Established Evidence Results

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): Feedback,

Intervention Description: Twenty-two women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization participated in semistructured interviews about their experiences receiving health care during pregnancy and birth. Interviews were audio-recorded and transcribed, and transcripts were analyzed using thematic analysis to highlight recommendations for improving perinatal care experiences.

Intervention Results: Participants shared experiences and provided recommendations for improving care at the individual health care provider level, including spending quality time, relationship building and making meaningful connections, individualized person-centered care, and partnership in decision making. At the health systems level, recommendations included continuity of care, racial concordance with providers, supportive health care system structures to meet the needs of women of color, and implicit bias trainings and education to reduce judgment, stereotyping, and discrimination.

Conclusion: Participants in this study shared practical ways that health care providers and systems can improve pregnancy and birth care experiences for women of color. In addition to the actions needed to address the recommendations, health care providers and systems need to listen more closely to women of color as experts on their experiences in order to create effective change. Community-centered research, driven by and for women of color, is essential to improve health disparities during pregnancy and birth.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Women of color living in the San Francisco Bay Area and receiving support services from a community-based nonprofit organization

Sample Size: 22

Age Range: Not disclosed

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Participation Incentives, Quality Improvement/Practice-Wide Intervention, Expert Support (Provider), Modified Billing Practices, Data Collection Training for Staff, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: The Vermont Child Health Improvement Program (VCHIP) at the University of Vermont collaborated with state agencies and professional societies to conduct a survey of Vermont pediatric and family medicine practices regarding their developmental screening and autism screening processes, referral patterns, and barriers. The survey was administered in 2009 to 103 primary care practices, with a 65% response rate (89% for pediatric practices, 53% for family medicine practices).

Intervention Results: The survey results revealed that while 88% of practices have a specific approach to developmental surveillance and 87% perform developmental screening, only 1 in 4 use structured tools with good psychometric properties. Autism screening was performed by 59% of practices, with most using the M-CHAT or CHAT tool and screening most commonly at the 18-month visit. When concerns were identified, 72% referred to a developmental pediatrician and over 50% to early intervention. Key barriers to both developmental and autism screening were lack of time, staff, and training. Over 80% of practices used a note in the patient chart to track at-risk children, and most commonly referred to child development clinics, audiology, early intervention, and pediatric specialists.

Conclusion: The survey conducted by VCHIP revealed wide variation in developmental and autism screening practices among Vermont pediatric and family medicine practices. While most practices conduct some form of screening, there is room for improvement in the use of validated tools, adherence to recommended screening ages, and implementation of office systems for tracking at-risk children. The survey identified knowledge gaps and barriers that can be addressed through quality improvement initiatives, which most respondents expressed interest in participating in.

Study Design: QE: pretest-posttest

Setting: Pediatric and family medicine practices in Vermont

Population of Focus: Children up to age 3

Data Source: Child medical record; ProPHDS Survey

Sample Size: Chart audits at 37 baseline and 35 follow-up sites (n=30 per site) Baseline charts (n=1381) - Children 19-23 months (n=697) - Children 31-35 months (n=684) Follow-up charts (n=1301) - Children 19-23 months (n=646) - Children 31-35 months (n=655)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, Reporting & Response System, CLASSROOM_SCHOOL, PATIENT_CONSUMER, Feedback

Intervention Description: This study evaluated whether immediate feedback in response to poor indoor air quality in children’s bedrooms can reduce the potential for SHS exposure, as measured by adherence to a World Health Organization (WHO) indoor air standard.

Intervention Results: The likelihood that a child’s bedroom met the WHO indoor air quality standard on a given day increased such that the baseline versus post-baseline odds ratio (OR) of maintaining indoor PM2.5 levels below the WHO guideline was 2.38 times larger for participants who received the intervention. Similarly, the baseline versus post-baseline OR associated with achieving an SFH was 3.49 times larger for participants in the intervention group.

