Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Guideline Change and Implementation, Provider Tools

Intervention Description: Parents were interviewed and instructed on creating a care map. That map was then shared with HCP. Both parents and HCP were intereviewed to learn what their thoughts were about implementing both care maps and care plans.

Intervention Results: Two themes reflected two primary categories: (a) the utility of care plans and care maps, and (b) the intersection of care plans and care maps. results indicated that care maps are useful and should be created and discussed with HCP prior to creating a care plan.

Conclusion: No Conclusion: Results: Data analysis exploring the relationship and utility of care plans and care maps revealed six primary themes related to using care plans and care maps that were grouped into two primary categories: (a) utility of care plans and maps; and (b) intersection of care plans and care maps. Discussion: Care plans and care maps were identified as valuable complementary documents. Their integration offers context about family experience and respects the parents' experiential wisdom in a standard patient care document, thus promoting improved understanding and integration of the family experience into care decision making

Study Design: A qualitative design with thematic analysis

Setting: CMC: Hospital/Clinic - tertiary pediatric academic health sciences center, The Hospital for Sick Children (SickKids), and at a community hospital, North York General Hospital (NYGH), both located in Ontario, Canada.

Population of Focus: CMC - healthcare providers, including pediatricians, pediatric subspecialists, pediatric nurse practitioners, social workers, occupational and physiotherapists, pharmacists, and community nurses, who provide care for children with medical complexity.

Sample Size: 15 parents, 30 HCP - 15 parents of children with medical complexity who created care maps, and 30 healthcare providers who provided care to children with medical complexity.

Age Range: 1/17/2024

Intervention Components (click on component to see a list of all articles that use that intervention): Provider, Education; Hospital, Chart audit and feedback, Elective induction policy, Guideline change and implementation, Quality improvement , HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement

Intervention Description: At a large Southern US women's hospital, new measures were made to reduce the rates of cesarian delivery at the facility. Endeavors were led by nurse / doctor leaders (VP & chief of staff). These included monitoring, benchmarking & disseminating information about CD at the facility; new protocols for oxytocin administration; Bishop's score assessment; elective CD performed only at 39 weeks; new protocols and intrapartum alternative positioning devices, the process of laboring down, and closed glottis pushing attempts in second-stage labor.

Intervention Results: Collectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and comparable significant reductions in the NTSV cesarean rates.

Conclusion: Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care.

Setting: One large obstetric hospital in the Southern USA

Population of Focus: NTSV births

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Peer Review, Quality Improvement

Intervention Description: To improve quality and safety of care to our obstetric and neonatal patients (presenting between 34 0/7 and 36 6/7 weeks) by lowering the overall induction rate, lowering the elective induction rate less than 39 weeks, decreasing the unanticipated admissions of late preterm infants to the special care nursery (SCN), decreasing the number of transports out of our level II SCN to a higher level III neonatal intensive care unit, and increasing safety culture scores of the Family Birth Center staff at Mercy Hospital Anderson, Cincinnati, OH.

Intervention Results: Rate of CS among electively induced women at the level II hospital decreased from 37.4% (2005) to 31.5% (2006) to 25% (2007). From 2005 to 2006, one year after hospital review was launched, there was a 5.9% decrease in CS (p<0.05)2. From 2006 to 2007, two years after hospital review was launched and supplemental changes to elective induction policies and practices were made, there was a 6.5% decrease in CS (p<0.05)2.

Conclusion: In 2007, outcomes including total induction rate, elective induction rate for less than 39 weeks, cesarean birth rate for elective inductions among nulliparas, and SCN unanticipated admissions of infants 34 0/7 to 36 6/7 weeks' gestation (late preterm infants) were compared with these same measures in 2005.

Study Design: QE: pretest-posttest

Setting: 1 level-II maternity hospital in Ohio

Population of Focus: Nulliparous women who gave birth between January 2005 to December 20072

Data Source: Not specified

Sample Size: n=2,172

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Guideline Change and Implementation, HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: This was a prospective cohort study of nulliparous women to determine how a new structured protocol of oxytocin augmentation within a single hospital obstetric department impacted labor outcomes. The new protocol instructs birth attendants to diagnose “prolonged labor” based on the World Health Organization (WHO) partograph before commencing oxytocin infusion for augmentation. Data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009–2010) and the study period cohort (2012–2013). Nulliparous women with singleton, term deliveries (>37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis.

Intervention Results: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively.

