SummaryIntermountain Healthcare adapted an existing guideline and developed associated care processes to ensure that pregnant women undergo early elective inductions (defined as before the baby reaching a gestational age of 39 weeks) only when medically necessary. An electronic system alerts labor and delivery charge nurses when medical indications do not support early elective induction, who then contact providers to notify them that the induction cannot be scheduled. Intermountain also uses various strategies to educate patients about the risks of early elective induction and shares performance reports with obstetric providers on their induction rates and related indicators. The program significantly reduced early elective inductions, average length of labor, and newborn complications, and slowed the rate of growth in cesarean sections (which often become necessary with early inductions).Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key outcomes measures, including early induction rates, average length of labor, rates of newborn complications, and overall and primary C-section rates.
Developing OrganizationsIntermountain Healthcare
Salt Lake City, UT
Date First Implemented1999
Problem AddressedThere has been a national increase in elective inductions since the early 1990s. In Utah, this increase was largely driven by patient preference and provider convenience. These inductions increase the risks to both mothers and babies, as well as increase utilization and drive up health care costs.
- Many convenience-driven early inductions: Many pregnant women request that their obstetric providers schedule early elective inductions for reasons of convenience, such as ease of scheduling or to avoid the uncomfortable last weeks of pregnancy.1 Provider convenience is a factor as well; in a climate of decreasing reimbursement, many providers try to appease patient requests as well as maintain a reasonable lifestyle by scheduling elective inductions.
- Leading to more Cesarean sections (C-sections): Early elective inductions increase the chance that a C-section will be necessary.2 The most common surgery performed in U.S. hospitals today, the number of C-sections has increased by almost 50 percent since 1996. In 2007, nearly one in three mothers (31.8 percent) gave birth by C-section.3
- Add to health risks for mother and baby: Early elective inductions and associated C-sections increase health risks for both mother and baby. For example, at Intermountain, women who deliver before 39 weeks gestational age have longer and more complicated deliveries, and their babies face greater risk of admission to the neonatal intensive care unit (ICU) and medical complications, such as respiratory disorders, elevated bilirubin levels, jaundice, and feeding disorders.1 Compared with vaginal delivery, women undergoing scheduled and unscheduled C-sections face a greater risk of complications (as does the baby), including the need for blood transfusion, hysterectomy, and internal iliac artery ligation (to control bleeding in the pelvis).4
- As well as increased costs and utilization: Inappropriate elective inductions (prior to 39 weeks gestation and/or with an unripe cervix in a nulliparous patient) leads to added risk to mothers and babies, which drives up health care costs.
Description of the Innovative ActivityIntermountain Healthcare adapted an existing guideline and developed associated care processes to ensure that pregnant women undergo early elective inductions only when medically necessary. An electronic system alerts labor and delivery charge nurses when medical indications do not support early elective induction, who then contact providers to notify them that the induction cannot be scheduled. Intermountain also uses various strategies to educate patients about the risks of early elective induction and shares performance reports with obstetric providers on their induction rates and related indicators. Key program elements include the following:
- Guideline regarding elective inductions: Intermountain adopted a modified version of the American College of Obstetrics and Gynecologists (ACOG) guideline stating that obstetric providers should not electively induce a patient before the baby reaches 39 weeks gestational age, except when approved clinical indications exist. Such indications include (but are not limited to) elevated blood pressure (preeclampsia), chronic hypertension, diabetes and insulin use, renal disease, antiphospholipid syndrome, autoimmune diseases, concerns about fetal growth, and risk of rapid labor. Intermountain developed specific parameters for these medical indications to ensure clarity. For example, Intermountain defines preeclampsia as blood pressure greater than 140/90 mm Hg with at least grade 1 proteinuria.
- Standardized process for scheduling elective inductions: Previously, unit clerks could schedule elective inductions. Under the new process, only labor and delivery charge nurses—who are less likely to be swayed by obstetric provider requests—can schedule them using an electronic scheduling system. Medical leadership follows up with physicians in cases of inappropriate elective and indicated inductions.
- Electronic flags, provider notification for inappropriate induction: When a doctor or a midwife refers a patient for elective induction, the labor and delivery charge nurse enters the patient’s clinical characteristics into the labor and delivery electronic charting program (an internally developed program called “StorkBytes”). The program generates an alert if the patient does not meet the health system’s criteria for elective induction. If so, the nurse notifies the physician or midwife that the induction cannot be scheduled and may ask the obstetrics department medical director to intervene with the provider if necessary.
