Quality issues in medicine have come to public attention, especially since the publication of “To Err is Human: Building a Safer Health System,” by the Institute of Medicine in 1999 (http://www.iom.edu/CMS/8089/5575/4117.aspx). It is not that physicians and healthcare providers intend to harm patients. Physicians have an obligation to provide safe care. Although guidelines established by American College of Obstetricians and Gynecologists do not support elective deliveries before 39 weeks of gestation, we found that a significant number of patients were being electively induced or delivered by cesarean below this age cutoff.
How did this practice become established? The reasons are myriad. First, the majority of deliveries occurring between 38 and 39 weeks of gestation do not result in harm. The absolute number of newborn respiratory complications is low. If an obstetrician performs 200 deliveries a year and 10% of his or her patients are electively delivered at 38 weeks of gestation, only one neonate would be admitted to the NICU per year. In addition, the obstetrician does not care for the neonate. Thus, there is a lack of awareness for any individual practitioner of the consequences of his or her actions. Over time, as each individual obstetrician does not see harm from delivering patients slightly early, there is a migration to an unsafe practice, or as Diane Vaughn called it, “the normalization of deviance.”22
There are certainly other reasons that drive this practice. Busy clinicians are trying to more efficiently manage and coordinate their office schedule with their surgery schedule and patient deliveries. They may want to schedule deliveries based upon financial concerns, convenience factors involving physician vacation schedules and patient request. Finally, patients themselves do not realize the consequence of a “slightly” early delivery. Thus, patient, physicians, and hospital staff have come to feel safer and safer about this practice, because there are significant perceived benefits and the perceived risks are thought to be rare.
The uniqueness in our endeavor was not that we confirmed the morbidity of elective deliveries before 39 weeks of gestation. The importance of this report is not only to shed light on this practice but also, more importantly, to be able to decrease it significantly. Using a quality improvement program in a large, vertically integrated health care system, we produced a substantial and persistent reduction in the incidence of elective deliveries before 39 weeks of gestation.
Our success was facilitated by the following conditions. We have an electronic medical records system with specific coded data that allowed both identification and tracking of elective deliveries by gestational age at the time of admission to labor and delivery. We also have in place a quality improvement structure that is system-wide, and is composed of a committee that includes a nursing and medical director, local hospital physician and nursing representation, hospital administrators, and data analysis staff. We had eventual “buy-in” from a majority of the obstetricians, who recognized that the current practice was below best-practice standards and were willing to support and comply with the program. It is important to emphasize that it was not until internal or local neonatal morbidity data were presented that significant initial buy-in by the medical staff was seen. One of the arguments from our medical staff was that our patients were by and large healthier than those reported in the literature. Once we showed our own local data that there was a significant increase in neonatal admissions to the NICU as well as increases in respiratory distress syndrome and ventilator use, this obstacle was overcome. We also engaged patients by developing and publishing a patient informational brochure on the risk of delivering before 39 weeks. We regularly report the early term elective delivery data at the local Obstetrics and Gynecology Department and Quality meetings, giving feedback directly to practicing obstetricians and front-line nurses on labor and delivery. The hospital administrative leadership was highly committed and supportive of this process, because part of their compensation was based upon the meeting of our goals of decreasing early term elective deliveries.
It is important to mention the difficulty of implementing and sustaining the results of this program. Just presenting the data and educating the obstetric providers was not sufficient. We found that there had to be oversight and policing of the program. Crucial to our success was having a committed Labor and Delivery nursing staff, along with strong local medical leadership in supporting, promoting, and enforcing the early term elective delivery guidelines and dialoguing regularly with the medical staff. We were able to generate and report morbidity data to the medical staff when requested and were able to assuage their fears of possible increase in maternal or neonatal morbidity because of a delay in early term elective deliveries. We also showed that there was true buy-in by showing that there was no shift in the indications for induction, but that there was an overall decline in the inductions in general. The desired results were not achieved overnight, but we did demonstrate that once achieved, they can be sustained.
There are limitations to this study. The indications for induction or cesarean delivery were entered by the nurse at admission, and in some circumstances the nurse could have left off some pertinent indications. However, such a situation would have been rare and unlikely, because elective conditions would have prevented the admission. It is more likely that there may have been a tendency for the admitting physician to be creative as to the indication for delivery. However, as shown in Figure 4A and 4B, there was not only a drop in the elective inductions without an increase in indicated inductions, but there was a decrease in the overall induction rate as well. This suggests that there was not a significant change in the designation of the induction type by providers.
Also, other data, such as outcome data, were retrieved from the database as entered and were not validated by manual chart review; they are thus subject to errors inherent with such entries. However, there were no changes in how the data were coded or entered before and after the initiation of the study and would have been consistent over time.
Finally, we acknowledge that other hospital and institutions may not have the same conditions nor the same resources. The health insurance environment is highly capitated. Intermountain Healthcare is the largest hospital system in the state of Utah, with more than 50% of births occurring in Intermountain Healthcare hospitals. Intermountain Healthcare also has an affiliated health insurance program and has a physician division that employs family practitioners, some obstetricians, nurse midwives, perinatologists, neonatologists, and pediatricians.
However, the hospitals do have an open staff structure, and the majority of obstetric providers are community physicians. Each individual hospital is very autonomous and located in an area where there are other competing hospitals where providers could do deliveries at non-Intermountain Healthcare Hospitals. Thus we feel that this program could work in other hospitals and in other areas of the country.
In conclusion, we were able to demonstrate that with institutional commitment, it is possible to implement a quality improvement process in an integrated healthcare system that resulted in a substantial and sustained decrease in elective deliveries before 39 weeks of gestation. Early elective delivery seems to be a problem nationwide.3–5 Indeed, quality organizations such as the National Quality Forum and the Institute for Healthcare Improvement have recently taken up prevention of elective deliveries before 39 weeks of gestation as a measure of quality.20,21 We hope this article will stimulate initiatives in other hospitals and institutions as well.
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© 2009 by The American College of Obstetricians and Gynecologists.
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