Conclusion: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Setting: Obstetric Department of Sørlandet Hospital, Kristiansand, Norway

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Guideline Change and Implementation, Quality Improvement

Intervention Description: This quality improvement initiative used a systematic approach to reduce nulliparous cesarean birth rates, aligning with recommendations developed by the Council on Patient Safety in Women's Health Care: Patient Safety Bundle on the Safe Reduction of Primary Cesarean Births. Health care providers and nurses received education on contemporary labor management guidelines developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine Obstetric Care Consensus regarding safe prevention of primary cesarean deliveries and nurses were instructed on labor support techniques. The preguideline implementation period was January 1, 2015, to June 30, 2015. The postguideline implementation period was July 1, 2016, to December 31, 2016. The primary outcome measured was the nulliparous, term, singleton, vertex cesarean birth rate.

Intervention Results: There were 434 women identified in the preguideline period and 401 women in the postguideline period. The nulliparous, term, singleton, vertex cesarean birth rate decreased from 27.9% to 19.7% [odds ratio (OR) 0.63, CI 0.46-0.88]. There were improvements in health care provider compliance with following the labor management guidelines from 86.2% to 91.5% (OR 1.73, 95% CI 1.11-2.70), the use of maternal position changes from 78.7% to 87.5% (OR 1.86, 95% CI 1.29-2.68), and use of the peanut birthing ball from 16.8% to 45.2% (OR 3.83, 95% CI 2.84-5.16) as provisions for labor support.

Conclusion: Implementing a systematic approach for care of nulliparous women is associated with a decrease in term, singleton, vertex cesarean birth rates.

Setting: Two rural community hospitals and one urban community hospital in North Carolina

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, , HOSPITAL

Intervention Description: To examine the impact of the American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine (ACOG-SMFM) 2014 recommendations for preventing unnecessary primary Cesareans.

Intervention Results: Among 192,405 NTSV births across 40 hospitals, the age-standardized NTSV Cesarean rate decreased after the ACOG-SMFM recommendations from 25.8% to 24.0% (Risk ratio [RR]: 0.93; 95% CI 0.89, 0.97), with no change in the control series. Decreases were observed among non-Hispanic White women (RR: 0.89; 95% CI 0.82, 0.97), but not among non-Hispanic Black women (RR: 0.97; 95% CI 0.88, 1.07), Asian/Pacific Islanders (RR: 1.01; 95% CI 0.91, 1.12), or Hispanic women (RR: 0.94; 95% CI 0.86, 1.02). Similar patterns were observed at teaching hospitals, with no change at nonteaching hospitals.

Conclusion: While low-risk Cesarean rates may be modifiable through changes in labor management, additional research, and interventions to address Cesarean disparities, are needed.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Quality Improvement, Policy/Guideline (State), STATE, Collaboration with Local Agencies (Health Care Provider/Practice), Collaboratives, Policy/Guideline (Hospital)

Intervention Description: Hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. As a requirement of participation, hospital teams sent at least one team member to each collaborative event. Activities included a June 2016 in-person kick off meeting for two to three representatives from each hospital to familiarize them with the cesarean delivery bundle and the requirements of participation, followed by conference calls that occurred every month in the first year and every 2 months in the second year. Additional in-person meetings for all hospital teams took place at 12 months and at the end of the collaborative (November 2018). Nice webinars on related clinical topics were presented throughout the 30-month period. The collaborative director provided facilitation support to site teams through calls and visits when requested by the site team or when site participation lapsed.

Intervention Results: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle.

Conclusion: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Setting: 31 Maryland birthing hospitals

Population of Focus: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0–23) already in place before the collaborative and implementing a median of four (range 0–17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P5.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P,.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the “Response” domain of the bundle.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Continuing Education of Hospital Providers, Policy/Guideline (Hospital), Educational Material (Provider), Guideline Change and Implementation

Intervention Description: We hypothesized that a pragmatic, multilevel treatment model including (ask, advise, refer [AAR]) coupled with individualized, telephone-based behavioral counseling promoting child tobacco smoke exposure (TSE) reduction would demonstrate greater child TSE reduction than would standard AAR.

Intervention Results: Complete case analysis demonstrated that compared with control parents (29.9%), significantly more parents in the experimental condition (45.8%) eliminated their children’s exposure to all sources of tobacco smoke both inside and outside their homes at 3-month follow-up. In addition, more parents in AAR/counseling than in AAR/attention control eliminated all sources of TSE (45.8% vs. 29.9%) and quit smoking (28.2% vs. 8.2%).

Conclusion: The results indicate that the integration of clinic- and individual-level smoking interventions produces improved TSE and cessation outcomes relative to standalone clinic AAR intervention. Moreover, this study was among the first in which researchers demonstrated success in embedding AAR decision aids into electronic health records and seamlessly facilitated TSE intervention into routine clinic practice.

