Targeting early deliveries
Initiative helped reduce admissions of premature babies to NICU by 25%
Healthy babies are worth the wait,” according to the March of Dimes, and I wholeheartedly agree. Research shows that babies born as the result of early-term, non-medically necessary deliveries have higher neonatal intensive-care unit admissions and increased complications. Babies’ organs continue to develop during the last few weeks of gestation, so those born prematurely have an increased chance of complications and often receive costly specialized care in the neonatal intensivecare unit. Yet the practice of non-medically necessary deliveries before 39 weeks continues. According to one estimate, such deliveries may constitute 10% to 15% of all births. An article from the November 2010 American Journal of Obstetrics and Gynecology estimates 500,000 NICU days at a cost of $1 billion annually would be saved if this practice were discontinued.
Medical professional societies, government leaders and national advocacy groups have encouraged physicians and hospitals to discontinue early-term, non-medically necessary deliveries. Hospitals have an important role to play, and several have implemented hard-stop policies to eliminate them. These policies include adopting a scheduling procedure that requires physicians to provide a medical indication before performing an early-term delivery or seeking approval from the department chair or another authorized person.
Woman’s Hospital’s launched its initiative in 2007 through a collaborative with the Institute for Healthcare Improvement. As a result of the policies we have implemented, admission of premature babies into our NICU has declined by more than 25%. In 2011, Louisiana’s Department of Health and Hospitals joined the effort as the first state agency to target elective births before 39 weeks, and Woman’s helped obtain signed pledges from hospitals in the state that performed more than 1,000 deliveries annually. In 2012, DHH modified the birth certificate to require the reason for delivery before 39 weeks gestation. DHH also provided financial assistance to participating hospitals to offset the cost of IHI membership so that hospitals are equipped with the tools they need to be successful. Because 70% of the babies in Louisiana are covered by Medicaid, it was a smart investment.
We began our journey by forming a multi-
The benefits of protecting the health
of newborns far outweigh the costs.
disciplinary council of nurse managers, quality specialists, administrators, physicians and the medical director. Team members, including nurse champions and community physicians, attended national meetings and IHI conferences every six months to review evidencebased practices and discuss progress with other organizations in the same pursuit.
Our team shared what they learned at the IHI meetings with staff and led a discussion on Woman’s most recent data. The entire team analyzed discrepancies in the data and suggested changes that could perfect the guidelines and improve outcomes. All team members provided input and came to an agreement on the appropriate next steps for Woman’s Hospital.
This type of collaboration was essential. To alleviate tension among patients and their families, physicians and the hospital, obstetricians were encouraged to advise patients that hospital regulations prohibited early-term deliveries that are not medically necessary. Obstetric patients received pamphlets during prenatal visits identifying the potential risks associated with births, the importance of waiting was discussed in prenatal classes and we worked with the March of Dimes to increase awareness.
Pediatricians also assisted by explaining the risks to the baby with expectant parents. The discomfort and inconvenience that caused mothers to request inductions quickly dissi- pated when they understood the consequences of delivering early.
The implementation of hospital policies to reduce early-term, non-medically necessary deliveries requires the investment of considerable resources to collect the data, monitor progress and educate employees, the medical staff, patients and their families. But the benefits of protecting the health of newborns far outweigh the costs. And although revenue in the NICU has been reduced considerably because of the elimination of admissions for early-term deliveries, we never questioned the decision because it is simply the right thing to do.
As a field, all hospitals must address the rise in early-term, non-medically necessary deliveries and educate patients on their potential consequences. That’s why the American Hospital Association’s board of trustees recently adopted a formal position that supports policies to eliminate early-term, non-medically necessary deliveries. The AHA is supporting its position statement regarding the elimination of early-term non-medically necessary deliveries by sharing strategies and best practices with our members online and in a webinar.
The CMS and its Partnership for Patients initiative also encourage facilities across the country to pledge to eliminate early elective deliveries. America’s hospitals are committed to protecting the health and well-being of all patients, including newborns. Improving our nation’s health by using evidence-based practices will improve patient outcomes while making the most effective use of resources.
For these reasons, eliminating elective deliveries prior to full-term gestation should be a priority for hospitals. We know that it will lead to better outcomes for patients and communities, and we encourage all hospitals to participate in this critical effort so that our youngest patients may reach their highest potential.
Teri Fontenot is president and CEO
of Woman’s Hospital, Baton Rouge, La., and American Hospital Association board chair.