Conclusion: The real-time intervention successfully drove clinically meaningful changes in smoking behavior that mitigated indoor PM2.5 levels in children’s bedrooms and thereby reduced SHS exposure. These results demonstrate the effectiveness of targeting sensitive microenvironments by giving caregivers actionable information about children’s SHS risks. Future extensions should examine additional microenvironments and focus on identifying the potential for SHS exposure before it occurs.

Intervention Components (click on component to see a list of all articles that use that intervention): Midwifery, PROVIDER/PRACTICE, HOSPITAL, Chart Audit and Feedback, Organizational Changes, Quality Improvement, POPULATION-BASED SYSTEMS, Community — Outreach, Outreach, COMMUNITY, COMMUNITY

Intervention Description: To improve quality of care by offering more women a safe and attractive normal vaginal delivery. The target group was primarily nulliparous women at term with spontaneous onset of labor and cephalic presentation.

Intervention Results: The CS rate in nulliparous women at term with spontaneous onset of labor decreased from 10% in 2006 to 3% in 2015. During the same period the overall CS rate dropped from 20% to 11%. The prevalence of children born at the unit with umbilical cord pH <7 and Apgar score <4 at 5 min were the same over the years studied. At present, 95.2% of women delivering at our unit are satisfied with their delivery experience.

Conclusion: The CS rates have declined after implementing the nine items of organizational and cultural changes. It seems that a specific and persistent multidisciplinary activity with a focus on the Robson group 1 can reduce CS rates without increased risk of neonatal complications.

Study Design: Time trend analysis

Setting: 1 public, medium-sized tertiary level obstetric unit

Population of Focus: Nulliparous women who gave birth between January 2006 and October 2015

Data Source: Not specified

Sample Size: n=~900 (880-924) per year

Age Range: Not Specified

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): Chart Audit and Feedback, Policy/Guideline (Hospital), HOSPITAL

Intervention Description: To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes.

Intervention Results: A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported.

Conclusion: A reduction in CB rate may be safely achieved through implementing a multifaceted strategy

Intervention Components (click on component to see a list of all articles that use that intervention): Telephone Support, Assessment, YOUTH, PATIENT_CONSUMER, Feedback, PARENT_FAMILY, Text Messaging

Intervention Description: This study evaluates a novel air quality feedback intervention using remote air quality monitoring with SMS and email messaging to promote smoke-free homes among families from deprived areas.

Intervention Results: Of 86 homes that completed the intervention study, 57 (66%) experienced pre-post reductions in measured PM2.5. The median reduction experienced was 4.1 µg/m3 (a reduction of 19% from baseline, p = 0.008). Eight homes where concentrations were higher than the WHO guideline limit at baseline fell below that level at follow-up. In follow-up interviews, participants expressed positive views on the usefulness of air quality feedback.

Conclusion: Household air quality monitoring with SMS and email feedback can lead to behaviour change and consequent reductions in SHS in homes, but within the context of our study few homes became totally smoke-free.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Participation Incentives, Modified Billing Practices, Data Collection Training for Staff, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: Early identification of children with developmental and behavioral delays is important in primary care practice, and well-child visits provide an ideal opportunity to engage parents and perform periodic screening. Integration of this activity into office process and flow is necessary for making screening a routine and consistent part of primary care practice.

Intervention Results: In the North Carolina Assuring Better Child Health and Development Project, careful attention to and training for office process has resulted in a significant increase in screening rates to >70% of the designated well-child visits. The data from the project prompted a change in Medicaid policy, and screening is now statewide in primary practices that perform Early Periodic Screening, Diagnosis, and Treatment examinations.

Conclusion: Although there are features of the project that are unique to North Carolina, there are also elements that are transferable to any practice or state interested in integrating child development services into the medical home.

Study Design: QE: pretest-posttest

Setting: Partnership for Health Management, a network within Community Care of North Carolina

Population of Focus: Children ages 6 to 60 months receiving Early Periodic Screening, Diagnosis, and Treatment services

Data Source: Child medical record

Sample Size: Unknown number of charts – screening rates tracked in 2 counties (>20,000 screens by 2004)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Expert Support (Provider), Modified Billing Practices, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: This report evaluates the impact of Phase II of Maine's First STEPS initiative

Intervention Results: Average percentage of documented use of a developmental screening tool increased substantially from baseline to followup for all three age groups (46% to 97% for children under one; 22% to 71% for children 18-23 months; and 22% to 58% for children 24-35 months). Rate of developmental screening based on MaineCare claims increased from the year prior to intervention implementation to the year after implementation for all three age groups (5.3% to 17.1% for children age one; 1.5% to 13.3% for children age two; and 1.2% to 3.3% for children age 3).

