Clinical, Hospital and Physician Initiatives

8/14/2019 Clinical, Hospital and Physician Initiatives

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Clinical, Hospital and Physician

Initiatives

Laura E. Riley, M.D.

Medical Director of Labor and Delivery

Massachusetts General Hospital

Boston, Ma


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MGH Quality Assurance and

Improvement as it relates to preterm

delivery

1. Social Inductions2. Elective repeat cesarean delivery

3. Evaluation and management of

threatened preterm labor


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Total Deliveries 3448 3287 3430 3526

Total Inductions 795 (23.1%) 746 (22.7%) 712 (20.7%) 782 (22.2%)

Average gestationalfor electiveinductions

38.7 39.3 39.2 39.1

Average gestationalage for all inductions

39.9 39.8 39.7 39.6

Social Inductions

CY 05 CY 06 CY 07 CY08

Raw data, MGH OBEMR


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What practice patterns exist:

R/O labor

Indications for induction R/O labor practice pattern example


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Specific algorithms are suggested for:

All indicated inductions

Postdates inductions

Diabetes mellitus

Chronic hypertensive women with or without medication do not require induction

prior to 40 0/7 weeks in the absence of other complications such as growth restrictionor oligohydramnios.

Other conditions such as intrauterine growth restriction, antiphospholipid antibodysyndrome, and cholestasis may be indications for induction at particular gestationalages. Management of these cases should be individualized.

In general, social circumstances are not indications for induction. However,management of these cases should be individualized.

.

Indications for Inductions


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Counseling for induction:

Risks/benefits of medications

Risk of cesarean delivery

When scheduling an induction for any indication:

Specify Bishop score and indication when scheduling the procedure.

Indications for Inductions


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I. Goals

The primary goal of this management proposal is to improve theefficiency of the evaluation of a patient with suspected hypertensive complicationof pregnancy in triage on Labor and Delivery at MGH. This goal will be achieved

by both decreasing the number of patients who come to triage for evaluation andby decreasing the length of stay in triage.

a. An evidence-based approach should be used to determine patient selectionfor evaluation.

b. It is recommended that whenever possible the evaluation of suspectedhypertensive complication of pregnancy should be performed in the outpatientoffice setting. L&D triage evaluation should be reserved for patients who are

potentially sicker and may need to be admitted to the hospital.

c. Attempts should be made to decrease the length of time necessary tocomplete the evaluation in triage.

Evaluation for R/O Preeclampsia


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II. Definition of preeclampsia

a. Mild preeclampsia is BP>=140/90, proteinuria >=300mg/24 hours

b. Severe preeclampsia is BP>= 160/110 x2, 6 hours apart, proteinuira>=5grams/24hours, symptoms ( HA,visual changes,RUQ pain), elevated LFTs, PLT


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IV. Location of evaluation

It is the goal within our group practice to complete the evaluation of a

patient with suspected hypertensive complication of pregnancy in theoutpatient office setting. This will permit the patients primary provider to

provide continuity of care and avoid the duplication of evaluations and

confusion in plan that occurs when multiple providers are

involved. This will also decrease the in house waiting time for patients

pending their results. However the following patients are candidates for

evaluation in L&D triage.

a. A patient at any gestational age (>20 weeks) who may have severe PET

should be evaluated in triage on L&D

b. A patient with mild preeclampsia at >or= 39 weeks with a favorable cervix should be

admitted directly to L&D by their primary provider for induction without stopping in triage.

c. A patient who has extremely difficult circumstances which might make their outpatientevaluation of PET incomplete may be evaluated in triage.

d. If none of the above apply and a patient is a suspect for mild preeclampsia we recommendthat the evaluation for preeclampsia is completed as an outpatient.

Evaluation for R/O Preeclampsia


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Postdate Decision Tree

Pregnancy

410/7 Weeks

YES

Favorable

Cervix

(Bishop >5)

NO

NST/Fluid

Check or BPP

Reassuring

NO YES

Tx to L & D

for Induction

Expectant

Management

Reassess fetalstatus with NST@ 41+ weeks &

Schedule

Induction by 42

Weeks

Schedule

Induction

Within 4 days

YES

B

Raw data, MGH OBEMR


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Scheduled Repeat Cesarean Section

Patients with lower segment incisions, who

decline a trial of labor, can be delivered at

term. If the cesarean section is scheduled>14 days prior to the EDD, then assessment

of fetal lung maturity. Alternately, the

patient and the clinician may choose toawait the onset of labor.

CRICO/RMF 1999-2006


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Election Repeat C/S prior to 39 weeks

2005 2006 2007 2008

Total C Singletons 1013 987 994 972

Repeat c/s (singleton) 296 316 301 305

Average GA for E c/s 38.95 38.83 38.9 38.86

Singleton c/s less than 39 weeks 83 117 105 115

Raw data MGH OB EMR


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Barriers to Efficient Evaluation of

Preterm Labor

Education AssessmentKnowledge of best practice

US unavailable

FFN kit unavailableFFN Contraindications

Lack of consensus about

best practices

Vaginal exam prior to FFN

Partial evaluation as OP

Efficient

evaluationDissatisfied w/dx

Fear of PTD

Unable to comply with f/u

Refuses discharge

Varying expectations

Patients

Not available

Unable to make decision

Fearful of misdiagnosis

Lack of OP support staff

Provider

P t L b A t i T i


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P r e te r m L a b o r A s s e s s m e n t i n T r i a g e

G e s t a t i o n a l A g e 2 3w k s< 3 4w k s S x: c tx,

c r a m p s, a b d p a i n, p e l v i c p r e s s u r e, P p r o m,

b a c k a c h e, v a g i n a l d/c , b l e e d i n g, s p o t t i n g

(3 4 3 7w e e k s i n d i v i d u a l i z e)

G B S C x GC/ch l am yd i a cx

U r i n e c x T o x s c r e e n

2 o r 8 0% p r i m i p

o r m u l t i p w i t h

C T X o r P P R O M

A d m i t A b x i f i n d i c a t e d( P R O M)P C N f o r G B S u n k n o w n

m e t h a s o n e i f

< 3 4w ks I n d o m e t h a c i n i f < 3 2w kso rM a g n e s i u m s u l fa t e x4 8h rs.

b e t w e e n32-34 w e e k s

r e p e a t e x a min 12 h o u r s

FF N+

C x c h a n g e

FF N

C x c h a n g e

FF N C x c h a n g e

F F N C x c h a n g e

E x t e n d m o n i to r i n g x4 h o u r s o r c o n s i d e r

B O P a n d

m e t h a s o n e

d /c t o h o m eCa l l i n24-48 h o u r s

F /U w i th i n7d

E x t e n d m o n i t o r in gx 4 hr s&

R e e x a m i n e A d m i t t o c o l y s is& m e t h a s o n e

N o c h a n g e

d /c h o m e

Ca l l i n2 4h o u r s, F o l l o w- u p w i t ho u t p a t i e n t a p p t. w i t h i n2-3 d a y s

I n it i a l a s s e s s m e n t:S t e r i le S p e c u l u m

FF N& R /O R u p t u r e

>2 cm> 8 0%

< 2cm< 8 0%

> 2 cm o r > 8 0% m u l t i pw i t h o u t C T X

O r< 2 c m o r < 8 0% p r i m i p


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Compliance with PTL Proto

0

5

10

15

20

25

3035

40

45

Jan Feb Mar Apr May June

Month

No

ofPTL

Patients

FFN contraindicate

FFN done

FFN missed


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Next Steps:

1. Drill down

2. Data or Practice

3. Re-educate

4. Re-evaluate

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Clinical, Hospital and Physician Initiatives