Study Design: RCT

Setting: Community (home)

Population of Focus: Tobacco-smoking parents living in low-income, urban communities with children <11 years old exposed daily to tobacco smoke in the home. Additional inclusion criteria: daily smoker, >17 years old, and speaking English

Data Source: Structured telephone interviews for baseline data collection and 3-month follow-up.

Sample Size: 334 providers. 327 participants (n=163 AAR and counseling, n=164 AAR and control)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, Food Supports

Intervention Description: The US Department of Agriculture Summer Food Service Program (SFSP) provides meals to children during the summer months, but these programs are underused. This advocacy case study describes the implementation and evaluation of situating an SFSP in the pediatric ED and explores the impact on participant intention to connect with community resources after the ED visit.

Intervention Results: In this 7-week pilot, we partnered with a community agency to provide free lunch to all children ages 2 to 18 during their ED visit at an urban, freestanding children's hospital. After patient rooming and clarification of nil per os status, boxed meals were delivered to patients and siblings along with information regarding the SFSP and how to access community program sites. Parents completed a survey about the experience with the meal program in the ED, previous knowledge of the SFSP, and intention to use community SFSP sites in the future.

Conclusion: This case study demonstrates that situating the SFSP in the acute-care clinical setting is acceptable and has strong potential to improve the historically poor connection between families and critical community resources. Additionally, this project highlights the potential of community-clinical partnerships to improve family resources and enhance the reach of established programs.

Study Design: Pilot program

Setting: The emergency department (ED) of urban medical centers

Population of Focus: Children

Sample Size: Unknown

Age Range: 2/18/2024

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage, Guideline Change and Implementation, Quality Improvement,

Intervention Description: Oregon’s Medicaid expansion provided an opportunity to investigate a potential causal relationship between insurance coverage for parents and their children. This expansion, often referred to as the Oregon Experiment, gave a subset of uninsured, low-income adults access to Medicaid through a randomized selection process. In 2008, Oregon’s Medicaid program, the Oregon Health Plan (OHP), sought to enroll 10,000 non–categorically eligible (i.e., not meeting federally mandated Medicaid eligibility criteria) low-income adults into its expansion program (OHP Standard), which had been closed to new enrollment since 2004. During a random selection process, uninsured, low-income adults were encouraged to put their names on a reservation list. From this list, there were 8 random drawings; individuals selected in these drawings were invited to apply for OHP coverage. The reservation list included more than 90,000 registrants; of these, approximately 30,000 were randomly selected to apply and about 10,000 were ultimately enrolled in OHP. Not everyone selected to apply completed an application, and not all applicants met enrollment eligibility criteria. This study of the Oregon Experiment examined the longitudinal effect of parents randomly selected to apply for Medicaid on their child’s Medicaid or CHIP coverage. The objective was to estimate the effect on a child’s health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage.

Intervention Results: Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected. In the immediate period after selection, children whose parents were selected to apply for Medicaid significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a non-significant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected (adjusted odds ratio [AOR] = 1.18; 95% CI, 1.10–1.27). The effect remained significant during months 7 to 12 (AOR = 1.11; 95% CI, 1.03–1.19); months 13 to 18 showed a positive but not significant effect (AOR = 1.07; 95% CI, 0.99–1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage.

Conclusion: Children whose parents were randomly selected to apply for coverage through the Oregon Experiment had higher rates of OHP coverage than children whose parents were not selected. Among children whose parents were selected, those whose parents obtained coverage benefited the most. This study demonstrates a causal link between Medicaid coverage for parents and their children. To maximize children’s health insurance coverage rates, parents must also have opportunities to obtain coverage

Study Design: Randomized natural experiment; generalized estimating equation models

Setting: Policy (Oregon Medicaid expansion program)

Population of Focus: Parents and Children

Sample Size: 14,409 children

Age Range: 2-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Guideline Change and Implementation

Intervention Description: The objectives of this retrospective cohort review were to determine the rate of adherence to the 2014 ACOG/SMFM guidelines for diagnosing failed induction of labor (FIOL) and arrest of dilation (AOD) and to compare guideline adherence with physician cesarean delivery (CD) rates and obstetric/neonatal outcomes. There were 591 cesarean deliveries that met inclusion criteria for this study. Of these, 263 were performed for failed induction and 328 for AOD.

