A series of interventions has reduced the cesarean delivery rate at Beth Israel Deaconess Medical Center from 40% to 29.1% over a seven-year period, and clinicians there say the program could be tailored for use at any hospital.
About one third of newborns are delivered by cesarrean delivery, but the procedure is associated with a number of increased health risks for mother and baby, including increased mortality, as well as longer hospital stays and increased healthcare costs. Clinicians at Beth Israel implemented a series of strategies to reduce the hospital’s nulliparous term singleton vertex (NTSV) cesarean delivery rate. An NTSV cesarean delivery refers to a baby carried to at least 37 weeks in the vertex position, born to women having their first baby delivered by cesarean delivery.
The rate of cesarean deliveries in low-risk women varies significantly from hospital to hospital across the nation, suggesting that some are not medically necessary, notes Mary A. Vadnais, MD, MPH, clinical instructor in the department of obstetrics, gynecology, and reproductive biology at Harvard Medical School, and a maternal fetal medicine physician in the department of obstetrics and gynecology at Beth Israel, both in Boston.
The high cesarean delivery rate at Beth Israel was not extraordinarily high, but many hospitals want to reduce this common measure of quality and outcomes, Vadnais says. The hospital’s rate was a bit higher than average, and focusing on the NTSV cesarean delivery rate helped clinicians discover the real causes.
“Prior to this concept of the NTSV cesarean delivery rate being identified, a lot of hospitals would have attributed their cesarean section rate to the fact that they are a tertiary care center, they take care of high-risk patients, and they are going to see more emergencies and more cesarean deliveries,” she says. “Then, people started separating out this low-risk population of women in their first pregnancy, at term, a singleton baby in a head down presentation, essentially what you would think of as a normal, routine birth. This subset of patients at the lowest risk is meaningful because it takes away the other factors that might influence your cesarean delivery rate in higher risk patients.”
Long Term QI Project
The study was challenging because it took place over seven years, Vadnais says.
“We were sincerely interested and passionate about the topic, and that made it possible for us to maintain the energy and keep the focus on this project over the years,” she says. “If it had not been something we really believed in, I think it would have been possible for the participants to lose interest and the project just fizzle out. When you’re thinking about doing this kind of work in quality improvement, choosing something that you really believe in will probably help make you successful.”
The project also benefitted from the formal support of Toni Golen, MD, medical director of labor and delivery and post-partum at Beth Israel, Vadnais says.
“Another factor is getting as many formal leaders and other stakeholders involved in the project as you can,” she says. “That is especially important in a big project like this, so that you have a lot of people invested in the success of the project and can help sustain it. The more people who feel a commitment to the endeavor, the better.”
Vadnais and other Beth Israel obstetricians implemented a series of interventions in five areas: interpretation and management of fetal heart rate tracings, provider tolerance for labor, induction of labor, provider awareness of NTSV cesarean delivery rates, and environmental stress. (See the story in this issue for some details about the interventions.)
Vadnais and colleagues designed the interventions using published data and assessments of environmental factors in the Beth Israel labor and delivery unit. Some interventions involved standardizing protocols, increasing provider education, or revising guidelines. (The team recently published a study based on their findings, available online at : http://bit.ly/2jxTZvB.)
“We did a big literature review of factors that might affect cesarean delivery rates, our own quality data, and guidelines coming out of the American Congress of Obstetricians and Gynecologists,” Vadnais says. “We were looking for strategies that had shown some benefit in reducing cesarean deliveries, but we didn’t want to have to decide which one was the single strategy we would implement and put all our hopes on. If an intervention had the data to support it, we considered implementing it.”
A common reason for a cesarean delivery is slow progression of labor, but the Beth Israel team noted that many of those procedures may not be warranted if historical norms for labor progress do not apply to modern obstetrical populations. In response, clinicians reassessed how to manage slower labors and avoid cesarean deliveries based solely on the previously expected rate of cervical changes.
Because a hospital’s environmental factors can affect its cesarean delivery rate, the Beth Israel team studied the environment in the labor and delivery unit. They also conducted emergency cesarean delivery drills to strengthen cohesiveness between the provider and unit staff members to improve the unit’s ability to support the physician during an urgent situation. The department also revised visitor guidelines to promote continual emotional support for the patient.
Vadnais notes that the improvement interventions were designed so that they can be easily customized to meet the needs of any medical institution.
“Many hospitals are focused on reducing cesarean delivery rates, so we designed these interventions in a way that we hope can be implemented by other institutions,” Vadnais says. “These are quality improvement initiatives that address some of the most common issues that affect the rate of cesareans in any hospital.”
