EP8EO: Nurses use internal and external experts to improve the clinical practice setting.
Provide one example, with supporting evidence, of an improvement that occurred due to a change in clinical practice setting resulting from the use of internal experts. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
OR
Provide one example, with supporting evidence, of an improvement that occurred due to a change in the clinical practice setting resulting from the use of external experts. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
Elective Deliveries Prior to 39 Weeks of Gestation
BACKGROUND/PROBLEM
According to the Center for Medicaid and Medicare Services, approximately 10-15% of all births in the United States are performed electively between 37 0/7 weeks and 38 6/7 weeks gestation without an accompanying medical or obstetrical indication. These “early elective deliveries” may be performed by induction of labor or cesarean section (C-section). Babies born by elective delivery at less than 39 weeks have a significantly higher risk for newborn complications. These include increased neonatal intensive care unit (NICU) admissions; increased transient tachypnea of the newborn (TTN); increased respiratory distress syndrome (RDS); increased requirement for ventilator support; increased incidence of suspected or actual sepsis; and increased problems with newborn feeding. Finally, with elective delivery, it is estimated by the March of Dimes to cost anywhere from $49,760 to $58,917 to care for these babies due to increased length of stay; higher level of care transfers; and complications related to early deliveries.
Patient-and family-centered care is one of the organization’s framework for its care delivery. Babies born at Homestead Hospital who require a higher level of care in a NICU must be transferred to another facility. This leads to a physical separation and emotional distress experienced by the newborns’ families and a big dissatisfier among the patients. In 2011, Homestead Hospital’s Perinatal Services began looking at their early elective delivery rates and over the years attempted to work with physicians and staff to look at ways to begin decreasing their rate which, at its highest, was 16% in March 2013. Due to the variability noted in the data, it was determined that there was a lack of a streamlined process in verifying appropriate gestational age prior to scheduling deliveries.
Use of Internal Experts
In July 2013, a team was put together to look at the existing split process of scheduling elective induction deliveries in Perinatal Services and elective C-Section procedures in Surgical Services. The team consisted of members from the Perinatal Services, Surgical Services, and Performance Improvement (PI) departments. PI Supervisor Larissa Vega, RN and PI Nurse Fritza Henry, RN were the internal experts who led the team. Vega has been a nurse for 14 years with an extensive medical-surgical nursing and clinical education background. She earned her Bachelor’s degree in Nursing (BSN) in 2000 and obtained her certification as a Certified Professional in Healthcare Quality (CPHQ) in 2014. She assumed the role of PI supervisor in July 2012 and managed 8 PI nurses. Additionally, she was well versed with PI data collection/abstraction; data analysis; use of controlled charts; PI methodology (e.g., Plan-Do-Check-Act [PDCA] and Teams, Refocus, Imagine and Measure [TRIM]); and PI team facilitation. She has attended multiple continuing education (CE) offerings pertaining to PI, data management and patient safety topics. On the other hand, Henry has been a nurse for 8 years with a broad medical-surgical nursing experience. She earned her BSN in 2006 and is currently matriculating for her Masters of Science in Nursing (MSN) degree with a focus on health systems management. She has been a PI nurse for 2 years and well versed in national databases; data collection/abstraction; and working with PI teams. Henry has also participated in several CE classes related to her specialty. As internal experts, Vega and Henry guided the team to focus on establishing deadlines and delegating tasks to team members to meet established goals using TRIM.
