Decreasing elective deliveries Prior to 39 weeks

1. Decreasing elective deliveries Prior to 39 weeks Melanie Hermann, MSN, RNC-OB, CNS-BC Perinatal Clinical Nurse Specialist Iowa Health Des Moines

2. 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

4. 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

6. 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

7. 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

9. Use of labor analysis form

10. 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:

11. 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

12. 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

14. Number of babies to NICU after elective induction >39 wks

18. 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

19. 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”

20. Questions?