Tiffany Kenny

Implementing an Induction Scheduling Procedure and Consent Form to Improve Quality of Care

Inappropriate elective inductions of labor put patients at increased risk of cesarean, neonatal morbidity, and elevated cost. A scheduling procedure and consent form were implemented to eliminate elective induction at less than 39 weeks gestation and align indications for induction with American College of Obstetricians and Gynecologists guidelines. In 25 of the 28 months following implementation of the new process, we achieved the goal of eliminating elective induction of labor at less than 39 weeks gestation.

Induction of labor in women with a history of fast labor

Abstract Objective: History of fast labor is currently subjectively defined and inductions for non-medical indications are becoming restricted. We hypothesized that women induced for a history of fast labor do not have faster previous labors and do not deliver more quickly. Methods: A retrospective case-control cohort design studied multiparas undergoing elective induction at one high risk center. Outcomes of dyads electively induced for a history of previous fast labor indication (PFast) were compared to controls with a psychosocial indication. Results: A total of 612 elective inductions with 1074 previous deliveries were evaluated: 81 (13%) PFast and 531 (87%) control. PFast had faster previous labors (median 5.5 h, IQR: 4.5–6) versus. control (10 h, IQR: 9–10.5; p < 0.001). Subsequent delivery time from start to expulsion was shorter for PFast (median 7 h, IQR: 5–9, p < 0.001) than controls with and without a previous labor <5.5 h (8.6 h, IQR: 6–14 and 9.5 h, IQR: 7–15, respectively). PFast were less likely to have a serious maternal complication. Neonatal complications were similar. Conclusions: Patients induced for a history of fast labor do have faster previous labors, suggesting a significant history of fast labor can be defined as <5.5 h. These women deliver more quickly and with lower morbidity than controls when subsequently induced, therefore the benefit may warrant the risk for a select number of women with a history of a prior labor length <5.5 h.

Healthcare Decision-making: Targeting Women as Leaders of Change for Population Health

This pilot study was a prospective survey of n = 500 postpartum mothers and n = 36 obstetricians (OBs) to assess characteristics, opinions, and experiences of healthcare. A convenient sample of women on the postpartum floors and OBs were invited to participate in a survey. The survey was distributed from 2013 to 2014 investigating general opinions from women about healthcare decision-making, healthcare experiences during a healthcare stay after delivery, and overall quality of life using the Patient Reported Outcomes Measurement Information System. The majority of women indicated that they made the healthcare decisions for themselves, n = 278 (57.3%) versus n = 191 (39.3%) indicated her and her spouse/partner together made healthcare decisions for her. Interestingly, only 39.3% (n = 69) of women reported that their spouse/partner were the only ones involved in their healthcare decisions whereas women reported to be more jointly involved in healthcare decisions of their spouse’s/partner’s health, n = 313 (66.6%). PROMIS® scores had a significant relationship (p = 0.022) in the global mental domain to age and insurance type with accessing the same facility for future healthcare. Further analysis revealed a significant (p = 0.013) relationship as PROMIS® global mental scores go down, the increased willingness to return to the same birthing facility for future healthcare goes up. Two specific PROMIS® global mental questions were identified as having a significant (p = 0.008) or trending towards significant (p = 0.08) negative value for Kendall’s tau indicating that the lower the score on the PROMIS® global mental question, the more likely they are to visit the same birthing facility in the future for other healthcare procedures. A substantial amount of women are responsible for their family’s health. Future studies should have a longitudinal design to assess the true lifetime impact of the birth experience for a woman on healthcare decision-making for her family.

Maximizing Maternal Birth Experience through the Use of a Labor Mirror

The purpose of this study was to describe the frequency with which mirrors are utilized and describe women’s experience with mirrors during birth. This was a descriptive study. An electronic survey was administered in the postpartum unit from June, 2013 to February, 2014. A convenience sample of n=500 was obtained. The survey intended to gauge the frequency of labor mirror use as well as women’s self-reported experience related to mirror use during labor and/or birth. Postpartum women were included in the project who were English literate and between the ages of 18-49. Statistical analysis included examination of the data and performance of descriptive statistics including Student’s T-Test, Chi-square, and Fisher’s Exact test. Women most likely to use the mirror were in the 18-29 years age group, Caucasian, and privately insured. 39% of women who were offered the mirror used it. According to the women who used the mirror during birth, 53% agreed that it helped them focus on pushing and reduced their pushing time during labor. Additionally, women who used the mirror reported that it added to their overall labor experience and was a positive experience (58%). More than half (53%) of women who used the labor mirror agreed that it assisted them during pushing, added to their overall labor experience (58%), and was a positive experience (55.5%). While additional research is needed, nurses may find the labor mirror to be a beneficial tool to increase pushing efficacy and enhance the maternal birth experience.