Conclusion: The authors summarize lessons learned in implementing changes in practices and challenges in using CHIPRA and IHOC developmental, autism, and lead screening measures at the practice-level to inform quality improvement.

Study Design: QE: pretest-posttest

Setting: Pediatric and family practices serving children with MaineCoverage

Population of Focus: Children ages 6 to 35 months

Data Source: Child medical record; MaineCare paid claims

Sample Size: Unknown number of chart reviews from 9 practice sites completing follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Services Policy, Motivational Interviewing/Counseling, Feedback,

Intervention Description: Contraception consultation combined with in-person brief interventions and motivational interviewing with support from community participants

Intervention Results: The study has shown preliminary success in changing behaviors and impacting how the community views the prevention of alcohol-exposed pregnancies. The CHOICES intervention was found to be acceptable and welcomed by the tribal community, indicating its potential for implementation with other interested populations. The program has demonstrated success in reducing the risk for alcohol-exposed pregnancies among participants, with the majority showing a reduction in risk through behavior changes such as increased use of birth control, reduced alcohol consumption, or a combination of both.

Conclusion: By incorporating community input and making appropriate modifications to the intervention materials, the program has been successful in addressing the issue of alcohol-exposed pregnancies within the American Indian community. The study highlights the importance of community-based participatory research (CBPR) in developing and implementing effective prevention programs. The researchers suggest that future implementation efforts can benefit from the methods and results discussed in the study to sustain and expand this important alcohol-exposed pregnancy prevention program. Overall, the study underscores the significance of primary prevention efforts, such as increasing the utilization of birth control, in reducing the risk of alcohol-exposed pregnancies, particularly among at-risk populations like American Indians

Study Design: The study design involves the modification and implementation of an existing alcohol-exposed pregnancy prevention program, Project CHOICES, to fit the needs and norms of the American Indian community, specifically the Oglala Sioux Tribe.

Setting: Oglala Sioux Tribe community,

Population of Focus: Non-pregnant American Indian women, particularly within the Oglala Sioux Tribe community

Sample Size: Not specified

Age Range: Reproductive age

Intervention Components (click on component to see a list of all articles that use that intervention): Community Health Services Policy, Motivational Interviewing/Counseling, Feedback,

Intervention Description: The intervention included MI counseling techniques, such as reflective listening and open questioning, to encourage participants to decrease binge drinking and/or increase birth control use to reduce the risk of alcohol-exposed pregnancies. The interventionists provided either two or four CHOICES sessions, held approximately 1-2 weeks apart, depending on the site's preference. Participants were given gift card incentives for participating in the intervention sessions and completing follow-up data collection. Additionally, referrals to local health care providers for birth control were provided, and participants were encouraged to make appointments to discuss their birth control options

Intervention Results: The results of the study showed a significant decrease in the risk of alcohol-exposed pregnancies (AEP) among American Indian women enrolled in the program

Conclusion: Even with minor changes to make the CHOICES intervention culturally and linguistically appropriate and the potential threats to program validity those changes entail, we found a significant impact in reducing AEP risk. This highlights the capacity for the CHOICES intervention to be implemented in a wide variety of settings and populations

Study Design: Pre-post intervention design

Setting: Three sites, two located on a reservation and a third that serves American Indian women in an urban setting

Population of Focus: Non-pregnant American Indian women at-risk for alcohol-exposed pregnancies due to binge drinking and being at-risk for unintended pregnancy

Sample Size: 193 women

Age Range: 18-46

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

Intervention Description: The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine‐item list. The list included the following: 1) monitoring of obstetric results, 2) a midwife coordinator, 3) risk 4) classification of women according to the Robson Classification, 5) three midwife-competence levels, 6) obstetric morning round, 7) fetal monitoring skills, 8) obstetric skills training, and 9) teamwork with a midwife, obstetrician and nurse working together with the common goal of a normal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1).