Intervention Results: Of the 591 cesarean deliveries in the study, 263 were for failed induction, 328 for AOD and 79% (468/591) were not adherent to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine (ACOG/SMFM) guidelines. Of the failed inductions, 82% (215/263) and of the AODs 77% (253/328) were not adherent. There was no difference between adherent and non-adherent CDs with regard to maternal characteristics, or obstetric/neonatal outcomes. Duration of oxytocin use after rupture of membranes, dilation at time of CD, and birth weight were statistically higher in adherent CDs. On multivariate linear regression, physician CD rates were inversely correlated with adherence to ACOG/SMFM guidelines (p<0.0001), gestational age (p=0.007), and parity (p=0.003).

Conclusion: Our study shows that physician non-compliance with ACOG guidelines was high. Adherence to these guidelines was associated with lower physician CD rates, without an increase in obstetric or neonatal complications.

Setting: Single urban academic center

Population of Focus: Nulliparous and multiparous primary cesarean delivery patients

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Guideline Change and Implementation, Provider Tools

Intervention Description: Participants were asked to complete the Family-Centered Care Questionnaire—Revised (FCCQ-R), a 45-item measure of healthcare professionals’ perceptions of the practice and importance of 9 core dimensions of family-centered care.

Intervention Results: Six main themes emerged from the analysis of the concerns and recommendations for family-centered care described in the comments: language translation; communication between staff and families; staffing and workflow; team culture and leadership; staff and parent education, and the NICU physical environment

Conclusion: No Conclusion: Implications for Practice: The NICU healthcare professionals identified a range of issues that support or impede delivery of family-centered care and provided actionable recommendations for improvement. Implications for Research: Future research should include economic analyses that will enable determination of the return on investment so that NICUs can better justify the human and capital resources needed to implement high-quality family-centered care.

Study Design: Data for this qualitative analysis were obtained from a multicenter survey of family-centered care practices completed by NICU healthcare professionals from 6 geographically and demographically diverse NICUs in California during the baseline (familycentered care) phase of a study comparing usual family-centered NICU care with mobile-enhanced family integrated care (mFICare) (NCT03418870)

Setting: NICU - six geographically and demographically diverse neonatal intensive care units (NICUs) in California

Population of Focus: NICU Professionals - NICU healthcare professionals, such as registered nurses, physicians, and neonatal nurse practitioners, who provided care in the NICUs involved in the study .

Sample Size: 382 NICU staff - The study involved 382 NICU healthcare providers from 6 NICUs who completed the survey, and 68 of them (18%) provided 89 free-text comments/recommendations about family-centered care , .

Age Range: adult professionals in NICU settings - The study reported that 65% of the sample were 50 years of age or younger, and 35% of the sample were older than 50 years .

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Prolonged Second Stage of Labor, HOSPITAL, Guideline Change and Implementation, Quality Improvement, Collaboratives, Policy/Guideline (Hospital)

Intervention Description: Standardized second-stage labor evidence-based practice recommendations were structured into an interdisciplinary “5 Ps practice bundle” (patience, positioning, physiologic resuscitation, progress, preventing urinary harm) and implemented across 34 birthing hospitals. The second-stage labor practices were derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines. The recommendations are designed to support the laboring woman's normal physiologic processes and avoid unnecessary interventions.

Intervention Results: Significant improvements were observed in second-stage practices. Association of Women's Health, Obstetric and Neonatal Nurses' perinatal nursing care quality measure Second-Stage of Labor: Mother-Initiated Spontaneous Pushing significantly improved [pre-implementation 43% (510/1,195), post-implementation 76% (1,541/2,028), p < .0001]. Joint Commission Perinatal Care-02: nulliparous, term, singleton, vertex cesarean rate significantly decreased (p = 0.02) with no differences in maternal morbidity, or negative newborn birth outcomes. Unexpected complications in term births significantly decreased in all newborns (p < 0.001), and for newborns from vaginal births (p = 0.03). Birth experience satisfaction rose from the 69th to the 81st percentile.

Conclusion: Clinical implications: Implementing 13 evidence-based second-stage labor practices derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines achieved our goals of safely reducing primary cesarean birth among low-risk nulliparous women, and optimizing maternal and fetal outcomes associated with labor and birth. By minimizing routine interventions, nurses support physiologic birth and improve women's birth satisfaction.

Setting: 34 birthing hospitals in the Trinity Health System

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Peer-Review of Provider Decisions, Elective Induction Policy, Guideline Change and Implementation, PATIENT_CONSUMER, Intensive Therapy, Psychoeducation

Intervention Description: We conducted a retrospective study was conducted in the Centre Hospitalier Universitaire Vaudois (CHUV) including all births between the 1st January 1997 and 31st December 2011 to analyze the cesarean section (CS) rate using the different groups of the Robson classification in a Swiss maternity hospital.

