SummaryAlice Peck Day Memorial Hospital, a small, rural facility, implemented a multifaceted quality improvement project to reduce the length of time between the decision to perform an emergency cesarean delivery and the start of surgery (decision-to-incision time). Key components include an automated call scheduling system, an anesthesia questionnaire that all pregnant mothers complete before delivery, elimination of unnecessary steps and paperwork before and during surgery, nightly preparation of the operating room with supplies for an emergency cesarean delivery, and periodic simulations of emergency scenarios. A 5-year evaluation found that the program reduced mean decision-to-incision time and increased the percentage of emergency cesarean deliveries that began in less than 30 minutes, as recommended by guidelines. In addition, the total number of emergency cesarean deliveries decreased.Moderate: The evidence consists of an evaluation of trends in decision-to-incision time, the percentage of cesarean deliveries beginning in less than 30 minutes, and the total number of cesarean deliveries.
Developing OrganizationsAlice Peck Day Memorial Hospital
Date First Implemented2002
Gender > Female; Vulnerable Populations > Rural populations; Women
Problem AddressedThe American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that emergency cesarean deliveries begin within 30 minutes of the decision to perform the procedure.1 Small, rural facilities face a challenge in meeting this goal due to the relatively few number of staff qualified to perform such deliveries and the challenges associated with quickly assembling qualified staff who may not be present in the hospital.
- Limited qualified staff: Small, rural hospitals have a limited number of staff, with varying levels of training. Not all providers with obstetric privileges are qualified to perform cesarean deliveries. Although a provider trained to do a cesarean delivery is always accessible, he or she may not be immediately available within the hospital.2
- Obstacles to getting qualified staff together quickly: To assemble a qualified surgical team within 30 minutes, key staff must be contacted quickly in an organized fashion. In addition, established mechanisms are needed to find backups in the event that staff members initially contacted are unavailable. Though many small, rural facilities have a designated emergency cesarean delivery team, they are faced with technological and infrastructural challenges to perform these tasks effectively.
Description of the Innovative ActivityAlice Peck Day Memorial Hospital implemented a multifaceted program to reduce decision-to-incision time. Key components include an automated call scheduling system, an anesthesia questionnaire that all pregnant mothers complete before delivery, elimination of unnecessary steps and paperwork before and during surgery, nightly preparation of the operating room (OR) with supplies for an emergency cesarean delivery, and periodic simulations of emergency scenarios.
- Automated call scheduling system: The hospital developed a more efficient way to assemble teams to perform emergency cesarean deliveries. Under the old system, team members were listed on the main hospital call schedule in multiple places, with nurses being responsible not only for maintaining the call schedule and paging each person individually, but also tracking his or her response. Compounding this problem, the schedule sometimes contained inaccurate or out-of-date telephone numbers. These inefficiencies resulted in critical time being lost while nursing staff waited for return phone calls and sorted through incomplete contact information. The new system uses a dedicated cesarean delivery phone line operated by an answering service that maintains the on-call list. When an emergency arises, the lead physician calls the answering service, which immediately contacts all team members simultaneously via computerized speed dialing. Team members respond by calling the answering service; an individual with the answering service receives these calls and notifies the birthing center when all team members have acknowledged that they are on their way to the hospital. In the event that a team member does not respond, the birthing center nurses and the answering service activate a calling tree algorithm to locate a substitute team member. Team identification and notification, which frequently took 20 minutes or more previously, now can be completed within 5 minutes, thus allowing nurses to focus on patient care. To ensure the system is always working properly, the answering service tests the system each night, with cesarean delivery team members being required to respond to the calls.
- Anesthesia questionnaire: Anesthesia staff created a standardized questionnaire that all prenatal patients must complete when they reach their seventh month of pregnancy. The questionnaire covers issues pertinent to anesthesia administration (e.g., allergies, family history of malignant hyperthermia). An anesthesiologist reviews the questionnaire well before delivery so that he or she can identify and evaluate patients at high risk for anesthesia complications in advance. The questionnaire, placed in the inpatient record, remains readily accessible in the event of an obstetric emergency.
