CONFIDENTIAL

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

2. Reduction of Inappropriate Inductions 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

3. Reduction of Inappropriate Unplanned Primary Cesarean Delivery in the uncomplicated Primigavida It will take us all Leasa Lowy BSN,MD,FACOG Medical Director Women’s Services PeaceHealth Washington State Perinatal Quality Improvement Collaborative

4. Inappropriate Induction • Definition: • Elective induction less than 39 weeks • Unfavorable cervix • Bishop score of at least 8 for nulliparas and 6 for multiparas

5. OUTLINE • 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

6. WHY ? • 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

7. 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

8. 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%

9. New Economy • Health care cost 2.2 trillion in 2007 • Growth 10% per year

10. 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.

11. EBM

12. 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

13. 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

14. EBM…

15. 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.

16. Standard… • Develop 1 standardized way for the team to act in a given situation and get really good at it.

17. Be Specific • We have to get specific with respect to killer items !

18. Overall… • 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

19. OXYTOCIN • 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

20. Obstetrics—Killer Items • Abnormal fetal heart rate tracing • Oxytocin • Misoprostol • MgSo4 • VBAC • Forceps/Vacuum • Shoulder Dystocia • Prolonged second stage

21. 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 • WOW THANKS!

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

30. Best to track… • Cesarean rate for uncomplicated elective inductions in nulliparas…not born by Cesarean section.

31. 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

32. 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

33. 3. Leadership/organizational support4. Create a new culture • IOM reports • ACOG • Premier • Outside review • CME • OB advisory

34. Great early team members… • CEO • Hospital insurance • Hospital risk management • Secondary insurance especially for OB • Private practice insurance • Docs • Nurses • Patient

35. 6. Indicator Measurement Monitor and Reporting

36. Quality Progress Dashboard

42. Dashboard

44. 5. Patient centered • Patient on our OB advisory team • Patient on our Hospital Board Quality Committee

46. SUMMARY

47. 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

48. 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

50. Thanks