Intervention Results: The overall CS rate was 29 %, mainly related to group 5 (multiparous with previous CS) and group 2 (nulliparous women induced or who had CS before labor). The study also shows that induction of labor on maternal request in nulliparous at term (group 2a) increased significantly the risk of CS compared to induction of labor for medical reason (p<0.001).

Conclusion: The Robson classification system appears as a simple tool for monitoring CS rates. The main strategies for reducing CS rates will be through better selection of women for VBAC (vaginal birth after caesarean) and limitation of induction of labor, especially in nulliparous women.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Guideline Change and Implementation, Organizational Changes, Quality Improvement, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National)

Intervention Description: To determine the success of a program designed to reduce the cesarean section rate in a rural community hospital, to identify reasons for any reduction in the rate and to identify any accompanying increases in the maternal and neonatal morbidity and mortality rates.

Intervention Results: The overall cesarean section rate decreased from 23% in 1985 to 13% in 1989 (p = 0.001). Among the nulliparous women the rate decreased from 23% to 12%, but the difference was insignificant (p = 0.069); this decrease was due to a drop in the number of dystocia-related cesarean sections. The rate among vaginal birth after cesarean section (VBAC) -eligible multiparous women decreased from 93% to 36% (p less than 0.001) because of an increased acceptance of VBAC by the patients and the physicians. The rate among multiparous women ineligible for VBAC was virtually unchanged.

Conclusion: The program was accompanied by a significant decrease in the cesarean section rate. Rural hospitals with facilities and personnel for emergency cesarean sections should consider the introduction of a similar program.

Study Design: Time trend analysis

Setting: 1 small, rural hospital

Population of Focus: Nulliparous women who gave birth between January 1985 and December 19892

Data Source: Not specified

Sample Size: n=456

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Guideline Change and Implementation

Intervention Description: This was a retrospective cohort study that compared maternal and neonatal outcomes before and after the implementation of the 2014 Obstetric Care Consensus on the safe prevention of primary cesarean delivery issued by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM). The study included 11,464 women.

Intervention Results: The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16-1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067-1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

Conclusion: The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Setting: A single university-affiliated medical center

Population of Focus: Nulliparous and multiparous women reaching the second stage of labor, at term

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, HOSPITAL

Intervention Description: In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of primary cesarean delivery. We aimed to assess whether these guidelines decreased the primary CD rate during the second stage of labor, in our department.

Intervention Results: The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16–1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067–1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

Conclusion: The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National)

Intervention Description: Estimate the frequency of failure to follow the French consensus guidelines for elective induction, and assess how failure affects the rate of cesarean delivery.

Intervention Results: Women with electively induced and spontaneous labor had identical cesarean rates (4.1%). The guidelines were not followed in 23.2% of elective inductions. The risk of cesarean was higher after induction with a Bishop score <5, than after spontaneous labor (adjusted OR = 4.1, 95% CI [1.3–12.9]), while elective induction with a favourable cervix did not increase the cesarean risk. In nulliparas, failure to follow the guidelines tripled the risk of cesarean (adjusted OR = 3.2 [1.0–10.2]). On the other hand, elective induction of labor for women with a favourable cervix did not increase the risk of cesarean over the risk with spontaneous labor.

Conclusion: Elective induction does not appear to increase the cesarean rate when the guidelines are met. Electively inducing labor with a low Bishop score increased the risk of cesarean, especially in nulliparas.

Study Design: Retrospective cohort

Setting: 138 maternity units

Population of Focus: Nulliparous women who gave birth between June 2001 and May 20022

Data Source: Not specified

Sample Size: Total (n=2,052) Intervention (n=69) Control (n=1,983)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Guideline Change and Implementation, Provider Tools

Intervention Description: The training intervention was delivered by the research team and a parent representative during a half-day face-to-face workshop. Real-life case studies were discussed, and the parent representative described his/her own journey of receiving different news and the impact of the news on his/her family nit, during the workshop. Data were collected through pretraining and post-training questionnaires (5-point Likert scale, ranging from 1, indicating strongly disagree, to 5, indicating strongly agree) on participants' skills, knowledge, and attitudes related to delivering different news, as well as emistructured interviews.

