Hospitals are limiting pre-term inductions to reduce birth risks
Hospitals are limiting pre-term inductions to reduce birth risks
Strict rules require permission for early delivery before 39 weeks
Hospitals are beginning to crack down on the use of oxytocin and induced delivery before 39 weeks gestation in an effort to reduce the high risks of birth trauma and liability. Strict policies on when induced labor is allowed can be effective, say some risk managers and clinicians, but enforcing the rule with obstetricians is no easy task.
Clinicians always have had the option of inducing labor early when necessary, but the practice has become far too common and often is done for the wrong reasons, says Kathy Connolly, RN, MSEd, CPHRM, assistant vice president of risk management at the insurance management unit of Premier, an alliance of 1,500 nonprofit hospitals based in San Diego. In response to concerns of too-common use of induction, the nonprofit Institute for Healthcare Improvement (IHI) launched a program in 2005 with Premier and Ascension Health in St. Louis that is designed to reduce those numbers. The program called "Idealized Design of Perinatal Care" includes steps for deciding whether induction is appropriate and another set of guidelines for managing a birth that is not progressing.
None of the criteria in the IHI program are new, Connolly says. In fact, they are all based on previously published criteria from clinical groups such as the American College of Obstetricians and Gynecologists (ACOG). The point of the IHI program is to encourage more judicious use of induction and a better adherence to professional guidelines. A goal of the IHI program is for a participating hospital to reduce the rate of birth trauma to 3.3 incidents per live birth, much lower than the national average of 6.34. The results for various hospitals vary, but IHI reports that some have reduced the rate to less than one per live birth. (Editor's note: For more on the IHI program, go to www.premierinc.com and enter "Idealized Design of Perinatal Care" in the search box.)
A concerted effort to reduce elective inductions can yield big results, but it won't be an easy task, says Janie Wilson, MS, RN, operations director for the Women and Newborns Clinical Program at Salt Lake City-based Intermountain Healthcare, which operates hospitals in Utah and Colorado. Intermountain delivers about 30,000 babies a year and about half of all babies delivered in Utah.
Intermountain started restricting the use of elective inductions in 1999, when 27% of all deliveries in the system were induced before 39 weeks. While far too high, Wilson says Intermountain's 27% rate was not even the highest in Colorado. Other providers in that state reported to Inter-mountain that their induced deliveries accounted for more than 30% of all births.
Now the rate at Intermountain is only 5%. Wilson says Intermountain cracked down on elective inductions when it became clear that babies were suffering from the too liberal use of this option. (See box below for more on the motivations behind induced delivery.) "We had babies coming to the neonatal intensive care for no reason other than we were medically inducing them early, sometimes as early as 36 weeks," she says. "We decided that was just bad practice, and it didn't comply with the clinical guidelines from ACOG."
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Induced delivery often for convenience, not care Risk managers should investigate the rate of induced deliveries in their organizations and determine what is motivating that practice, suggests Janie Wilson, MS, RN, operations director for the Women and Newborns Clinical Program at Intermountain Healthcare, based in Salt Lake City. Chances are you will find that women and babies are being put at high risk of complications for no good reason. Before 2001, many women at Intermountain underwent elective inductions because they and their doctors wanted it, usually not for any good clinical reason, Wilson says. Doctors sometimes chose to induce because they wanted to deliver their patients' babies and they were going out of town that weekend, for instance, and women often pushed for an elective induction for convenience. "Women want to schedule a birth the way they schedule a manicure," Wilson says. "If grandparents are flying in, they want that baby born while they're in town. You can't underestimate how much patients push for this. It's not just doctors." Wilson says Intermountain has even had nurses within its own system, who should know better, request a premature delivery for convenience. One even manipulated her doctor into scheduling an induction by complaining of the appropriate symptoms before labor and delivery nurses intervened and convinced her that she was risking her child's health. "People tell us that it'll be OK because preemies do so well in intensive care these days and they'll be fine in the long run," Wilson says. "It's a strange result of how much better our preemie care is that now some people don't take it seriously. That fact is that delivering before 39 weeks is still very risky and not something you should do without a good reason." |
To change the status quo, Intermountain organized meetings with obstetricians and the labor and delivery staff in 1999 and 2000. When everyone went over the rates of induced delivery and looked at the ACOG guidelines, there was quick agreement that something was amiss. The suggestion that Intermountain forbid delivery before 39 weeks without a solid clinical reason was greeted with praise. "They said it would sort of take the monkey off their back if we just made a rule," Wilson explains. "They wouldn't have to argue about it or try to convince someone that early induction was wrong if they could just point to the rule and say they didn't have a choice."
