Tracking Scheduled Cesarean Section On-Time Starts on Labor & Delivery Unit University of Colorado-Denver Quality Improvement Project Alex Behm, MD Nick Stringer, MD Paul Scott, MD Ben Scott, MD Breanden Sullivan, MD May 8th, 2017

Problem Frequently, scheduled first start weekday C-sections do not make it to the OR on time This is likely related to several factors including: No designated OR specific nursing staff in AM OR frequently not ready/set up for patient at scheduled start time First case starts scheduled immediately after OB morning report “Unit Acuity” Most importantly, lack of communication amongst Nursing, OR, Obstetrics and Anesthesia teams This issue potentially affects residents’ education, OB team and patient’s satisfaction, and quality of care for patients in the labor unit Can lead to downstream “backup” of other anesthesiology team tasks – delaying epidurals, other c-sections, etc

Late First Case Start on L&D Fishbone Team Factors -currently no way for nursing to contact the appropriate anes provider (anes resident vs. OB CRNA) -OB morning signout takes place just before scheduled OR Patient Factors -patients typically arrive 1-2 hrs prior to scheduled start time -non-English speaking patients -difficult IV access not uncommon Task Factors: -consents for C-section frequently not performed until just before taking patient back to OR Individual/Staff Factors -no dedicated OR nursing team to ensure the patient arrives to the OR on time Communication -miscommunication between the nursing team, anesthesia team, OR team and OB team -lack of communication by OB team for potential floor acuity -> delay Late First Case Start on L&D Supplies and Equipment -OR frequently not set up for scheduled surgical procedure Organizational Education/Training Factors -Morning signout Working Conditions -high acuity unit w/ several laboring patients concurrently w/ potential for crash C-sections to OR at any moment

Our Hypothesis Assuming we cannot change unit acuity, MISCOMMUNICATION leads to the majority of late first case starts

What we did Helped the OB RN’s create a dedicated OR nursing team This was (luckily) already somewhat in process when we started, thanks to Charge RN Amy Sailor Continue to have the anesthesia consent done at a minimum 30 minutes prior to procedure start time (assuming patient readiness) Created the expectation that the new OR OB RN’s would be responsible for timely patient arrival in OR Created the expectation that the new OR OB RN’s would call both the anes team and OB team to ensure readiness 30 minutes prior to start time

Data Collection and Analysis First case starts tracked before and after the intervention Anesthesia providers asked to chart reason for delays Student t-test p value 0.009   Before Intervention (December) After Intervention (April, May) Number of first case starts 13 19 Number of on-time first starts 1 9 % on-time first starts 7.7% 47.4%

Conclusions Improving communication as well as creating a dedicated RN position for the OB OR has improved the number of first case starts Improved first case starts but still plenty of room for improvement, only 47% on-time first starts since intervention

Future Work Plenty of room to continue improving on-time first case starts What is the source of the continued delays Only 30% of cases have charted reason for delays More information about delays needed before making future interventions

Questions