Intervention Results: There was a significant improvement in domain 1 (of the TDF), which related to knowledge, skills, and beliefs about capabilities. Specifically, there were increased mean postworkshop scores relating to understanding of the effect of different news, importance of empathy when delivering different news, confidence to deliver different news, and skills to deliver different news (p < .001). Domain 2 related to social/professional roles and identity and social influences. All participants believed that HCPs who deliver different news needed appropriate training; however, only 30.8% (n ¼ 8) of the participants had received formal training in delivering different news. Domain 3 was related to environmental context and resources, wherein it was recorded almost all participants (96.2%; n ¼ 25) agreed that the training covered topics relevant to their practice. Domain 4 was optimism, wherein there was a significant improvement in understanding how to provide a balanced description of a condition (p < .001). Domain 5 related to beliefs and consequences. All participants stated they would recommend the training to colleagues. Domain 6 was emotion. There was a significant improvement (p < .001) with participants' rating being better able to manage their emotions related to delivering different news.

Conclusion: Communication between family members and HCPs is routine practice and influences all aspects of patient care and how families cope during their relatives' stay in the ICU. Critical illness and recovery is difficult for both patients and family members, which is why honest, accurate, PFCC-focused communication is fundamental. The READY framework allows HCPs to prepare themselves to deliver information in a supportive family-focused manner to minimise the distress, anxiety, and depression associated with receiving distressing information. The effectiveness of this framework should be examined further in the ICU context and include both economic and family member evaluation.

Study Design: sequential mixed-methods design

Setting: ICU England - National Health Service in South East England

Population of Focus: HCP - healthcare providers who deliver different news to parents, specifically those working in the National Health Service in South East England.

Sample Size: 26 multidisciplinary HCPs - 26 multidisciplinary healthcare providers who delivered different news to parents within the National Health Service in South East England. Eight of these healthcare providers were interviewed as part of the study .

Age Range: patients were children to adults

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation

Intervention Description: To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

Intervention Results: Among nulliparous women, there was a reduction in the number of women who were admitted with cervical score of < or = 4 (24%, 40%, and 54% in 1997, 1996, and 1995, respectively; p=0.0001), an increase in the number of women who had amniotomy on admission (32%, 25% and 12% in 1997, 1996, and 1995, respectively; p=0.0001) and a shorter induction-delivery interval. No change in outcome measures was noted among multiparous women despite reduced dose of prostaglandin E2 used for induction of labor. A marginal reduction of both Cesarean section and failed induction rates were noted in both nulliparae and multiparae. Level of compliance improved with successive rounds of audit.

Conclusion: Explicit guidelines do improve clinical practice, when introduced and monitored in the context of rigorous evaluations. However, the size of improvement could vary.

Study Design: Time trend analysis

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between January 1995 and November 1997 with scheduled induction of labor and for whom completed medical forms were available

Data Source: Not specified

Sample Size: Total (n=531) Pre-intervention (n=168) Post-intervention (n=164)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Provider Training/Education, HOSPITAL, Guideline Change and Implementation, Quality improvement

Intervention Description: This was a quality improvement project and practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives. It was designed to increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesarean births among nulliparous women with low-risk pregnancies. The multi-component intervention, called the “Comfort in Labor Safety Bundle,” included updating existing labor policies, providing nurse education and training workshops, modifying the documentation of care, and procuring labor support equipment. Nurse confidence and skill in labor support techniques was measured using the Self-Efficacy Labor Support Scale. The study also tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk.

Intervention Results: Nurses' mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019.

Conclusion: Implementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.

Setting: Level II regional hospital in Virginia

Population of Focus: Nulliparous women with low risk pregnancies

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: An internal clinical audit committee was established at a secondary hospital in Spain, and modifications were made to the clinical management protocol. A clinical audit was conducted and evaluated for two periods: years 2011−2014 (as baseline preaudit data) and the years 2015−2018 (the audit period). All C-sections were retrospectively classified according to the Robson TGCS to allow comparisons between both periods. The audit committee met biweekly with all obstetric staff involved in order to review, discuss, and evaluate individual cases and to determine whether cesarean indication was reasonable and adequate based on standards.

Intervention Results: Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group.

Conclusion: Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

Setting: Spanish secondary hospital

Population of Focus: All women who gave birth

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Labor Support, Midwifery, Prolonged Second Stage of Labor, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: 419 consecutive patients were divided into two groups, with one group (216 patients) receiving “standard management” (with medical acceleration of labor commencing at the ‘‘action line’’ in the case of arrested or protracted labor) and the other group (203 patients) receiving “comprehensive management” (CM) where arrested or protracted labor was considered a warning sign promoting further diagnostic assessment prior to considering intervention. Comprehensive management included the daily audit and discussion of clinical cases by medical and midwifery staff; the introduction of intrapartum ultrasonography alongside traditional clinical assessment to determine fetal head and trunk position accurately; one-on-one labor support facilitated by midwives and/or labor partners; and attention to the psychological well-being of the patient throughout labor and delivery.

