DECREASING ELECTIVE DELIVERIES PRIOR TO 39 WEEKS Melanie Hermann, MSN, RNC-OB, CNS-BC Perinatal Clinical Nurse Specialist Iowa Health Des Moines.

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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 Slide 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 Slide 3 2006 Baseline data March 2007 Policy created, labor analysis form developed Feb 2008 Labor analysis form implemented Oct 2009 Scheduler hired 2010 Letter to providers regarding cervical ripening and elective inductions 2012 Brochure created and patient education Slide 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 Slide 5 Slide 6 STEPS TAKEN 2006 Baseline data for meeting elective induction bundles and number of elective inductions and Cesarean sections39 weeks Reassuring fetal status All pelvic exam elements documented No tachysystole and if there was tachysystole the appropriate treatment was done Slide 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 couldnt 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 Slide 8 Slide 9 USE OF LABOR ANALYSIS FORM Slide 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 ofSlide 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 Slide 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 Slide 13 Slide 14 NUMBER OF BABIES TO NICU AFTER ELECTIVE INDUCTION >39 WKS Slide 15 Slide 16 Medical InductionsElective InductionsTotal Inductions IHDM Total Births % Inductions ILHIMMCMWILHIMMCMWILHIMMCMWIHDM 2008102511N/A79319N/A181830N/A1011424223.8% 200979519N/A69249N/A148768N/A916401622.8% 20107659026351856411177590976389825% 20119456924 1576911872693937397323.6% 1 st Q 2012 11136043011151661119295920% Slide 17 Slide 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 Medicals Electives Slide 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 Slide 20 QUESTIONS?