- Streamlining of steps before and during surgery: Streamlined processes eliminate steps that previously provided no benefit to patients but delayed decision-to-incision time. For example:
- Nurses developed a concise preoperative checklist specific to cesarean deliveries to replace a lengthy preoperative form for all surgeries that routinely caused delay and frustration.
- Patients are no longer transferred to a stretcher before being transported to the OR, as this step further delayed the patient's arrival. Instead, the patient's bed is wheeled directly to the OR, with the patient remaining in the bed during the delivery.
- Nurses and certified nurse midwives are now empowered to transport patients to the OR in certain circumstances (e.g., cord prolapse, hemorrhage, bradycardia) instead of waiting for the attending obstetrician to make the decision.
- Foley catheters are no longer routinely inserted before transport to the operating room. The attending obstetrician decides in the OR if there is sufficient time to insert a Foley catheter.
- OR preparation: Although emergency cesarean deliveries remain relatively rare events (occurring approximately once every 90 days), nurses and OR staff prepare the OR for an emergency cesarean delivery each evening and conduct a nightly check of preparedness. To reduce last-minute scrambling for supplies, nurses created a list of all needed equipment that would allow a surgeon to start a case, which is stocked in cesarean delivery kits in the OR. Staff also place a dedicated infant stabilet (warming table for newborns) outside the OR each evening.
- Emergency simulations: Staff periodically conduct mock drills of various scenarios of an emergency cesarean delivery, using a volunteer as the patient. These simulations were initially conducted each month and are now done on a quarterly basis. Staff response is timed, and after the simulation, staff review and discuss potential opportunities for improvement.
Context of the InnovationAlice Peck Day Memorial Hospital is a 32-bed hospital in Lebanon, NH, with a birthing center and Level I nursery. Cesarean deliveries are performed in the hospital's main OR by a team consisting of an attending obstetrician, a pediatrician, an anesthesiologist, a nurse, and two OR staff. The impetus for this project came from a sentinel event in 2001 that followed a complicated pregnancy. The hospital's root-cause analysis identified several potential contributing factors, one of which was delayed initiation of cesarean delivery. A subsequent review found that the hospital was not consistently meeting the 30-minute guideline. An obstetrician and birthing center nurse manager agreed to co-chair a quality improvement project aimed at reducing decision-to-incision time.
ResultsA 5-year evaluation found that the program reduced mean decision-to-incision time and increased the percentage of emergency cesarean deliveries that began in less than 30 minutes. In addition, the total number of emergency cesarean deliveries decreased.
Moderate: The evidence consists of an evaluation of trends in decision-to-incision time, the percentage of cesarean deliveries beginning in less than 30 minutes, and the total number of cesarean deliveries.
- Reduced decision-to-incision time: The mean decision-to-incision time decreased from 31 minutes before program implementation (in 2002) to 20 minutes in the spring of 2006.
- More on-time starts: The percentage of emergency cesarean deliveries beginning within 30 minutes increased from 50 to 100 percent over the same timeframe.
- Fewer emergency cesarean sections: The number of cesarean deliveries classified as emergencies dropped significantly, from an average of 22 in 2002 to an average of 4 per year in the subsequent years. Although the precise cause of this decline is not known, hospital officials theorize that the program has resulted in better communication and increased trust and confidence among staff. Because many of the same staff participate in all deliveries (emergency and nonemergency), physicians may feel more capable of completing a difficult delivery without calling for an emergency cesarean delivery.
Planning and Development ProcessPlanning and development included three phases:
- Phase I: The first phase, completed in the summer of 2002, included three key steps:
- Developing working model: The project co-chairs formed four working groups based on job category, with separate groups consisting of birthing center nurses, obstetric and pediatric physicians, anesthesiologists, and OR personnel. This approach helped to solicit input from all staff even though not everyone could meet at the same time.