Intervention Results: Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine-item list from 7.8% to 5.1% and thereafter remained unchanged.

Conclusion: Implementation of the nine-item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine-item list intervention seems to provide long-term sustainable results.

Setting: Delivery unit in Linköping, Sweden

Population of Focus: Nulliparous women at term with spontaneous onset of labor and cephalic presentation

Intervention Components (click on component to see a list of all articles that use that intervention): Adult-led Support/Counseling/Remediation, Reporting & Response System, YOUTH, CLASSROOM_SCHOOL, PATIENT_CONSUMER, Feedback

Intervention Description: This SHS reduction trial assigned families at random to brief coaching and continuous real-time feedback (intervention) or measurement-only (control) groups.

Intervention Results: PEs were significantly correlated with air nicotine levels (r=0.60) and reported indoor cigarette smoking (r=0.51). Interrupted time-series analyses showed an immediate intervention effect, with reduced PEs the day following intervention initiation. The trajectory of daily PEs over the intervention period declined significantly faster in intervention homes than in control homes. Pretest to post-test, air nicotine levels, cigarette smoking and e-cigarette use decreased more in intervention homes than in control homes.

Conclusion: Results suggest that real-time particle feedback and coaching contingencies reduced PEs generated by cigarette smoking and other sources.

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

Intervention Description: The Robson classification was introduced in Lithuanian hospitals, prospectively classifying all the deliveries in 2012 and repeating the analysis in 2014. The overall C-section rate, sizes of the Robson groups of women, and C-section rate in each group was calculated and the results were discussed. In 2013 all the data from hospitals were analyzed and a summit conference was organized specifically for the project. The attendees of the meeting included administrators of the participating hospitals, members of the Lithuanian Society of Ob-Gyns, the Lithuanian Health Ministry, and the Lithuanian Parliament. During the conference the C-section rates among different hospitals and different groups of women were compared and discussed. The general consensus to try and reduce the cesarean section rate was accepted.

Intervention Results: Nineteen Lithuanian hospitals participated in the study. They represented 84.1% of the deliveries (23,742 out of 28,230) in 2012 and 88.5% of the deliveries (24,653 out of 27,872) in 2014. The CS rate decreased from 26.9% (6379/23,742) in 2012 to 22.7% (5605/24,653) in 2014 (p < 0.001). The greatest contributions to the overall CS rate were made by groups 1, 2 and 5. The greatest decrease in the CS rate was detected in group 2. The absolute contribution to the overall CS rate decreased from 4.9% to 3.8%.

Conclusion: The Robson classification can work as an audit tool to identify the groups that have the greatest impact on the CS rate. It also helps to develop a strategy focussing on the reduction of the CS rate.

Setting: 19 Lithuanian hospitals

Population of Focus: All women who gave birth

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Quality Improvement/Practice-Wide Intervention, Data Collection Training for Staff, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, POPULATION-BASED SYSTEMS, STATE, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: The objectives of this study were to assess the feasibility of implementing a bundle of strategies to facilitate the use of Bright Futures recommendations and to evaluate the effectiveness of a modified learning collaborative in improving preventive and developmental care.

Intervention Results: Office system changes most frequently adopted were use of recall/reminder systems (87%), a checklist to link to community resources (80%), and systematic identification of children with special health care needs (80%). From baseline to follow-up, increases were observed in the use of recall/reminder systems, the proportion of children's charts that had a preventive services prompting system, and the families who were asked about special health care needs. Of 21 possible office system components, the median number used increased from 10 to 15. Comparing scores between baseline and follow-up for each practice site, the change was significant. Teams reported that the implementation of office systems was facilitated by the perception that a component could be applied quickly and/or easily. Barriers to implementation included costs, the time required, and lack of agreement with the recommendations.