The NTSV cesarean delivery rate decreased from 34.8% to 21.2%, below the U.S. Department of Health and Human Service’s recommended target rate of 23.9%. The hospital’s overall cesarean delivery rate also declined from 40% to 29.1% over the same period. There was no clinically significant rise in complications among babies or mothers, Vadnais notes.
Because multiple interventions were used at the same time, the Beth Israel team was not able to isolate how much each one affected the cesarean delivery rate, Vadnais says.
“We really couldn’t measure what worked the best. We would implement one intervention, and then that intervention would continue as we implemented more interventions on top of that,” Vadnais says. “The rate reduction was the cumulative effect of everything we implemented. The results do show that quality improvement initiatives can significantly reduce cesareans in low-risk women, which is a benefit to mothers and babies while also reducing healthcare costs.”
Vadnais and her colleagues are continuing the effort to reduce the hospital’s cesarean delivery rates, and this year’s rate is about 20%, half the rate when the interventions began and almost another 10% lower than when formal study ended. Of the cesarean deliveries that still occur, a larger proportion are performed after a period of trying to deliver vaginally, she notes.
For quality leaders interested in reproducing the Beth Israel results, Vadnais recommends choosing one of the interventions that seems most promising to implement at the hospital.
“Start with the one that looks easiest. There was no one that we can say was the best, so start with the one that you think will be easiest to implement and then build from there, adding another intervention when you can,” she says.
There was some resistance to the interventions at Beth Israel, though most clinicians soon got on board because Vadnais and her colleagues could point to the data supporting the effort. However, not everything was received with enthusiasm.
“We make everyone participate in an annual simulation training that takes about four hours, and everyone has something else they’d rather do with those four hours,” Vadnais says. “One way we got compliance with that was to make participation a requirement for hospital privileges. Most things weren’t that demanding and were easier for people to adopt.”
Vadnais cautions that, especially with a long-term project like this, the leaders must not be dissuaded easily by resistance or less than complete adherence to the interventions.
“Don’t take any resistance personally, because it is a natural reaction to change, but most obstetricians are committed to women’s health and will embrace initiatives that will improve patient safety and reduce costs,” she says. “Know that you will encounter some resistance, but stay with the cause and push through.”
SOURCE
- Mary A. Vadnais, MD, MPH, Clinical Instructor, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School; Maternal Fetal Medicine Physician, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston. Email: [email protected].
Series of Interventions Target Cesarean Delivery Rates
Clinicians at Beth Israel Deaconess Medical Center implemented a series of interventions in five areas to reduce Cesarean rates, all evidence-based.
This summary of the interventions is provided by Mary A. Vadnais, MD, MPH, a maternal fetal medicine physician in the department of obstetrics and gynecology at Beth Israel:
- Standardization in interpretation and management of fetal heart rate tracings.
- “Failure to perform a cesarean delivery for non-reassuring fetal heart rate tracing” was removed from the hospital’s peer review committee quality measures. The hospital stopped providing provider feedback on this indicator.
- The hospital educated providers on the use of category systems to describe fetal heart rate tracings, including large posters and pocket cards with category nomenclature and details of each category.
- Communication about fetal heart rate tracings required an assigned category; the term “non-reassuring fetal heart rate tracing” no longer was accepted at board sign-out and in chart documentation.
- Provider tolerance for labor.
- The hospital required participation in didactic and annual simulation training to address operative vaginal delivery and management of shoulder dystocia.
- Beth Israel and the National Institutes of Health consensus statement on vaginal birth after cesarean and encouraged providers to strongly consider it for eligible patients.
- Providers were educated on the modern labor curve and redefined arrest of labor.
- Induction of labor.
- The hospital implemented a hard stop on inductions prior to 39 weeks of gestation. The policy was relaxed somewhat over time, but early inductions still must meet strict criteria and receive approval.
- Cervical ripening agents were limited with a departmental guideline outlining appropriate use.
- The hospital created a guideline on tachysystole to reduce the number of iatrogenic cesarean deliveries occurring with induction or augmentation of labor.
- Clinical practice environment.
- The scheduling system improved so that scheduled cesarean deliveries would start on time consistently so providers could commit to scheduling them when they were not covering the labor and delivery unit.
- Emergency cesarean delivery drills were implemented on the labor and delivery unit, to increase provider confidence in the labor and delivery unit’s ability to support the physician.
- Rules regarding visitors were liberalized to allow more emotional support for the laboring woman.
- Provider awareness of the NTSV cesarean delivery rate.
- All physicians with a biannual letter with personal and departmental rates for NTSV cesarean delivery.
A series of interventions has reduced the cesarean delivery rate at Beth Israel Deaconess Medical Center from 40% to 29.1% over a seven-year period, and clinicians there say the program could be tailored for use at any hospital.
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