Comparative Effectiveness of Cerclage With and Without Adjunctive Therapy on Maternal-Fetal Outcomes [25N]

INTRODUCTION: Often cerclage, alone and in combination with antibiotic coverage, progesterone, and tocolytics are used in women at high risk of preterm birth or cervical insufficiency. METHODS: A retrospective chart review of women who underwent history- or ultrasound-indicated transvaginal cervical cerclage at 12 to 24 gestation. Patients were divided into two groups: cerclage only (CO) or cerclage with adjunctive therapy (CAT). Outcomes of race, insurance type, maternal age (MA), gestational age at placement (GAAP), time from cerclage placement to delivery (TCTD), gestational age at presentation (GAPR), neonatal intensive care unit admission (NICU), APGAR 1-minute (APGAR) were analyzed using SPSS 22.0. RESULTS: No significant differences were noted in general demographics between the CO (n=112) and CAT (n=52) groups in race: White 36% versus 44%, African/American 51% versus 55%, Other 11% versus 6%, (P=.394); insurance type: public 51% and private 48% versus public 55% and private 44% P=.652; MA: 28±5 years, 29±5 years, (P=.211); and GAAP: 115±25 days versus 118±5 days, (P=.804), respectively. Similarly, no significant differences were noted in maternal-fetal outcomes between CO and CAT for TCTD: 130±45 days, 133±46 days, (P=.723); GAPR: 243±39 days, 245±35 days, (P=.804); NICU: 36 admissions versus 18 admissions, (P=.807); and APGAR: 7±2.3, 7.1±2.3, (P=.834), respectively. CONCLUSION: These results indicate that the use of cerclage or cerclage with adjunctive therapy does not provide additional benefits. Further studies with larger samples are encouraged to continue evaluation of the best treatment approach.

A Standardized Postpartum Oxytocin Administration Protocol to Prevent Postpartum Hemorrhage [293]

INTRODUCTION: Postpartum hemorrhage is the leading cause of maternal mortality. Oxytocin is routinely used to prevent postpartum hemorrhage in the United States but dosing is based on limited evidence. Standardized postpartum oxytocin administration is lacking in many facilities. We hypothesized that a standardized postpartum oxytocin administration protocol would prevent postpartum hemorrhage. METHODS: A retrospective quality improvement assessment compared postpartum hemorrhage rates at one level III urban perinatal center for 6 months preprotocol implementation and 6 months postprotocol implementation (60 units of oxytocin over 5 hours). Postpartum hemorrhage was defined as postpartum hemorrhage treatment by pharmaceutical, mechanical, or surgical methods. Inclusion criteria included all deliveries at greater than 23 weeks of gestation from April 2012 to March 2013. RESULTS: The preprotocol group (n=1,267) and postprotocol group (n=1,440) were similar for race, age, parity, gestational age, delivery type, and neonatal weights. The postpartum hemorrhage rate decreased 37% after protocol implementation (adjusted relative risk 0.63, 95% confidence interval 0.46–0.91). Administration of misoprostol, carboprost, methylergonovine maleate, and blood products decreased postprotocol implementation by 36%, 38%, 32%, and 22%, respectively. The postpartum hemorrhage rate for women with a vaginal delivery lowered significantly after protocol implementation (5.9% compared with 3.8%, P=.03). The postpartum hemorrhage rate for women with a cesarean delivery increased but not significantly after protocol implementation (6.9% compared with 8.6%, P=.34). CONCLUSION: Implementation of a standardized oxytocin administration protocol reduced the overall incidence of postpartum hemorrhage. Although we did not control for some postpartum hemorrhage risk factors, our postpartum hemorrhage rate for women delivered by cesarean remains lower than other published rates. This protocol warrants further study.

Rates of Self-Reported Antenatal Mood Symptoms and Obstetric Management Practices

INTRODUCTION: The consequences of untreated, self-reported, antenatal mood symptoms can be detrimental to the mother, neonate, and family but are rarely formally evaluated or treated. The objective of this study was to determine the prevalence of antenatal mood symptoms, implementation of a treatment plan, and associations with race and payor status. METHODS: A 1-year retrospective quality improvement review was performed using OBTraceVue history and physical perinatal data from an urban community hospital. We evaluated and compared self-reported antenatal mood symptoms, referrals to mental health professionals, and psychiatric medication use. &khgr;2 tests were performed to examine the degree of association. RESULTS: Two thousand seven hundred fifty-nine pregnant women were returned with a mean age of 27.4 (±5.94) years: 1,877 (68%) white, 676 (25%) African American, and 206 (7%) other. Six hundred seventy (25%) endorsed anxiety, depression, or other mood symptoms. Of these, 430 (64%) had no mental health treatment; 185 (27%) were referred to a mental health professional only; 43 (6%) received medication only; and 10 (1%) received both. There was a significant difference (P<.001) in self-reporting of antenatal mood symptoms in public benefit pregnant women compared with private benefit pregnant women (odds ratio 3.068, 95% confidence interval 2.492–3.77). There was no significant difference in self-reported antenatal mood symptoms in regard to race. CONCLUSIONS: Antenatal mood disorder symptoms are common and require improved implementation to treatment plans. Public benefit patients endorse mood disorder symptoms more frequently. Further research is needed to better identify and respond to mood disorders in the antenatal period.