- Process mapping: Periodically, each group met separately with both co-chairs present to identify and improve components of the emergency cesarean delivery process. The co-chairs also met on their own between these sessions, allowing them to integrate the improvements and spread changes across working groups.
- Data collection: To identify barriers to efficiency, the co-chairs collected data after each emergency cesarean delivery, including decision-to-incision time, time needed to contact team members, and time needed to move the patient from the birthing center to the OR. The co-chairs shared these data with the working groups.
- Phase II: The second phase, completed in the spring of 2003, included two key steps:
- Simulations: Selected members of each working group participated in several simulations of emergency cesarean deliveries. These sessions clarified participants' roles and identified unnecessary steps that could be eliminated.
- STAT pathway: Knowledge gained from the simulations led to the creation of the new emergency process, known as the STAT pathway, which was represented on a flowchart posted in the birthing center. Each working group provided feedback on the pathway, leading to the development of a final flowchart.
- Phase III: The third phase, completed in the spring of 2004, included two key steps:
- Implementation of new procedures: The STAT pathway flowchart was used to train birthing center nurses on how to prepare the OR and the patient for an emergency cesarean delivery.
- Institutionalization of process improvement: The co-chairs instituted several measures to prevent complacency, such as running periodic simulations of emergency cesarean deliveries, conducting an ongoing evaluation of decision-to-incision time for emergency deliveries, and incorporating the STAT pathway into staff orientation (including making it part of the annual assessment of nursing core competencies).
Resources Used and Skills Needed
- Staffing: The project did not require the hiring of additional staff members. The working groups met during regular work hours, so no overtime was required.
- Costs: The project led to the purchase of additional supplies, such as the delivery kits, but these costs were not significant. In addition, the hospital auxiliary donated funding for the purchase of the infant stabilet, which cost about $12,000.
Tools and Other ResourcesKey documents related to the program, such as the emergency cesarean section flowchart and the emergency OR checklist, are available via e-mail from the innovator.
Getting Started with This Innovation
- Develop simple goals: When working to improve a complex procedure, such as an emergency cesarean delivery, program leaders can easily become distracted by details related to how to define success. They can avoid this by choosing a simple goal, such as working to ensure that decision-to-incision time remains below 30 minutes, and by constantly reminding staff that the ultimate goal is to ensure patient safety.
- Choose skilled facilitator: Because job responsibilities may change, it is critical that those spearheading the project have credibility among all staff. Ideally, one of the project leaders should be an obstetrician with experience performing emergency cesarean deliveries.
Sustaining This Innovation
- Continue with simulations: Ongoing simulations of emergency cesarean deliveries (at least once each quarter) help ensure that staff members stay focused on the project's 30-minute goal and continue searching for ways to improve the process.
- Incorporate pathway into staff orientation: All new staff members should be trained on emergency cesarean procedures during orientation.
Contact the InnovatorSusan E. Mooney, MD, MS
Chief Medical Officer, VP, Staff Gynecologist
Alice Peck Day Memorial Hospital
125 Mascoma St.
Lebanon, NH 03766
Innovator DisclosuresIn addition to being employed by the Alice Peck Day Memorial Hospital, Dr. Mooney is also a member of the hospital's Board of Trustees.
References/Related ArticlesMooney S, Ogrinc G, Steadman W. Improving emergency caesarean delivery response times at a rural community hospital. Qual Saf Health Care. 2007;16:60-66. [PubMed]
American Academy of Pediatrics, The American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, (5th ed). Washington, DC: American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2002, p. 147.
1 American Academy of Pediatrics, The American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, (5th ed.). Washington, DC: American Academy of Pediatrics and The American College of Obstetricians and Gynecologists; 2002, p. 147.
Mooney S, Ogrinc G, Steadman W. Improving emergency caesarean delivery response times at a rural community hospital. Qual Saf Health Care. 2007;16:60-66. [PubMed
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Original publication: March 31, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 13, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 04, 2013.
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