Conclusion: This project demonstrated the feasibility of implementing specific strategies for improving preventive and developmental care for young children in a wide variety of practices. It also confirmed the usefulness of a modified learning collaborative in achieving these results. This model may be useful for disseminating office system improvements to other settings that provide care for young children.

Study Design: QE: pretest-posttest

Setting: Primary care practices (15 at baseline, 8 at follow- up) throughout the US (9 states total), with most in the Midwest

Population of Focus: Children from birth through 21 years of age

Data Source: Child medical record

Sample Size: Unknown number of chart audits from 8 practice sites completing follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Participation Incentives, Quality Improvement/Practice-Wide Intervention, Data Collection Training for Staff, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: Seven pediatric primary care practices participated in New Mexico's Developmental Screening Initiative in a year-long quality improvement project with the goal of implementing standardized developmental screening tools.

Intervention Results: At baseline, there were dramatic differences among the practices, with some not engaged in screening at all.

Conclusion: Overall, the use of standardized developmental screening increased from 27% at baseline to 92% at the end of the project.

Study Design: QE: pretest-posttest

Setting: Seven primary care practices in a large urban area and small regional community in New Mexico

Population of Focus: Children ages 1 through 60 months

Data Source: Child medical record

Sample Size: Total medical records reviewed at baseline and follow-up (n=1139)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Educational Material, Home Visits, Midwife, Feedback

Intervention Description: Maternal smoking can cause health complications in pregnancy. Particulate matter (PM2.5) metrics applied to second hand smoke (SHS) concentrations provide indoor air quality (IAQ) measurements and have been used to promote smoking behaviour change among parents of young children. Here, we present the qualitative results from a study designed to use IAQ measurements to help pregnant women who smoke to quit smoking.

Intervention Results: There were 39 women recruited (18 in Aberdeen and 21 in Coventry) and qualitative interviews were undertaken with nine of those women. Diverse accounts of smoking behaviours and experiences of participation were given. Many women reported changes to their smoking behaviours during pregnancy. Most women wanted to make further changes to their own behaviour, but could not commit or felt constrained by living with a partner or family members who smoked. Others could not envisage quitting. Using themes emerging from the interviews, we constructed a typology where women were classified as follows: 'champions for change'; 'keen, but not committed'; and 'can't quit, won't quit'. Three women reported quitting smoking alongside participation in our study.

Conclusion: Pregnant women who smoke remain hard to engage,. Although providing IAQ measurements does not obviously improve quit rates, it can support changes in smoking behaviour in/around the home for some individuals. Our typology might offer a useful assessment tool for midwives.

Study Design: Mixed methods case series

Setting: UK National Health Services (NHS) antenatal clinics

Population of Focus: Pregnant women who smoked receiving NHS antenatal services

Data Source: Indoor air quality measurements (IAQ), interviews

Sample Size: 39

Age Range: Not specified

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): Home Visits, Educational Material, Motivational Interviewing, PATIENT_CONSUMER, Feedback

Intervention Description: This study aimed to change parents’ perceptions of exposure by providing information on second- and third-hand exposure and personalised information on children’s exposure [NIH.

Intervention Results: Parental perceptions of exposure (PPE) were significantly higher at the study end (94.6 ± 17.6) compared to study beginning (86.5 ± 19.3) in intervention and enhanced control groups (t(72) = −3.950; p < 0.001). PPE at study end were significantly higher in the intervention group compared to the regular control group (p = 0.020). There was no significant interaction between time and group. Parallel changes in parental smoking behaviour were found. Parental perceptions of exposure were increased significantly post intervention, indicating that they can be altered.

Conclusion: By making parents more aware of exposure and the circumstances in which it occurs, we can help parents change their smoking behaviour and better protect their children.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Labor Support, Midwifery, HOSPITAL, Chart Audit and Feedback, Peer Review, Quality Improvement

Intervention Description: This quality improvement initiative involved multiple interventions that were monitored over time by statistical process control charts. Components included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. The nursing team received training and certification in holistic nursing, and certified nurse-midwives were employed and given delivery privileges. The six-bed Karmanos Center for Natural Birth (NBC) was opened in November 2014 for low-risk women who were managed without continuous fetal monitoring, epidural analgesia, and obstetrical interventions.

