST/FHR category I (if uterine contractions present). Confirmed by 2 practitioners (RN, MD, DO, CNM)
    • Pain control adequate with appropriate outpatient interventions as needed
  • Admitted to Labor and delivery (delay admission criteria not met)
  • Discharged home for:
    • Cervix 4-5 cm without change x 2-4 hrs
    • < 80% effacement
    • Reactive NST/FHR category I (if uterine contractions present)
    • Contractions less than 3/10 minutes
  • Further observation for:
    • Cervix 4-5 cm without change x 2-4 hrs
    • 90 – 100% effacement
    • Membranes intact
    • Reactive NST/FHR category I (if uterine contractions present)
    • Contractions less than 3/10 minutes
  • Cesarean delivery for (all criteria present)
    • Cervix 6 cm or greater
    • Membranes ruptured (if feasible)
    • Uterine activity
      • >200 Montivideountis x 4 hrs, or every 3 minutes palpabley strong contractions x 4 hrs when not feasible to rupture membranes
  • OR
      • <200 Montivideo units or <3/10 minute contractions x 6 hrs despite Oxytocin administration per protocol
  • Second Stage:
  • Assessment of decent and position of presenting part at least every 1-2 hrs
  • Operative vaginal delivery or Cesarean delivery for (if presenting part not on perineal floor: +4 or lower)
  • Time from complete dilation*/**
    • Nulliparous with epidural - 4 hrs
    • Nulliparous without epidural - 3 hrs
    • Multiparous with epidural - 3 hrs
    • Multiparous without epidural – 2 hrs
  • OR
    • Total time from complete dilation 5 hours or greater
    • > 2 hrs, adequate pattern, no descent
  • *Passive decent (laboring down) is included in these time periods
  • **Each may need an additional hour if occiput posterior position and rotation of greater than 45 degrees toward anterior has been previously achieved

DRAFT

Presented at Washington State Hospital Association Safe Table 11/19/2013

pdsa on 4 campuses nov 2013 both sets of algorithms respective checklists
PDSA on 4 Campuses Nov 2013Both sets of Algorithms & Respective Checklists
  • 29 Algorithms/Checklists evaluated
  • 27 RNs or LIPs
  • Common Themes
    • What to do for <4cms with pain
    • 4-5 cms but not in labor
    • Do we suggest the amt of walk & reassess time?
    • ?SROM: Induction vs Augmentation
    • Should we note effacement, station?
    • Are there separate considerations based on parity?
    • Can a little more guidance be put into algorithms but still keep them easy to follow?

Presented at Washington State Hospital Association Safe Table 11/19/2013

slide7

Indication for Induction see Induction Algorithm and Checklist

Maternal or Fetal Indication

for Admission either in Labor or Needs Induction

TRIAGE

Spontaneous Labor > 37wks

Stable Mother and Baby

Assess Exam and Pain

New

New

Cervix < 4 cm

Draft

Cervix 4 cm or More

in Labor

DRAFT

Inadequate

Progress

First Stage

Walk and Reassess

Admit to L&D

Home

Adequate

Progress

First Stage

First Stage Arrest

New

Operative Vaginal

or Cesarean

Depending on assessment;

Home vs AROM and/or Oxytocin vs Cesarean

Vaginal Delivery

Adequate Progress Second Stage

  • Definitions
  • Examples:
  • Adequate progress
  • reVITALize

Inadequate Progress Second Stage

Second Stage Arrest

Presented at Washington State Hospital Association Safe Table 11/19/2013