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

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

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: 20102011 ILH21%0% IMMC3.8%0.3% MWH2%1.9%

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

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%

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

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?