1. 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

2. 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

3. 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

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

5. 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

6. 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%

7. 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

8. 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

9. Questions