- Patient education: Providers are encouraged to provide patient education (both written and verbal) regarding the risks of early elective inductions, highlighting the potential for poorer health outcomes for mother and baby. Specific strategies include the following:
- Patient brochure: All Intermountain obstetric providers receive educational brochures to distribute to pregnant women that outline the risks of early elective inductions.
- Health plan-sponsored strategies: Intermountain’s health plan, Select Health, educates pregnant women about the risks of early induction as part of its care management activities. For example, the health plan distributes educational materials to pregnant women about safe labor and delivery, covers the topic of elective inductions in regular childbirth education classes, and instructs perinatal care managers to discuss appropriate and inappropriate induction with high-risk patients.
- Provider performance reports: Obstetric provider-specific reports, distributed at department meetings, depict each provider’s performance (as compared with hospital and health system averages) on multiple indicators, including rates of elective and medically indicated inductions, neonatal ICU admissions, length of stay (LOS), complications, and other measures.
Context of the InnovationA nonprofit health system based in Salt Lake City, UT, Intermountain Healthcare operates 23 hospitals, 21 of which offer maternal and newborn services, delivering more than 30,000 babies annually (representing approximately 56 percent of all total deliveries in Utah). The labor and delivery sites vary widely in volume (ranging from 28 to more than 5,000 deliveries a year), patient acuity, and culture. In 1998, Intermountain created a formal Maternal and Newborn Services clinical program to ensure the adoption of evidence-based labor and delivery practices across the system. While evaluating opportunities to improve women and newborns care processes, neonatologists expressed concerns that they were seeing babies in the NICU largely due to inappropriate elective inductions, which frequently led to respiratory distress and the need for neonatal intensive care after birth. In November 1999, ACOG published a practice bulletin stating that elective inductions should not occur before 39 weeks. The Maternal and Newborns Services program decided to adopt this recommendation as a standard of care to improve birth outcomes and support obstetric providers in denying elective inductions.
ResultsThe program significantly reduced early elective inductions, average length of labor, and newborn complications, and slowed the rate of growth in C-sections. As a result, it has generated significant cost savings for insurers, including Intermountain's health plan.
Moderate: The evidence consists primarily of pre- and post-implementation comparisons of key outcomes measures, including early induction rates, average length of labor, rates of newborn complications, and overall and primary C-section rates.
- Fewer early inductions: In 1999, approximately 28 percent of all inductions at Intermountain's hospitals occurred before the baby reached a gestational age of 39 weeks. By 2011, that figure had decreased to less than 2 percent.
- Shorter labor: The significant drop in early elective inductions has reduced the average length of labor for deliveries across the health system, which decreased from 8.3 to 7.8 hours. Several Intermountain facilities experienced larger declines, with the average decreasing by nearly 2 hours. Shorter labors reduce the risk of complications (as discussed in the next bullet).
- Fewer newborn complications: Rates of certain newborn complications have declined since implementation of the program, including anemia (which decreased from 9.9 to 7.4 percent), meconium aspiration (2.0 to 1.3 percent), and low 1-minute Apgar score (defined as a score below 5, which decreased from 8.3 to 6.4 percent).
- Below-average use of C-sections: The Intermountain C-section rate increased by about 30 percent between 1999 and 2011, well below the 50-percent increase experienced nationwide. Intermountain's overall C-section rate currently stands at 21 percent, below the national average of 31.8 percent in 2007 (latest data available). Intermountain's primary C-section rate (women undergoing C-section for the first time) leveled off at 12 percent in 2011 (up modestly from 10 percent in 1999), well below the national rate of 24 percent in 2006 (latest data available).
- Significant cost savings: Intermountain leaders estimate that the elective induction guideline saved insurers (including Intermountain's own plan) nearly $1.7 million over a 5-year period. (As discussed in the Adoption Considerations section, some of this savings comes in the form of lost revenues to Intermountain's hospitals and physicians.)
- Normalization of deviance: Information provided in September 2012 indicates that overall induction rates dropped steeply in Intermountain Healthcare between 1999 and 2002, primarily due to a significant decrease in elective inductions. During this time period, indicated inductions remained stable. By 2004, Intermountain noted a significant increase in the rate of indicated inductions, which was attributed to a liberal interpretation of "medical indications" for induction. In 2010, the system renewed vigilance around scheduling indicated inductions, and coupled this with individual provider data reports and one-on-one provider education as needed in order bring induction rates back down.
Planning and Development ProcessSelected steps included the following:
- Creating guideline: The Women and Newborns Services’ executive council (made up of clinical experts) worked with a group of physicians, nurse midwives, and nurse leaders to adapt the ACOG guideline for use at Intermountain. The team further defined the guideline and added specificity to the ACOG criteria to facilitate use by system obstetric providers.
