Oak­wood’s suc­cess in­spires statewide OB pro­gram curb­ing early de­liv­er­ies

Modern Healthcare - - BEST PRACTICES - By Mau­reen McKin­ney

A decade ago, it wasn’t unusual for doc­tors at Oak­wood Hos­pi­tal and Med­i­cal Cen­ter in Dear­born, Mich., to in­duce la­bor or per­form elec­tive ce­sarean sec­tions on women who had not yet reached the 39th week of preg­nancy.

The rea­sons for those early elec­tive de­liv­er­ies var­ied, in­clud­ing physi­cian con­ve­nience, pa­tient pref­er­ence and a poor un­der­stand­ing of the se­ri­ous med­i­cal risks in­volved, said Dr. Charles Cash, med­i­cal direc­tor of women’s ser­vices for four-hos­pi­tal Oak­wood Health­care, based in Dear­born. “We ex­pe­ri­enced a num­ber of oc­ca­sions where ba­bies were de­liv­ered early and de­vel­oped lung com­pli­ca­tions and needed to be trans­ferred to the ICU,” he said.

The tip­ping point for Cash, then Oak­wood Hos­pi­tal’s chief of ob­stet­rics and gy­ne­col­ogy, came when Chil­dren’s Hos­pi­tal in Detroit said it would no longer ac­cept trans­ferred new­borns from Oak­wood if they had been in­duced or de­liv­ered be­fore 39 weeks with­out a good med­i­cal rea­son. “They said we were fill­ing their ICU with ba­bies de­liv­ered at 36 and 37 weeks,” he said. “We re­al­ized we needed to in­ter­vene and de­velop cri­te­ria so th­ese ba­bies had time to de­velop.”

Or­ga­ni­za­tions such as March of Dimes sounded the alarm for decades about high com­pli­ca­tion rates as­so­ci­ated with elec­tive de­liv­er­ies be­fore 39 weeks, in­clud­ing breath­ing prob­lems, feed­ing is­sues and higher mor­tal­ity rates. Still, the num­ber of th­ese de­liv­er­ies held stub­bornly steady un­til about four years ago, af­ter the re­lease of sev­eral com­pelling stud­ies and an ag­gres­sive im­prove­ment ef­fort led by or­ga­ni­za­tions such as the Leapfrog Group.

Since then, early elec­tive de­liv­er­ies have fallen sharply across the coun­try, with many states now re­port­ing rates of less than 10%, ac­cord­ing to Leapfrog data re­leased this year. Rates at some hos­pi­tals, how­ever, are still higher than 30%, Leah Bin­der, Leapfrog CEO, said in a news re­lease. “There is still work that needs to be done,” she said.

Oak­wood Hos­pi­tal took steps to curb early elec­tive de­liv­er­ies long be­fore the is­sue was on most hos­pi­tals’ radar, Cash said. In 2005, the hos­pi­tal adopted a “hard-stop” pol­icy that for­bade elec­tive in­duc­tions and C-sec­tions be­fore 39 weeks. The en­tire Oak­wood sys­tem soon im­ple­mented the same pol­icy.

Oak­wood ex­pe­ri­enced some push­back from a few physi­cians at the out­set, but ad­dressed it with an ap­proach com­bin­ing physi­cian ed­u­ca­tion and sham­ing, mainly by turn­ing away pa­tients re­ferred be­fore 39 weeks. “If a pa­tient showed up for an in­duc­tion at 38 weeks, six days, they were sent home and the physi­cian was called and coun­seled,” Cash said.

Those early ef­forts caught the at­ten­tion of the Michi­gan Health and Hos­pi­tals As­so­ci­a­tion. The as­so­ci­a­tion had achieved dra­matic re­sults re­duc­ing cen­tral-line as­so­ci­ated blood­stream in­fec­tions and ven­ti­la­tor-as­so­ci­ated pneu­mo­nia, and it was look­ing to tackle other pa­tient-safety is­sues.

In 2009, the as­so­ci­a­tion launched MHA Key­stone: Ob­stet­rics, a 15-hos­pi­tal pilot aimed at pro­mot­ing peri­na­tal safety prac­tices and im­prov­ing out­comes for moth­ers and ba­bies. The par­tic­i­pat­ing hos­pi­tals, in­clud­ing Oak­wood, were pro­vided with ed­u­ca­tional tools and re­ceived reg­u­lar feed­back. Over the course of the year­long pro­gram, elec­tive in­duc­tions fell 62% and elec­tive C-sec- tions dropped 68%, ac­cord­ing to re­sults pub­lished in the Joint Com­mis­sion Jour­nal on Qual­ity and Pa­tient Safety.

The pro­gram since has been ex­panded to in­clude 65 Michi­gan hos­pi­tals, ac­count­ing for 80% of all births statewide, said Sam Wat­son, the hos­pi­tal as­so­ci­a­tion’s se­nior vice pres­i­dent who heads the MHA Key­stone Cen­ter for Pa­tient Safety and Qual­ity. Hos­pi­tals have re­duced early elec­tive de­liv­er­ies by 68%, from 4.75% in 2010 to 1.53% in 2012, and neona­tal ICU ad­mis­sions fell 35%. Wat­son credits the project’s suc­cess to the use of ev­i­dence-based prac­tices and to cul­ture change among clin­i­cal staff.

Prac­tices like hard-stops for early de­liv­er­ies and ap­pro­pri­ate use of the la­bor-in­duc­ing drug pitocin are now stan­dard at Oak­wood, Cash said. “The med­i­cal staff un­der­stands what they can and can’t do,” he said. “It’s ev­i­dence­based care—it’s as sim­ple as that.”

The num­ber of early elec­tive la­bor in­duc­tions across Oak­wood Health­care’s hos­pi­tals fell from three in 2009 to zero for 2010, 2011 and 2012. There have been no early elec­tive C-sec­tions since 2011, said Nancy Gray, Oak­wood’s ad­min­is­tra­tor of women’s ser­vices.

Wat­son praised the work of Cash and oth­ers at Oak­wood. “They were a strong voice in en­cour­ag­ing their col­leagues, and they set the ex­am­ple of that de­sire to seek im­prove­ment,” he said.

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