In addition, Intermountain officials printed brochures to educate patients about the risks of early induction in an effort to relieve some of the pressure on clinicians from patients eager to deliver. But the rate of inductions really started to fall in 2001 when Intermountain programmed its best practice guidelines into its labor and delivery charting system.
"We took the ACOG criteria and programmed that into our system, so that if you try to schedule an elective delivery without meeting that criteria, an alert pops up on the screen that says the patient does not meet the criteria and a delivery cannot be scheduled," Wilson says. "The physician has to go to a regional supervisor to ask for permission, and the supervisor usually says no. We make exceptions for some unusual family situations, but they are few and far between."
Document the reasons for induction
Premier followed a similar path and began implementing the IHI guidelines in February 2005. Ten hospitals introduced the guidelines for obstetric care, and each was required to have a obstetrician champion who would be the leader in teaching the guidelines and encouraging compliance. The key part of the program is that obstetrical teams are discouraged from inducing labor before 39 weeks.
"We weren't dictating that you can't induce before then, but we said that if you induced you should have good documentation of the reasons in the medical record," Connolly says. "Our experience with claims was that the reason was not always documented well, and that made our defense difficult if we had a bad outcome and a claim."
Connolly says Premier sometimes had a difficult time in court because juries would look at the guidelines from ACOG and other standards that said labor should not be induced before 39 weeks without a good reason, and then they would look to the medical record for the good reason. Too often, there wasn't one, she says. Part of the problem was that the clinical guidelines make reference to a desire on the patient's part to induce early, so some obstetricians have used that as wiggle room to say that early induction for nonclinical reasons still fit the clinical guidelines. It had become common for women to ask for early induction as a matter of convenience, such as avoiding a delivery on a holiday or simply because the woman was tired of being pregnant, Connolly says.
"We discourage that kind of interpretation," Connolly says. "If the patient has preeclampsia and the early induction is necessary for the safety of the mother and child, we're not going to question that clinical judgment. We just hope to see it documented well so that we can explain that reasoning to a jury if there is an unfortunate outcome."
Premier's experience shows that in nearly 90% of childbirths leading to claims, oxytocin was used to start or augment labor.
The program was introduced through educational sessions held with obstetrics staff at each hospital, but Connolly says the different hospital teams were allowed to determine their own methods of compliance. The goals were made clear and then, for instance, each facility's obstetrics team developed its own method for making sure that proper documentation was in the record before any labor induction. Some developed systems that required special stickers to be placed on the chart indicating that certain examinations had been done, and others introduced paperwork for the doctor to fill out.
"However they decided to meet the goals, we let them do it in a way that conformed to their existing processes rather than forcing them to adopt a totally new process," Connolly says. "That helped with getting the buy-in. It was a gradual thing, with the physician champion encouraged to get some of his peers to adopt the changes first and then spread it throughout the department."
Premier provided the physician champions with slides and other educational materials to present to their peers. The teams also were required to perform chart audits to gauge compliance, and many teams chose to post the audit reports in the department, which helped encourage interest and better participation.
Premier still is monitoring the results of the effort, and Connolly notes that it can take years to see a reduction in claim costs related to birth trauma. But she says the new guidelines already have produced some positive results, including better communication among obstetrical staff and improved satisfaction among staff.
"Some of the teams report that they're seeing better staff retention, less turnover than they were seeing before," Connolly says. "The reason is that this is a program that encourages better care through a more systematic adherence to the guidelines that everyone knows will help them provide care, and better communication. It's more than just declaring that we don't want to see labor induced before 39 weeks.
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Injury and liability risk high without induction The risks from early induction are known to be high, and risk managers don't need any more risk from the obstetrics unit than they already have. The American College of Obstetricians and Gynecologists (ACOG) reports that obstetricians and gynecologists have an average of 2.6 claims filed against them during their career. Of these, 61% are obstetrics-related cases. The most recent data (2004) from the National Practitioner Data Bank notes that obstetrics-related cases generated 8.1% of all physician malpractice payment reports and had the highest median ($300,000) and the highest mean ($503,564) payment amounts. They also took the longest amount of time to resolve, with a mean delay between incident and payment of 6.01 years. For comparison, the mean delay for anesthesia-related cases was 4.09 years. |
Sources
For more information on reducing liability associated with induced labor, contact:
- Kathy Connolly, RN, MSEd, CPHRM, Assistant Vice President of Risk Management, Premier, 12225 El Camino Real, San Diego, CA 92130. Telephone: (704) 733-5096. E-mail: [email protected].
- Janie Wilson, MS, RN, Operations Director, Women and Newborns Clinical Program, Intermountain Healthcare, 36 S. State St., Floor 22, Salt Lake City, UT 84111. Telephone: (801) 442-2964. E-mail: [email protected].
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