The mean of the maximum dose in each time period was as follows: 2006: 14.27 mU/min (SD 8.2); 2007: 13.20 mU/min (SD 7.2); 2009: 13.21 mU/min (SD 6.9); 2011: 13.07 mU/min (SD 6.9); and 2013: 11.10 mU/min (SD 7) (Figure 3b). There was a trend toward lower means each year, with a significant difference between those patients in which the standard approach was followed compared with those in which it was not (p < 0.001).
There were four infants in which the 1-minute Apgar score was less than 3; three of these were in the 2011 group and one in the 2013 group. When comparing all years, there were significantly more infants with a 1-minute Apgar score less than 5 in 2011 (year of poorest compliance) when compared with all other years (p = 0.002). No difference was observed over the years when comparing the cesarean birth rate.
Through the modified Delphi process at the consensus building event, the participants agreed that protocols have value in that they help the nursing staff carry out the obstetric provider's intentions and may provide protection against future litigation. It was concluded that collaboration between nurses and birth providers working together to write a protocol could yield greater compliance. Individual birth provider autonomy was respected by allowing orders to be written that were outside the protocol, provided that the explanation for this variance was documented in the medical record. Although communication challenges are common among a diverse group of healthcare providers, the event allowed an introduction of a common language around fetal heart rate and uterine contraction monitoring between nurses and birthing providers, promoting collaboration concerning dosing changes.
Labor and delivery staff observed an initial improvement in adherence to recommended oxytocin dosing after the consensus protocol was initiated. However, they noted that compliance to the standard approach seemed to decrease after initiation. The observed decrease was reported to the Perinatal Safety Committee and triggered a follow-up review showing providers were less compliant over time. This decline in protocol success was compounded when CPOE was introduced, which required specific orders to be entered with each encounter without careful direction toward the accepted standards. When the CPOE protocol was revised and standardized to match the original consensus protocol, adherence to recommended dosing increased to 100%. As compliance to the protocol improved, so did the balancing measures of maximum dose of oxytocin and time to birth. These measures were chosen based on the bias that “restricting” the way oxytocin could be administered would result in longer periods from initiation of induction to birth; however, the opposite was found. Other safety measures such as the cesarean birth rate and Apgar scores were unchanged. These findings are consistent with previous reports on the effect of standardization of oxytocin use (Clark, Belfort, Byrum, et al.; 2008; Hayes & Weinstein, 2008; Rhinehart-Ventura et al., 2014; Sundin et al., 2018). Recent guidelines have been published that illustrate the use of protocols for oxytocin dosing to produce greater efficacy and patient safety (ACOG, 2011; California Maternal Quality Care Collaborative, 2018).
As projects and priorities shifted, intensive data were no longer collected for this project. Since the conclusion of the data collection described here, there have been periodically noted deviations from the protocol. When drilling down into the cases, the task force found that these deviations have often been related to EMR changes, which has resulted in continuing education and monitoring of this effect.
The goal of this QI project was to create a consensus-driven, evidence-based protocol to guide the use of oxytocin. This goal was accomplished using a modified Delphi Technique to help build camaraderie and consensus, a sense of shared purpose, and attention to supportive evidence within the medical literature. Despite this success, barriers to the consistent use of this protocol presented over time. The utility of ongoing QI measurements after the “completion” of a project is demonstrated within this report. An important lesson learned is that a standardization process must be integrated into the EMR to become a sustained part of a practice culture. It is important to note, however, that the EMR can present opportunities for providers to deviate from standard protocols without recording their rationale for this deviation in the progress notes. Therefore, continued policing of unintended variation is needed.
The authors would like to thank the members of their multidisciplinary team over the years of this project: Patricia A. Reuter, MSN, RNC-NIC; April Crouch, BSN, RN; Corinna Cooper, MD; Anne Daniels, BSN, RN; Shana Hett, BSN, RN; Sally Jordan, RN, RNC-OB; Denise Martinek, MSN, RN; Laurie McElwain, RN, CBE; Debra Ohnoutka, MHA, BSN, NEA-BC; Dawn Caspers BS, Pharm RPH; Nancy Raile, BSN, RN; and Eva Shay, BSN, RN. Without them, this project could have never been successful. The authors' work allowed them all to experience and demonstrate the power of multidisciplinary collaboration.
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