Intervention Results: Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.

Conclusion: Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.

Setting: Beaumont Hospital, Royal Oak, an academic-community hybrid facility in southeastern Michigan

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): Motivational Interviewing, , PATIENT_CONSUMER, Feedback

Intervention Description: We offered 102 participants smoking cessation advice, using motivational interviewing and exhaled carbon monoxide measurements to help them quit smoking.

Intervention Results: In total, 16 of 102 participants quit smoking, with 4 lost to follow-up. A further 40 participants cut down on how much they smoked.

Conclusion: Formal screening questions on smoking and the provision of smoking cessation advice should form a regular part of all respiratory clinics where CYP and their parents are seen. Simple smoking cessation interventions can lead to reduced smoking in this population.

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): Home Visits, Adult-led Support/Counseling/Remediation, PATIENT_CONSUMER, YOUTH, Feedback

Intervention Description: This paper reports the findings of qualitative interviews with participants that explored their experiences of the intervention and why outcomes varied.

Intervention Results: The intervention increased women’s capability to change home-smoking behaviour, through increasing awareness and salience of SHS risks to their children, and motivation to act. However, taking effective action was constrained by their limited social and environmental opportunities, including others’ smoking in the home.

Conclusion: The FS2SF intervention was ineffective as it was unable to fully address the precarious, complex life circumstances that make creating a smoke-free home particularly difficult for women experiencing intersecting dimensions of disadvantage.

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): 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): Motivational Interviewing, Adult-led Support/Counseling/Remediation, YOUTH, PATIENT_CONSUMER, Feedback

Intervention Description: This study assessed the effect of Project Zero Exposure-an intervention program designed to help parents protect children from TSE-on children's exposure.

Intervention Results: Most enrolled families completed the trial (IG: 98.6%[68/69], RCG: 97.1%[68/70]). Log hair nicotine (LHN [ng/mg]) decreased in both the IG (Baseline: -1.78 ± 1.91, Follow-up: -2.82 ± 1.87, p = .003) and RCG (Baseline: -1.79 ± 1.54, Follow-up: -2.85 ± 1.73, p = .002), but did not differ between groups at study end (p = .635). Three of five parentally-reported outcomes showed improvement over time in the IG, and one in the RCG. Among IG participants, 90% found hair nicotine feedback useful.

Conclusion: No difference between the intervention and control groups was found on the objective biomarker, LHN. Child TSE decreased during the trial in intervention and control groups. Trial participation, which included hair nicotine monitoring, may have contributed to decreasing exposure in both groups. Concurrent control group improvements may partially explain lack of proven intervention benefit. Biomarker monitoring warrants further investigation for reduction of child TSE.

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, Quality Improvement, Policy/Guideline (Hospital), Collaboratives

Intervention Description: This was a multifaceted quality improvement initiative designed to decrease the cesarean delivery rates for NTSV births in California. From 2016 to 2019, the California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Guided by the Consolidated Framework for Implementation Research, efforts were aimed at both the internal (hospital level) and the external (statewide) environment. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives.

Intervention Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]).

Conclusion: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

Setting: 238 nonmilitary hospitals providing maternity services in California

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): Communication Tools, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool,

Intervention Description: The intervention description in the study "Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology" included several key components aimed at improving the warm handoff process and referral workflow. Some of the interventions implemented during the study period are as follows: 1. Dedicating CHW Space: The study involved dedicating space near providers for Community Health Workers (CHWs) and creating electronic CHW schedules and warm handoff blocks. 2. Improving Communication: Efforts were made to improve communication with providers using email and huddle reminders, as well as posting informative signs in exam rooms to facilitate the warm handoff process. 3. Workflow Enhancements: Workflow enhancements were implemented, including the creation of warm handoff blocks in the electronic medical record (EMR) and the CHW's schedule, as well as the co-location of CHWs with pediatricians for a specified period each week. 4. Regular Updates and Reminders: Monthly update emails were sent to the entire clinic staff, providing program data, workflow reminders, and success stories of patients who were referred to community resources. Additionally, workflow reminders were placed in exam rooms to prompt and enable providers to conduct warm handoffs. 5. Leadership Engagement: Leadership buy-in to the workflow changes was emphasized, and monthly emails were used to keep providers and staff updated on the screening and referral workflow and improvement initiatives. Success stories of patients who connected with a referral resource were shared to positively reinforce referral behavior. These interventions were part of the Plan-Do-Study-Act (PDSA) cycles performed during the study and were aimed at optimizing the warm handoff process and increasing the effectiveness of referrals for patients with unmet social needs.

