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Sunday, September 26, 2010
Title: Decision to Incision Time for Unscheduled Cesarean Deliveries: Can We Meet the Standard?
Discipline: Childbearing (CB)
Learning Objectives:
Submission Description:- Identify potential barriers to achieving timely delivery for unscheduled cesarean birth
- Discuss the importance of interdisciplinary problem solving and planning for improved care
- Describe spceific opportunities for improved workflow for unscheduled cesarean birth
Decision to Incision Time for Unscheduled Cesarean Deliveries:
Can We Meet the Standard?
The national standard for performing unscheduled cesarean delivery is 30 minutes from the time of decision for cesarean delivery to the time of the incision. There is little evidence supporting a relationship between the decision-to-incision interval and maternal or neonatal outcomes. Despite the lack of evidence, the 30 minute standard is the benchmark in medical-legal proceedings where the timeliness of cesarean delivery is questioned. Published studies indicate that the 30 minute standard is met in only 50 -75% of cases of emergency cesarean delivery.
Observations in our facility suggested that we were not meeting the standard. Review of 36 cases of unscheduled cesarean delivery performed for nonreassuring fetal status demonstrated that the average time from decision to incision was 39 minutes, with a range of 10-90 minutes. The 30 minute standard was met in 25% of cases. This prompted a full review of the process and resources for performing unscheduled cesarean deliveries.
In 2008, 5988 mothers were delivered in our facility, 1226 by unscheduled cesarean delivery. In 1998, 615 laboring women, from a total of 4728 deliveries, required unscheduled cesarean delivery. Despite the near doubling of unscheduled cesarean deliveries, the process had changed minimally and the resources (personnel and physical) had not increased, making it difficult to meet the standard.
Data were shared with medical and nursing staff and a concerted effort was started to improve performance. An audit form was completed for each unscheduled cesarean delivery allowing measurement of:
· Average time from decision to incision for unscheduled cesarean deliveries
· Frequency of meeting 30 minute standard by indication for cesarean
· Reasons for delay when standard not met
With increased awareness, the frequency of meeting the 30 minute standard for cases of nonreassuring fetal status quickly increased to 44% and remained 43-47% over the next year. An interdisciplinary team under the direction of the Executive Medical Director and the Clinical Nurse Specialist formed to review reasons for delays and evaluate the workflow for unscheduled cesarean delivery. The team created a new workflow that included additional resources, delineation of roles, clarification of communication and streamlined procedures. The team provided education on the new workflow to medical and nursing staff and the change was implemented. The new workflow was practiced and reinforced for approximately 3 weeks before data collection resumed.
Our goal is to achieve a decision-to-incision interval of 30 minutes or less for all unscheduled cesarean deliveries. As we move forward with this project we are collecting feedback, identifying unforeseen issues (i.e. neonatal limitations to attend simultaneous deliveries) and revising the workflow as necessary. Initial data collection ( including only 2 weeks of deliveries) revealed improvement in the frequency of meeting the 30 minute standard for all unscheduled cesarean deliveries (33%, previously at 26%) and for cases of non reassuring fetal status, 64%. We are committed to continuing to monitor and refine this project as needed in order to meet our goal.
Can We Meet the Standard?
The national standard for performing unscheduled cesarean delivery is 30 minutes from the time of decision for cesarean delivery to the time of the incision. There is little evidence supporting a relationship between the decision-to-incision interval and maternal or neonatal outcomes. Despite the lack of evidence, the 30 minute standard is the benchmark in medical-legal proceedings where the timeliness of cesarean delivery is questioned. Published studies indicate that the 30 minute standard is met in only 50 -75% of cases of emergency cesarean delivery.
Observations in our facility suggested that we were not meeting the standard. Review of 36 cases of unscheduled cesarean delivery performed for nonreassuring fetal status demonstrated that the average time from decision to incision was 39 minutes, with a range of 10-90 minutes. The 30 minute standard was met in 25% of cases. This prompted a full review of the process and resources for performing unscheduled cesarean deliveries.
In 2008, 5988 mothers were delivered in our facility, 1226 by unscheduled cesarean delivery. In 1998, 615 laboring women, from a total of 4728 deliveries, required unscheduled cesarean delivery. Despite the near doubling of unscheduled cesarean deliveries, the process had changed minimally and the resources (personnel and physical) had not increased, making it difficult to meet the standard.
Data were shared with medical and nursing staff and a concerted effort was started to improve performance. An audit form was completed for each unscheduled cesarean delivery allowing measurement of:
· Average time from decision to incision for unscheduled cesarean deliveries
· Frequency of meeting 30 minute standard by indication for cesarean
· Reasons for delay when standard not met
With increased awareness, the frequency of meeting the 30 minute standard for cases of nonreassuring fetal status quickly increased to 44% and remained 43-47% over the next year. An interdisciplinary team under the direction of the Executive Medical Director and the Clinical Nurse Specialist formed to review reasons for delays and evaluate the workflow for unscheduled cesarean delivery. The team created a new workflow that included additional resources, delineation of roles, clarification of communication and streamlined procedures. The team provided education on the new workflow to medical and nursing staff and the change was implemented. The new workflow was practiced and reinforced for approximately 3 weeks before data collection resumed.
Our goal is to achieve a decision-to-incision interval of 30 minutes or less for all unscheduled cesarean deliveries. As we move forward with this project we are collecting feedback, identifying unforeseen issues (i.e. neonatal limitations to attend simultaneous deliveries) and revising the workflow as necessary. Initial data collection ( including only 2 weeks of deliveries) revealed improvement in the frequency of meeting the 30 minute standard for all unscheduled cesarean deliveries (33%, previously at 26%) and for cases of non reassuring fetal status, 64%. We are committed to continuing to monitor and refine this project as needed in order to meet our goal.
