Clinical, Hospital and Physician Initiatives
Transcript of 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