Improving Perinatal Care: A Tertiary Care Hospital's Experience with Implementation of the Institute for Healthcare Improvement (IHI) Perinatal Bundles

Rationale:
Adverse events in obstetrics can result in irreparable harm to mothers and neonates. According to the Institute for Health Care Improvement (IHI), oxytocin is estimated to be involved in >50% of the situations leading to birth trauma.  Additionally, failures in communication and documentation are common factors in adverse perinatal events.
The IHI Idealized Design for Perinatal Care model provides that “reliable processes are used to evaluate and manage labor and delivery- the elective induction and augmentation bundles.”  The use of bundles in obstetrics is relatively new.   Care bundles are groups of evidence-based interventions related to a care process that, when executed together, result in better outcomes than when implemented individually.  The perinatal bundles contain elements important to the safe management of patients receiving oxytocin.  Our goal is to create a new level of safety in the care of patients receiving oxytocin and/or dinoprostone.  Major components of the process involve looking at our documentation and communication surrounding induction and augmentation of labor.  Nurses are collecting data, and in collaboration with the medical staff, are analyzing the data, and implementing changes.
Methods/Outcomes:
Nursing and physician leadership participated in an IHI web educational program in 2006.  We customized IHI data collection tools, defining each of the elements of the bundles using current evidence from IHI, AWHONN, ACOG, & AAP guidelines.  In late 2006, we performed pre-implementation chart reviews, examining documentation and management of patients undergoing elective induction or augmentation of labor. Compliance with the augmentation bundle elements were: estimated fetal weight (80%), FHR reassurance (70%), complete pelvic assessment (40%), and monitoring and management of hyperstimulation (50%).  With the elective induction bundle, compliance was: gestational age (80%), FHR reassurance (100%), complete pelvic assessment (20%) and monitoring and management of hyperstimulation (30%).  The team then developed tools to improve  the areas which had the lowest compliance.  A hyperstimulation algorithm and a standardized pre-induction/augmentation progress note were created.  All the nursing and medical staff were given education about the IHI model, our pre-implementation data, and the tools. We reevaluated charts in early 2007.  Improvements were seen in all elements of the augmentation bundle. For the elective induction bundle, there were improvements in pelvic assessment and monitoring and management of hyperstimulation. There was no change in the gestational age element, and a decrease in documentation of FHR reassurance. Commencing July 2007,  we will be reviewing charts using an “all or nothing” concept-  the team will get credit for implementing the bundle only if every element is delivered for each patient, unless medically contraindicated.  We have also collected data about patient outcomes, such as delivery mode, Apgars, birth trauma, resuscitation, hemorrhage, and infection. This information will be utilized to make further improvements as we move forward with the project. Focus groups and an obstetrical service retreat are planned for 2008.
Conclusions/Implications:
The IHI Perinatal Bundles have provided effective processes for evidence-based improvements in documentation and communication in the care of patients during induction and augmentation of labor. It is an ongoing interdisciplinary effort, with nurses providing leadership.