GOAL STATEMENT(S)
The goal of the team was to establish a standardized process and guidelines to decrease early elective deliveries from 16% to at or below national benchmark of 6%.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
The team met at various times to go through the TRIM process from September through December 2013. In order to improve the quality of care provided to Perinatal patients, they began by researching evidence-based best practices from the American College of Obstetricians and Gynecologists(ACOG), VHA, Inc. blue prints, The Joint Commission and March of Dimes. The team identified an area of opportunity in the scheduling process during the Value Stream Mapping process. (EP8EO 01 Value Stream Map) ACOG recommended adopting a scheduling birth criteria, which included proper pregnancy dating by earliest ultrasound confirmation and improved physician documentation of medical indication. The team then proceeded in developing the action plan as follows:
What |
Who |
When |
Outcome |
Audit trail faxed to L& D |
Surgical Coordinator |
9/13 |
Increased compliance with 39 week rule |
Created HH 878 |
Team |
10/13 |
Form was utilized to help formalize the process |
Educated Perinatal Patient Care Supervisors (PCS) on new approval process |
Perinatal Services |
11/13 |
PCS was aware of the new process |
Educated surgery scheduler on new process |
Surgical Services Director and Surgical Coordinator |
11/13 |
Schedulers were aware of their role in the new process |
Obtained approval from obstetric/gynecology (OB/GYN) and Neonatology Physician Steering Committee |
Team |
11/13 |
Received physician approval for the new process |
Right Fax system implemented in Labor and Delivery |
Vega (PI), IT, and Perinatal |
12/13 |
Faxes received at all PC stations in Perinatal Services |
Set-up shared drive folder organized by patient’s last name alphabetically with year |
Perinatal Director |
12/13 |
Used a single location to capture approved patients’ information |
Educated physician offices on need for prenatal record and medical indication for deliveries under 39 weeks to be provided to all OB/GYN physicians with privileges. |
PI Department |
12/13 |
Increased use of the standardized form and understanding of |
The team presented the project to all of OB/GYN physicians and gained their support in November 2013. This would ensure compliance and acceptance of this quality focus as well as promote patient-and family-centered care.
The team developed a streamline approach to ensure that patients scheduled in the Perinatal Services and Surgical Services were screened utilizing the new form in October 2013. This standardized pre-screening process was collaboratively developed by Surgical Services, Perinatal Services, OB/GYN physicians, and OB/GYN offices to not only decrease elective delivery rates, but also improve communication between departments and increase physician and patient satisfaction. As the initiative rolled out, the team continuously obtained feedback from all departments involved to modify the process and sustain results.
Exhibit EP8EOa: Early Elective Delivery Pre-Screening Process for OR Scheduler
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Fritza Henry, BSN, RN, CMSRN |
PI Nurse |
PI |
Facilitator and Internal Experts |
Larissa Vega, BSN, RN, CMSRN, CPHQ |
PI Supervisor |
PI |
Facilitator and Internal Experts |
Katherine Adamson, BSN, RN,RNC |
Clinical Nurse Educator |
Perinatal |
Team Member |
Carmen Bouchard, MSN, RN, CNOR |
Director |
Surgical Services |
Team Member |
Lisa Everett, RN |
Patient Care Supervisor |
Perinatal |
Team Member |
Jan Weatherspoon, MSN, RN, NEA-BC |
Director |
Perinatal |
Team Member |
Leah Williams-Jones, MSN, RN, RNC, CNML |
Patient Care Manager |
Perinatal |
Team Member |
Charles Augustus, MD |
OB/GYN Physician |
Medical Staff |
OB/Neonatology Physician Steering Committee Chair |
Julie Reed |
OR Scheduler |
|
Team member |
OUTCOMES
Improvement Due to a Change in Clinical Practice
Exhibit EP8EOb: Percentage of Elective Deliveries Prior to 39 Completed Weeks of Gestation in Homestead Hospital
Analysis: The early elective delivery rates have decreased from 16% in March of 2013 to a consistent 0% since July of 2013. There was one outlier noted in April 2014 but the percentage went back again to 0 for 4 consecutive months since then. The number of early elective delivery newborn NICU transfers has also consistently remained at zero since implementing this pre-screening process in July of 2013.
Summary of Attachments/Hyperlinks/Evidences
Exhibit EP8EOa: Early Elective Delivery Pre-Screening Process for OR Scheduler
Exhibit EP8EOb: Percentage of Elective Deliveries Prior to 39 Completed Weeks of Gestation in Homestead Hospital