Intervention Results: his study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: Obstetric Unit of Sesto San Giovanni Hospital, Milan, Italy, an urban community hospital

Population of Focus: nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Guideline Change and Implementation, Provider Tools

Intervention Description: Nine primary care sites from pediatrics, family medicine, and medicine-pediatrics implemented the Adolescent Champion model. Each site identified a multidisciplinary champion team to undergo training on adolescent-centered care, deliver prepackaged trainings to other staff and providers, make youth-friendly site changes, implement a standardized flow to confidentially screen for risky behaviors, and complete a quality improvement project regarding confidentiality practices. Adolescent patients, staff, and providers were surveyed at baseline, year-end, and 1-year follow-up to assess changes.

Intervention Results: Adolescent patients’ perceived experience with both their provider and the clinic overall significantly improved from baseline to year-end across every survey measure, and this improvement was consistently sustained at 1-year follow-up

Conclusion: Implementing the Adolescent Champion model successfully helped primary care sites become more adolescent-centered. Further studies are needed to evaluate the effects of this model on patient outcomes.

Study Design: Over the first 6 months of implementing the model, Adolescent Champion teams gathered to attend 3 2-hour trainings (Continuing Medical Education credits provided). Clinic staff at the Adolescent Champion sites administered baseline and year-end paper surveys to (1) adolescent patients aged 12-21 years to assess satisfaction with the site and providers (with a goal of 50 surveys per site per collection period), (2) providers to assess attitudes and usual practice when caring for adolescents, and (3) staff members to assess the clinic climate related to the care of adolescents.

Setting: Primary care sites in MI - nine primary care sites, including pediatrics, family medicine, and medicine-pediatrics

Population of Focus: Providers of adolescent care & their patients - primary care providers with an interest in adolescent health

Sample Size: The sample size varied across the different surveys and time points. For example, the adolescent patient surveys had 474 respondents at baseline, 386 at year-end, and 331-343 at 1-year follow-up . The staff survey had 121 respondents at baseline and 109 at year-end . However, it's important to note that the exact number of unique adolescent patients, providers, and staff who completed the surveys at all three time points is unknown .

Age Range: 12-21 year old patients - The research focused on adolescent patients aged 12-21 years . This age range is consistent with the World Health Organization's definition of adolescence, which spans from 10 to 19 years of age .

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Organizational Changes, Quality Improvement

Intervention Description: Our purpose was to determine whether completion of the medical audit cycle in labor ward practice could safely reduce cesarean section rates.

Intervention Results: After management change the overall cesarean section rate was decreased (9.5% vs 12%, p < 0.0001). In our population spontaneously laboring nulliparous women with a singleton, cephalic, term pregnancy contributed a significant number of cesarean sections 1982 to 1988 (19.7% of all cesarean sections). Applying principles of early diagnosis and treatment of dystocia in these women resulted in a decrease in the cesarean section rate (2.4% vs 7.5%, p < 0.0001). This was primarily responsible for the overall decrease in the cesarean section rate.

Conclusion: Effective medical audit of labor management can reduce cesarean section rates.

Study Design: Prospective cohort

Setting: 1 private hospital

Population of Focus: Nulliparous women who gave birth between 1984 and 1988 and between September 1989 and August 1992

Data Source: Not specified

Sample Size: Total (n=9,207) 1984-1988 (n=5,622) 1989-1992 (n=3,585)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Elective Induction Policy, Guideline Change and Implementation, Policy/Guideline (Hospital)

Intervention Description: To assess the cesarean delivery (CD) rate among low-risk pregnancies before and after implementation of a hospital-based program in Canada.

Intervention Results: At the intervention hospital, 30.3% (964/3181) of women underwent CD in 2009–2010, compared with 26.4% (803/3045) in 2012–2013 (difference −3.9%, P<0.001). By contrast, no significant difference was recorded in control hospitals (28.1% [23 694/84 361] vs 28.2% [23 683/83 895]; difference 0.1%, P=0.5157).

Conclusion: Implementation of the CARE strategy reduced rates of cesarean delivery among the target population.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, Guideline Change and Implementation, Provider Tools

Intervention Description: We collected parent demographic information via survey and infant characteristics via medical record review. Study staff interviewed parents at 3 distinct time points: (1) following recorded family conferences, (2) at discharge from the hospital, and (3) 6 months following hospital discharge.

Intervention Results: We present parent-driven recommendations for the provision of information about neurologic prognosis. ALIGN represents a novel, inductively-derived framework that centers the voices and lived experiences of parents caring for critically ill children. These recommendations are organized by key phases of information delivery and can guide clinicians as they navigate conversations with caregivers of critically ill infants and support interventions to improve prognostic communication.

