Evidence–Based Practice: I Know It’s the Best Practice; Where on Earth Do I Start with the Changes? (A look at how to implement changes to decrease elective deliveries < 39 weeks gestation.)
- Review the importance of reducing elective deliveries less than 39 weeks gestation.
- Discuss typical behaviors impeding change processes in various disciplines and discuss various ways to overcome these behaviors.
- Describe a variety of methods to implement process changes to reduce elective deliveries less than 39 weeks gestation in the private OB/GYN physician office as well as the hospital setting.
After multiple complaints from OB/GYN physicians regarding scheduling inductions, we revised our induction process. In the process we discovered challenges especially when working with over 40 private physicians, administration, departmental leadership and staff nurses. The idea of practicing ‘as we’ve always done it’, was a huge hurdle for our team.
Feedback from private OB/GYN physicians revealed a lack of a process for scheduling inductions for labor. Any physician office could schedule the induction with any individual on the unit at any point during the patient’s pregnancy and for any gestational week. This led to difficulty scheduling inductions for medical concerns, which further led to chaos on the labor and delivery unit.
Framework for the talk:
A thorough literature review revealed that scheduling elective deliveries less than 39 weeks might cause an increased length of stay, an increased chance for a cesarean delivery and an increased chance of NICU admission. During implementation, the process of scheduling inductions, induction standing orders, and the induction policy were revised. Various educational opportunities were provided for physicians, physician offices, administration, leadership and staff nurses. Medical records of patients delivering less than 39 weeks were reviewed by both nursing staff and the Medical Staff Quality Liaison. Although we had a physician peer review committee, we strengthened that committee with a sub-committee of physicians to review medical records of patients delivering less than 39 weeks. Medical records were assigned to physicians on the sub-committee and only the records with a questionable reason for induction were processed through to the full physician peer review committee. Physicians practicing outside the set standard were sent a letter stating their chart was tagged and given the option to further discuss with the chief of OB/GYN services.
Implications for practice:
Our induction of labor for elective deliveries less than 39 weeks gestation has decreased by 6%. Our healthcare system ended monthly meetings for constructing a transitional care nursery since the well baby nursery rarely has the number of newborns needed to support a ‘step down’ unit. This is not only a cost savings to our healthcare system; this is also a savings to the stress to those parents.
Although deliveries less than 39 weeks continue for medical reasons, the dramatic decrease in elective deliveries has changed how our healthcare system views evidence based practice and the process of making those changes.