Intervention Results: Using quality improvement (QI) methods our pediatric clinic worked to increase the warm handoff rate between Community Health Workers (CHWs) and patients with unmet social needs. CHW warm handoff rates increased two-fold over the intervention period. Our results illustrate that QI methods can be used to optimize workflows to increase warm handoffs with CHWs.

Conclusion: Yes, the study reported statistically significant findings related to the impact of the interventions on increasing warm handoffs with Community Health Workers (CHWs) and improving the referral process for patients with unmet social needs. Specifically, the study found the following statistically significant results: 1. CHW Referral Rate: The study reported a significantly higher referral rate in the intervention period compared to the baseline period (P = 0.03). 2. Warm Handoff Rate: The study found a statistically significant increase in the warm handoff rate between families requesting assistance with unmet social needs and CHWs over the intervention period compared to the baseline period (P < 0.001). These statistically significant findings indicate that the quality improvement (QI) interventions implemented during the study had a significant impact on increasing the warm handoff rate and improving the referral process for patients with unmet social needs.

Study Design: The study design used in the research article is a quality improvement (QI) project. The study aimed to optimize community-based referrals in primary care using QI methodology. The authors used Plan-Do-Study-Act (PDSA) cycles to test and implement interventions aimed at increasing the warm handoff rate between patients with unmet social needs requesting assistance and Community Health Workers (CHWs). The study used a pre-post design, comparing the baseline period to the intervention period, to evaluate the effectiveness of the interventions. The study did not use a randomized controlled trial (RCT) design, which is commonly used in clinical research to evaluate the effectiveness of interventions.

Setting: The setting for the study was a pediatric clinic affiliated with the Albert Einstein College of Medicine and Montefiore Medical Group in Bronx, NY, USA. The study took place at an academic-affiliated Federally Qualified Health Center (FQHC) where providers and residents are accustomed to partaking in Quality Improvement (QI) and research projects. The clinic served underserved communities and aimed to optimize community-based referrals in primary care using QI methodology.

Population of Focus: The target audience for the study includes healthcare professionals, particularly those working in pediatric primary care settings, as well as professionals involved in community health and social services. Additionally, individuals and organizations involved in quality improvement initiatives within healthcare settings may also find the study relevant. The findings and recommendations of the study are likely to be of interest to practitioners, researchers, and policymakers seeking to improve social needs screening and referral programs, especially in underserved communities.

Sample Size: The sample size for the study was not explicitly mentioned in the provided excerpts. However, the study reported that a total of 3100 patients were screened for social needs in the baseline period, and 6278 patients were screened in the intervention period. Additionally, the study mentioned that 527 patients (8.4%) were referred to a Community Health Worker (CHW) in the intervention period. While the specific sample size for the intervention group was not provided, the study's findings were based on the outcomes observed during the intervention period involving the referred patients.

Age Range: The provided excerpts from the study "Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology" did not explicitly mention the specific age range of the study participants. However, based on the context of the study, which focused on pediatric care and addressing the social needs of families, it can be inferred that the study likely involved children and their families. The study primarily focused on the impact of warm handoffs and referrals in a pediatric clinic, indicating that the age range of the study participants likely encompassed children and possibly their caregivers or family members.

Intervention Components (click on component to see a list of all articles that use that intervention): Screening Tool Implementation, Quality Improvement, Expert Feedback Using the Plan-Do-Study-Act-Tool, Screening in Nontraditional Settings

Intervention Description: The intervention includes a standardized postpartum depression screening tool into pediatric primary care practice to increase postpartum depression screening rates.

