Reducing Cesarean Deliveries in Low Risk (NTSV) Women
Title: Reducing Cesarean Deliveries in Low Risk (NTSV) Women
- Appreciate why the National Quality Forum (NQF) and the Joint Commission (TJC) have selected PC02 – Cesarean Section (low risk deliveries – NTSV) as a quality measure of perinatal care.
- Recognize essential tools to improve the quality of care and achieve breakthrough outcomes.
- Illustrate the RPI (Rapid Process Improvement) process. Share lessons learned and the path forward.
Reduce cesarean deliveries (C/S) in Nulliparous, Term, Singleton, Vertex (NTSV) women by 10% over the next 18 months (from 28.3% to 25.5%)
Proposed change:
Training a multi-disciplinary team in Rapid Process Improvement (RPI) techniques and promoting use of quality tools to plan, prioritize and execute rapid cycle testing empowers team members to actively participate in successful quality initiatives; laying the foundation to build a culture of continuous quality improvement.
Implementation, outcomes and evaluation:
Reducing Cesarean delivery (C/S) rates in NTSV women is a NQF and Joint Commission endorsed perinatal quality measure. In 2014, TJC is mandating hospitals with > 1100 deliveries/year to report this quality indicator (PC02). When we embarked on this journey, our C/S rate in NTSV women was 28.3%. A multi-disciplinary team convened to participate in a 90-day RPI program. The team established a goal to reduce C/S in NTSV women by 10% (25.5%) over the next 12-18 months. Utilizing tools provided in the RPI program, the team collected baseline data, mapped current and ideal flow processes, completed a cause and effect analysis (Fishbone diagram) and priority impact matrix to determine what initiatives to focus on first. Administrative support was secured. Oxytocin order sets were standardized. A minimum Bishop score of >8 was mandated to schedule an elective induction. Widespread educational efforts were set in motion including a Grand Rounds presentation on “Preventing the First Cesarean Delivery”. Nurses were educated on calculating Bishop Scores, order set changes, benefits of laboring down, and the importance of adhering to existing guidelines. Ideas solicited from our Family Advisory council fostered community educational efforts promoting the importance of going the “full 40 weeks of pregnancy”.
As of July, 2013 (7 months into this initiative), our rate is 26.3%, demonstrating a 7% reduction in NTSV C/S. Hospitalist and resident staff (early adopters) that embraced an evidence-based labor algorithm realized a 14.8% reduction in C/S (27% down to 23%) and NICU admissions in NTSV deliveries decreased 18% (17.1 to 13.9%) for our early adopters.
It is critical to fully understand processes and collect complete baseline data to effectively target interventions for the greatest impact. Future efforts will focus on medically induced patients.
Implications for nursing practice:
It is essential to involve frontline staff and set clear expectations to promote evidence-based practices. Valuable quality tools exist to guide and sustain quality improvement endeavors.
Keywords:
PCO2, Perinatal Quality measure, RPI, CQI, Low risk cesarean, NTSV