Conclusion: No Conclusion section - Discussion: The ALIGN framework offers a novel, parent-informed strategy to effectively communicate neurologic prognosis. Although ALIGN represents key elements of a conversation about prognosis, each clinician can adapt this framework to their own approach. Future work will assess the effectiveness of this framework on communication quality and prognostic understanding.

Study Design: Interviews were audio recorded. Each interview was transcribed and deidentified. We analyzed qualitative data using a conventional content analysis inductive approach.

Setting: NICU: Intensive care unit (ICU) with parents of infants with neurologic conditions. Duke Hospital

Population of Focus: parents of critically ill infants with neurologic conditions - healthcare professionals, particularly those working in neonatal and pediatric neurology contexts, who are involved in communicating information about neurologic prognosis to parents of critically ill infants.

Sample Size: 61 parents - The study enrolled 61 parents (40 mothers and 21 fathers) of 40 infants with neurologic conditions in the ICU. Of these, 52 parents (37 mothers and 15 fathers) completed 123 interviews.

Age Range: parents (>18) of infants - The median age of the parents who participated in the study was 31 years, with a range from 19 to 46 years. This indicates that the parents included in the study were primarily in their late teens to mid-forties, reflecting a broad range of ages within the parent population .

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, HOSPITAL, Guideline Change and Implementation, Quality Improvement

Intervention Description: Hospital protocol was modified to align with the new consensus recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). In the new protocol, the cutoff point between the latent and active phases of the first stage of labor was changed from 4 to >6 cm and the definitions of arrest of labor, lack of progress, and failed induction were revised to allow laboring women more time to progress before additional medical interventions were indicated.

Intervention Results: This study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59–0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31–0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44–1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06–13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66–0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: University referral hospital in Poissy, France

Population of Focus: All women with a singleton pregnancy at term (!37 weeks of gestation), in vertex presentation, with spontaneous or induced labor, and with epidural anesthesia

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, HOSPITAL, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National), PROFESSIONAL_CAREGIVER, Consensus Guideline Implementation, HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines.

Intervention Results: Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.

Conclusion: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

Study Design: Retrospective cohort

Setting: 1 public university hospital in Pennsylvania

Population of Focus: Nulliparous women who gave birth between September 13, 2013 and February 28, 2014 and between May 1, 2014, to September 28, 2014

Data Source: Not specified

Sample Size: Total (n=567) Pre-intervention (n=275) Post-intervention (n=292)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Provider Training/Education, HOSPITAL, Quality Improvement, Chart Audit and Feedback, Guideline Change and Implementation,

Intervention Description: This quality improvement project was planned, implemented, and evaluated over an 8‐month time period from July 2018 through March 2019. Within this time frame, 7 weeks from October through December were devoted to four plan‐do‐study‐act (PDSA) cycles. The tests of change implemented during the PDSA cycles included both team engagement (interdisciplinary team huddles) and process changes (pilot of a best practices checklist (based on evidence-based guidelines) and audits of unplanned cesarean births). Interdisciplinary teams met regularly (53 times during the study period) to review individual cases, checklists, and audit data, and contribute to the decision-making process with the aim of reducing C-section rates.

Intervention Results: Over 7 weeks, 13 of 55 NTSV patients gave birth by cesarean, resulting in an NTSV CB rate of 23.6%. Fifty-three huddles were held by 218 staff members for 28 patients. Team engagement scores improved from 85% to 98%. Although the effective care CB scores trended upward, the overall mean was 51%.

Conclusion: Interdisciplinary team huddles, coupled with the use of a best practices checklist and feedback from audits, achieved a more effective use of CB in the NTSV patient population.

Setting: Community hospital in Mid-atlantic state

Population of Focus: Nulliparous patients with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Guideline Change and Implementation, Patient-Centered Medical Home,

Intervention Description: Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMART AIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period. The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED.

Intervention Results: The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients.

Conclusion: This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.

Study Design: Evaluation of a quality improvement initiative

Setting: A tertiary care pediatric medical system with more than 100,000 annual visits at its two pediatric emergency departments (PEDs). The system includes 50 urgent, primary, and subspecialty locations with over 1 million visits per year. The initiative was based at the Akron Children's Main Campus PED, which has more than 65,000 patient visits per year. The adjoining LP primary care office is a 5-minute walk from the PED via a connected indoor walkway. The primary care office has 7919 patients in the panel.

Population of Focus: Nonurgent patients who presented to the pediatric emergency department (PED) and were eligible for redirect to their primary care office.

Sample Size: 518 eligible pediatric patients

Age Range: Children and adolescents 0-17 years