- Incorporating into electronic medical record (EMR): Intermountain’s information technology (IT) staff programmed the guideline into the labor and delivery electronic charting program so that a patient’s medical record would be flagged if indications for elective induction were not met.
- Developing patient education materials: Intermountain staff developed a patient education brochure and other materials for use by providers.
- Customized launch by hospitals: Intermountain promulgated the guideline across the system, but allowed each site to develop its own process and schedule for educating clinicians and implementing the guideline and associated process changes.
Resources Used and Skills Needed
- Staffing: Initial development of the program required some staff time to customize the guideline and develop associated process changes, including IT staff to program the EMR. Once the program became operational, existing staff incorporated it into their daily routines.
- Costs: As noted, upfront development required some staff time, along with a minimal financial outlay for production of patient education materials.
Funding SourcesIntermountain Healthcare
Tools and Other ResourcesAmerican College of Obstetrics and Gynecologists' “Induction-of-Labor” guideline is available at: http://www.guideline.gov/content.aspx?id=14884.
Getting Started with This Innovation
- Identify clinical champions: Administrator, physician, and nurse champions must promote a culture change around early elective inductions, with an emphasis on supporting clinicians in “doing the right thing.” Intermountain selected clinical champions who had taken improvement courses or who were in medical and nursing leadership roles. Other clinicians also took on leadership roles after being approached by nursing or administrative staff members who asked for their assistance.
- Design clear guideline: The guideline needs to specify clearly the clinical circumstances that define when early induction can be used.
- Implement guideline consistently across sites: The process of guideline implementation varied considerably across Intermountain hospitals, resulting in variation in outcomes and processes across the system. In retrospect, a standardized launch between all hospitals in the system and implementation of improvements as a system would have led to more consistent outcomes between hospitals.
- Involve whole labor and delivery team: Single sites adopting this program should involve the whole labor and delivery team (e.g., physicians, nurses, unit clerks, obstetric provider office staff) in adapting and implementing the guideline. This approach helps to ensure total team support for the new processes and overall culture change.
Sustaining This Innovation
- Share performance data with providers: Providers respond to outcomes data. Giving them information on their performance versus that of their peers can encourage them to modify their practices to better adhere to the guidelines. Commit medical leadership to tracking and following up with consequences for nonadherence.
- Monitor program impact and develop incentives tied to data tracking: Ongoing data tracking and analysis help to sustain (or even accelerate) improvements. Information provided in September 2012 indicates that monitoring performance can lead to continued or renewed vigilance with regard to induction rates; in addition to monitoring, Intermountain and SelectHealth provide provider-specific patient satisfaction data and other clinical indicators, and offer financial incentives to those who follow best practices related not only to early induction, but also to breast and cervical cancer screening and other areas of women's health. Such data tracking can also uncover potential issues that may need to be addressed. Program developers believe that this increase may be due to “fudging” by some obstetricians who still want to meet patient requests for early induction. Currently, the focus at Intermountain is improving the accuracy and validity of medically induced pregnancies.
- Consider financial implications: As noted, this program and other best practices related to elective inductions typically result in fewer C-sections and neonatal ICU admissions, lower length of stay in labor and delivery, and other utilization reductions. In a fee-for-service payment system, these declines can have a negative impact on hospital and health system revenues. For example, Intermountain leaders estimate that this program has reduced net system revenues by $3.3 million over a 5-year period. (As noted, insurers saved approximately $1.7 million over the same 5-year period, and Intermountain has recouped a portion of this revenue loss through cost savings in its own health plan.) Intermountain leaders have decided to continue the program despite its negative financial impact, believing that the improved outcomes for patients are consistent with their corporate mission and that this approach will position Intermountain advantageously within the health care reform reimbursement system.
Contact the InnovatorTeri Kiehn, MS, RNC
Operations Director for Women and Newborn Clinical Programs
36 South State Street
Salt Lake City, UT 84111
Innovator DisclosuresIn addition to the external funders that supported this program that are listed in the Funding Sources section, Ms. Kiehn reported being on the board of directors of the March of Dimes (which this year is focusing on reducing elective inductions before 39 weeks of gestation) and receiving payments for speaking engagements and reimbursement of travel expenses from the March of Dimes for presentations related to this program.
References/Related Articles(added September 2012) Oshiro BT, Henry E, Wilson J, et al. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol 2009 April;113(4):804-11. [PubMed]
Leonard W. C-sections more common, less healthy for baby. Deseret News. January 18, 2011. Available at: http://www.deseretnews.com/article/705364691/C-sections-more-common-less-healthy-for-baby.html.
Original publication: July 06, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.