Intervention Results: The study found that postpartum depression screening practices improved from 83% to 88% after the implementation of the standardized screening tool, although this improvement was not statistically significant . The study also found that certain infant and family characteristics, such as male gender, Medicaid or sliding-scale payment for services, and Hispanic ethnicity, were associated with higher rates of positive postpartum depression screens, although again, these associations were not statistically significant . Another study mentioned in the text found that the implementation of a standardized screening tool increased the rate of screening for postpartum depression from 83% to 100%

Conclusion: Pediatric health care providers can effectively screen for postpartum depression. Certain infant and family characteristics may alert the provider to higher risks for mothers.

Study Design: The study design/type is not explicitly mentioned in the given texts. However, the study is a quality improvement project that aimed to improve postpartum depression screening in a pediatric primary care clinic . The study used pre- and post-intervention data to compare the screening rates before and after the implementation of a standardized screening tool . Therefore, it can be classified as a quasi-experimental study.

Setting: The quality improvement project took place in a nurse-led, rural FQHC (Federally Qualified Health Center) in north-central Indiana that offers primary care services, including pediatrics, family health, women's health, and behavioral health

Population of Focus: The target audience for this study is pediatric health care providers who are interested in improving postpartum depression screening in their practice

Sample Size: The sample size for this study was 116 women

Age Range: The age group is not specified in the given texts. However, since the study is about postpartum depression screening, it can be inferred that the sample consists of women who have recently given birth

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Continuity of Care (Caseload), HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: Using data from Robson classification, a novel labor–ward management protocol termed Comprehensive Management (CM) was carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy, from 1 January 2012 to 31 December 2013. CM included regular labor monitoring, documentation of events, audit and feedback, the use of intrapartum ultrasound, mobility in labor and birth posture of choice, a partograph conceived as a screening tool, continuity of care; respectful labor and childbirth care; oral fluid and food intake, and emotional support from a person of choice. The CM “framework” provides tools to make medical interventions performed during childbirth quantitatively measurable and comparable.

Intervention Results: Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusion: The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Setting: Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy

Population of Focus: Nulliparous or multiparous women, at term, with single cephalic baby in either spontaneous or induced labor

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, Quality Improvement

Intervention Description: The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth. Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks

Intervention Results: The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

Conclusion: Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

Setting: Urban community teaching hospital

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Active Management of Labor, HOSPITAL, Chart Audit and Feedback, Quality Improvement,

Intervention Description: From 2008 through 2015, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the cesarean delivery rate among nulliparous patients with term singleton vertex gestations. This quality improvement initiative included the standardization of fetal heart rate tracing, provider training based on consensus guidelines, and the implementation of audits and provider feedback.

Intervention Results: More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.

Conclusion: Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.

Setting: A single tertiary care academic medical center

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): Expert Feedback Using the Plan-Do-Study-Act-Tool, Clinical Decision Support System,

Intervention Description: This study aimed to determine whether youth access behavioral health (BH) care earlier (i.e., when problems are less severe) when receiving services in colocated pediatric primary care clinics. Six primary care clinics in the Midwest with a colocated BH provider participated in this study. Data on number of sessions attended/not attended with the BH provider, BH symptom severity as measured by the Child Behavior Checklist, parent report of length of presenting problem, and improvement ratings were collected and compared for on-site referrals and off-site referrals. Descriptive, independent sample t tests and regression analyses compared those referred from on-site physicians versus off-site referral sources.

Intervention Results: Results demonstrated that youth receiving BH services at their primary care physician's office accessed services when problems were less severe and had been impacting their functioning for a shorter duration.

Conclusion: This study is among the first to explore whether youth receiving BH services in primary care are accessing those services earlier than those who are referred from outside sources, resulting in improved patient outcomes.

Study Design: Medical record reviews

Setting: Six colocated primary care clinics in the Midwest region of the United States

Population of Focus: Pediatric patients who initiated behavioral health treatment in six colocated primary care clinics in the Midwest

Sample Size: 617 children

Age Range: Children ages 1 to 19 years old

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