Innovative ProgramsImplementing a New Nurse‐Sensitive Quality Metric: Initiation of Breastfeeding Within 60 Minutes of Birth

Paper Presentation Purpose for the Program The purpose of this presentation is to propose a feasible nurse‐sensitive quality metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth,” along with a toolkit for implementation. Proposed Change To develop and define quality measures that are sensitive to obstetric nursing care and can be replicated across institutions. Implementation, Outcomes, and Evaluation A team of seven Magnet‐accredited hospitals collaborated to define the elements of quality obstetric nursing care. The team included perinatal nurses, nurse managers, informaticists, and report writers. A pilot project was established by The Christ Hospital and Summa Health System for the first proposed metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth.” Development of documentation and reporting tools followed. Priorities for development included evidence‐based, simple, and uniform documentation; efficient data collection methods; and reporting tools to track and drive improvements in quality of care. The documentation tool specifies exclusions to breastfeeding and then a presents a single question, “Breastfeeding,” with cascading documentation options based upon the staff entry of yes or no. Staff input was imperative so that the documentation integrated with normal workflow and allowed real‐time access at the point of care. Standardized reporting tools were then developed for enterprise and departmental information systems as well as paper‐based records. Pilot work has resulted in the development of a toolkit for the proposed quality metric, “Initiation of Breastfeeding within 60 Minutes of Birth” and includes documentation and reporting tools, staff education modules, and result dissemination materials. Pilot hospitals have met monthly to evaluate the effectiveness of the toolkits implementation and replicability. Pilot hospitals have been tracking nurse adherence to the metric. Rates of initiation of breastfeeding within 60 minutes of birth based on standardized numerators and denominators are also being evaluated to establish short‐term and long‐term benchmark goals for quality improvement. The next steps for this project involve creating a data‐sharing database and extending pilot work to include the two other quality measures proposed by the team of Magnet‐accredited hospitals. Implications for Nursing Practice Labor and delivery nurses have a critical role to ensure that women initiate breastfeeding within 60 minutes of birth. Implementation of a toolkit to track and improve the initiation of breastfeeding has the potential to increase national breastfeeding success rates and improve maternal and neonatal outcomes. Improving rates of the initiation of breastfeeding can also positively affect the established national metric of exclusive breastfeeding.

Implementing a New Nurse-Sensitive Quality Metric: Initiation of Breastfeeding within 60 Minutes of Birth

Paper Presentation Purpose for the Program The purpose of this presentation is to propose a feasible nurse‐sensitive quality metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth,” along with a toolkit for implementation. Proposed Change To develop and define quality measures that are sensitive to obstetric nursing care and can be replicated across institutions. Implementation, Outcomes, and Evaluation A team of seven Magnet‐accredited hospitals collaborated to define the elements of quality obstetric nursing care. The team included perinatal nurses, nurse managers, informaticists, and report writers. A pilot project was established by The Christ Hospital and Summa Health System for the first proposed metric, entitled “Initiation of Breastfeeding Within 60 Minutes of Birth.” Development of documentation and reporting tools followed. Priorities for development included evidence‐based, simple, and uniform documentation; efficient data collection methods; and reporting tools to track and drive improvements in quality of care. The documentation tool specifies exclusions to breastfeeding and then a presents a single question, “Breastfeeding,” with cascading documentation options based upon the staff entry of yes or no. Staff input was imperative so that the documentation integrated with normal workflow and allowed real‐time access at the point of care. Standardized reporting tools were then developed for enterprise and departmental information systems as well as paper‐based records. Pilot work has resulted in the development of a toolkit for the proposed quality metric, “Initiation of Breastfeeding within 60 Minutes of Birth” and includes documentation and reporting tools, staff education modules, and result dissemination materials. Pilot hospitals have met monthly to evaluate the effectiveness of the toolkits implementation and replicability. Pilot hospitals have been tracking nurse adherence to the metric. Rates of initiation of breastfeeding within 60 minutes of birth based on standardized numerators and denominators are also being evaluated to establish short‐term and long‐term benchmark goals for quality improvement. The next steps for this project involve creating a data‐sharing database and extending pilot work to include the two other quality measures proposed by the team of Magnet‐accredited hospitals. Implications for Nursing Practice Labor and delivery nurses have a critical role to ensure that women initiate breastfeeding within 60 minutes of birth. Implementation of a toolkit to track and improve the initiation of breastfeeding has the potential to increase national breastfeeding success rates and improve maternal and neonatal outcomes. Improving rates of the initiation of breastfeeding can also positively affect the established national metric of exclusive breastfeeding.