1. Family Birth Center Performance & Quality Improvement: Labor Induction Process September 16, 2010

2. PDSA Process Aim: Improve Induction Process based on the evidence and ACOG and AWHONN guidelines. Describe your first (or next) test of change:Person responsible When to be done Where to be done Revise “Oxytocin Guidelines for Induction of Labor” Policy and Procedure. Jamie Vincent November 2009 JMH

3. PDSA Process Plan List the tasks needed to set up this test of change Person responsible When to be done Where to be done Literature Review Identify Physician champion. Identify Stakeholders Discussion on criteria for elective induction Make proposed changes to P&P Create Induction Checklist Present P&P revisions to OB Quality committee for input and approval. Present P&P to OB/GYN committee for approval Educate nurses and physicians regarding changes in P&P Research Patient education on inductions Utilize ACOG Pamphlet on Inductions for consistent patient education Resources for staff nurses Plan roll out Jamie Vincent Team Jamie Vincent Pavna Sloan Team Jamie and Pavna Jamie Team

4. PDSA Process Predict what will happen when the test is carried out Measures to determine if prediction succeeds Resistance from staff and physicians Lack of follow through Inconsistency in following policy Policy and checklist followed as educated Lack of documentation, delayed initiation of pitocin Utilizing old policies and practices Lack of documentation, delayed initiation of pitocin Improved process and improved outcomes Plan

5. PDSA Process Do Describe what actually happened when you ran the test Physician and Staff Nurse education on new induction policy and checklist through email communication, staff meetings, in-services, one-on-one communication, OB Quality and OB/GYN Department Meetings. Resource RN position added. Resource/Staff nurses obtained necessary documentation utilizing checklist 24 hours prior to scheduled induction. MD offices faxed in required documentation. Induction not initiated until required documentation in chart. Oxytocin administered per new protocol. ACOG pamphlet provided to all patients scheduled for induction of labor. Track elective inductions less than 39 weeks resulting in NICU admission. Present data to OB Quality. Continued physician and nursing education

6. PDSA Process Study Describe the measured results and how they compared to the predictions 2010 YTD: Only one elective induction less than 39 weeks resulted in NICU admission 100% of elective inductions had appropriate documentation prior to initiation of pitocin. Admission to initiation of pitocin within 30 minutes as planned.

7. PDSA Process Act Describe what modifications to the plan will be made for the next cycle from what you learned Physician buy-in for changing criteria to a firm 39 weeks for elective induction as recommended by ACOG. Consider adding Informed Consent for Induction of labor.

8. Induction Checklist

9. Single Oxytocin Protocol Reference / Regulations: ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists #107, August 2009 Induction of Labor ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists #49 December 2003 Dystocia and the Augmentation of Labor. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists, #106, July 2009 Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles

10. Documentation of Indication for Induction

11. Oxytocin IV bags Oxytocin Infusion bags are Pre-mixed in the Pharmacy to ensure consistency and safety 20 units Oxytocin in 1000 ml Lactated Ringers

12. Consistent Patient Education ACOG Patient Education Pamphlet on “Labor Induction” given to each patient prior to Induction of Labor.