A drive to improve outcomes without increasing costs has encouraged hospitals to eliminate early elective newborn deliveries. Although it takes time and support to restructure labor and delivery practices, hospitals and health systems have demonstrated significant improvement in outcomes soon after implementing initiatives.
We spoke with three organizations, each with a different journey toward eliminating such deliveries: Seton Family of Hospitals in Central Texas, Sinai Health System in Chicago and Woman's Hospital in Baton Rouge, La. They had four approaches in common: 1) forming multidisciplinary planning teams; 2) instituting a "hard-stop" rule to encourage compliance; 3) showing accountability through a peer-review process; and 4) educating physicians and patients.
Incentives to Eliminate Early Delivery
Up to 10 percent of all U.S. deliveries are induced before 39 weeks. Although a mother is considered at term, clinical evidence has shown that inducing labor before 39 weeks increases the likelihood of negative health outcomes for the newborn, including admission to a neonatal intensive care unit, respiratory distress syndrome and feeding difficulties.
National organizations are beginning to monitor hospital progress: The Leapfrog Group releases an annual survey on early elective deliveries, and the Institute for Healthcare Improvement, the March of Dimes, and the Partnership for Patients from the Centers for Medicare & Medicaid Services all provide programs to guide hospitals through a "39-week rule," which restricts inductions before that time unless medically necessary.
The aim to improve birth outcomes has encouraged state governments to join the quest. More than 16 states have either established initiatives or passed legislation — or are in the process of doing so — to prevent elective, early-term deliveries. They are offering incentives such as providing reductions in malpractice insurance, or they are imposing penalties such as withholding Medicaid reimbursement.
Forming Multidisciplinary Teams
It is essential to assemble a cohesive team that understands the importance of eliminating elective deliveries before 39 weeks.
To begin the process, Woman's Hospital, a private nonprofit tertiary care center for women, formed a council comprising nurse managers, quality specialists and the chief of obstetrical services. This multidisciplinary team attended Institute for Healthcare Improvement meetings that reviewed evidence-based practices and discussed progress with other organizations.
Five years after launching its initiative, Woman's has not performed any elective early-term deliveries. The hospital also has recorded a 19 percent decrease in primary cesarean section deliveries and a 28.9 percent decline in NICU admissions over the same period.
Instituting a Hard-Stop Rule
To guarantee successful outcomes, medical and administrative leaders must gain strong consensus to establish a hard-stop rule that no early elective deliveries will be permitted.
At Sinai Health System, located on Chicago's West Side and serving a predominately Medicaid patient population, senior leaders aimed to achieve a "zero-defect culture" in all areas of patient care. Senior managers focused on education and collaboration among nurse executives and physician leaders to create a systemwide hard-stop protocol.
Prior to implementing the hard-stop rule, 20 percent of all deliveries in the health system were counted as elective before 39 weeks. Within one year after implementation, the elective early-term delivery rate dropped to less than 5 percent. Though that number shows great progress, the goal is to reach an elective early-delivery rate of 0 percent.
Improving Accountability through Peer Review
Labor induction guidelines should outline the process for scheduling and performing inductions and identify a clear chain of command for all individuals involved. In addition, these guidelines should include a peer-review procedure for individuals who disregard the process.
Seton Family of Hospitals, a member of Ascension Health, took part in a systemwide quality initiative, "Journey to Zero." Since July 2005, Seton has not performed one elective induction before 39 weeks. The hospital held physicians accountable for declining all elective induction requests that were not medically necessary. The unit clerk reviews all early induction requests, then sends them to a labor and delivery nurse for approval. If necessary, the request goes to the chief of obstetrics for final sign-off.
This process holds each member of the team accountable for the delivery and avoids placing only one staff member in a policing role. This process has been standardized across all six Seton hospitals that provide labor and delivery services.
Educating Physicians and Patients
Woman's, Sinai and Seton all noted that it was essential to gain physician buy-in from the beginning. Each organization provided irrefutable evidence to their community physicians, including induction rates per physician and the resulting quality outcomes and NICU admissions. Physicians were able to view their current rates, analyze where they could improve, and play key roles in the implementation process.
Many community physicians expressed concern that patients still would demand early-term inductions. To reduce such requests, hospitals informed patients, directly and through their physicians, of the risks posed to the child. Providing educational materials to patients can help underscore the importance of the last few weeks of pregnancy.
Implementing a perinatal safety initiative will hit snags, but the improved outcomes are worth the effort. Karen Teitelbaum, chief operating officer of Sinai Health System, observed, "This is the right thing to do for our organization, and more importantly, the right thing to do for our babies."
Jill Seidman is a program manager and Dana Hill is a research specialist, both with the Health Research & Educational Trust.
Click here to download a copy of the Hospitals in Pursuit of Excellence API Snapshot guide, "Improving Perinatal Safety: The Elimination of Elective Deliveries Before 39 Weeks."