• Enhanced Recovery After Surgery for Cesarean Delivery Clinical Practice Guideline: Postoperative Interventions

      Wali, Alexandra; Amos, Veronica Y. (2020-05)
      Problem & Purpose: In the United States, the cesarean delivery rate is approximately 32% of all births, with well over a million performed each year. Compared to women who performs spontaneous vaginal births, cesarean deliveries are associated with a prolonged length of stay. These women are usually young and healthy, possess the ability to achieve a rapid recovery, and have a unique incentive to return to their baseline functional capacity in order to care for their newborn. Enhanced Recovery After Surgery (ERAS) is a standardized set of perioperative interventions implemented to improve surgical outcomes, optimize patient care, and reduce hospital costs. Even though there is an enormous amount of evidence to support the improvements ERAS has made for perioperative care pathways among many surgical specialties, obstetrical surgery lacks established protocols based on such principles. The purpose of implementing the ERAS clinical practice guideline (CPG) is to standardize care throughout the perioperative period and optimize recovery for parturients undergoing elective cesarean deliveries. Methods: The CPG was created using high quality evidence and subsequently evaluated by elected stakeholders using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Dissemination took place following the incorporation of stakeholder recommendations and feedback. A Practitioner Feedback Questionnaire (PFQ) survey following the formal presentation or the CPG during grand rounds was given to anesthesia staff to assess acceptability and usability of the CPG. Results: Feedback received from the AGREE II Tool and PFQ show satisfactory results on the quality, usability, applicability, and acceptance of the CPG. Conclusion: The favorable AGREE II Tool assessment results, widespread acceptance of the interventions among staff as evidenced by the PFQ results, as well as the strength of evidenced utilized to create the recommendations included in the CPG, will facilitate the quality and safety of recovery for elective cesarean deliveries at the institution of interest.
    • Increasing Early Skin-to-Skin for Newborns of Uncomplicated Cesarean Birth

      Showunmi, Harsana; Hoffman, Ann G. (2019-05)
      Background: Following a cesarean birth (CB), newborns can be separated from the mother for up to 3 hours, delaying skin-to-skin contact (SSC). Immediate or early SSC is recommended as a standard of care to prevent hypothermia, hypoglycemia, tachypnea in newborns and to increase bonding, yet few newborns of CB engage in this practice. When mothers are unable to engage in SSC, fathers/support persons are viable options to facilitate early SSC in newborns. Local Problem: The proposed clinical site houses a small labor and delivery unit where it was not standard practice for newborns of cesarean births to engage in SSC within 1 hour following delivery. The purpose of this quality improvement (QI) project is to implement early SSC between fathers/support persons and stable, full-term newborns of uncomplicated cesarean births when the mother is unable to provide SSC. For this QI project, early SSC was considered to be SSC within 1 hour of birth Interventions: A process change was introduced to allow fathers/support persons perform SSC soon after CB. Nurses learned how to identify eligible participants and a checklist was used to serve as a reminder for when and how to execute the new process. Once identified, families were educated on SSC, then the mother appointed an alternative SSC provider. Unit practice was changed to allow fathers/support persons to follow the newborn and the nurse to the nursery after an uncomplicated CB for an opportunity to perform early SSC. If newborns were determined to be stable, SSC was initiated. During the course of the project, goals, information and results were disseminated on the unit via presentations, discussions, posters and handouts. Results: There was a total of 21 CBs during the implementation timeline; nine ineligible cases and twelve eligible cases. Out of the 12 eligible cases, 5 newborns received SSC in less than 1 hour, 5 newborns received SSC more than 1 hour but less than 2 hours and 2 newborns did not receive SSC in the required time frame. The nurses also engaged mothers in early SSC with their newborns. As a result, outcomes included 6 mothers who performed SSC with their newborns within 2 hours of birth. Conclusions: Creating an environment that incorporates early SSC as a standard of care, regardless of method of delivery, is important to improving newborn and family outcomes. In situations where mothers are not available to perform SSC, it is feasible for fathers/support persons to act as alternative SSC provider. This process change allows the newborns of uncomplicated CB to safely enjoy the same benefits as newborns of vaginal deliveries, who routinely perform immediate or early SSC. During this QI project, the checklist made it easier for the nurses to facilitate early SSC. Although adoption to utilize the checklist was slow, when used, it served to streamline the process change. By the end of implementation there was an increased awareness of fathers/support persons as alternative SSC providers and increased action to initiate SSC earlier for newborns of uncomplicated CB on the unit.
    • Optimization of Oxytocin Dosing During the Intraoperative Period: Rule of Three’s

      Lam, Xuan Hanh; Pellegrini, Joseph (2020-05)
      Problem and Purpose: Due to the lack of national guidelines for intraoperative oxytocin administration, anesthesia providers utilize various oxytocin dosing regimens during cesarean deliveries to attain uterine tonicity and prevent postpartum hemorrhage (PPH). Large, unregulated oxytocin infusions result in high serological levels of oxytocin that cause significant hemodynamic instability. The literature has demonstrated similar efficacy with less adverse side effects when using smaller and regulated oxytocin regimens, like the “Rule of Three’s. The “Rule of Three’s” provides a systematic approach to obtain uterine tonicity through small intravenous oxytocin boluses and an infusion. The purpose of this Quality Improvement (QI) project is to develop a Clinical Practice Guideline (CPG) for intraoperative oxytocin administration among the cesarean population at a tertiary Baltimore hospital. Methods: The first project phase began with the formation of a stakeholder team to design and formulate a CPG based upon an extensive literature review. The proposed CPG underwent quality review utilizing the AGREE II tool. After preliminary approval from the chief anesthesiologist (MDA), a formal presentation was conducted discussing the CPG and current evidence based oxytocin management. CPG feedback was anonymously collected through the Practitioner Feedback Questionnaire (PFQ) and revisions were made based upon the data collected. Final approval was then received from the chief MDA for institutional use. All data was analyzed using inferential and correlational statistics. Results: The CPG achieved a 93% rating for overall quality based upon the AGREE II tool, which translates to a high quality CPG that would be recommended for clinical use. The PFQ (n=12) results indicated an overall 80.7% agreement among the questionnaires for CPG’s quality, acceptance of recommendations, applicability of recommendations, comparative value, and outcome variables. Conclusion: Based upon the AGREE II tool and PFQ results, practitioners regarded the CPG as high quality with a high acceptance of recommendations into clinical practice. Limitations of the QI project includes the resistance from anesthesia providers to change current practice and lack of generalizability. Thus, the next phase of this project includes reducing these institutional barriers to sustain a practice change in order to reduce the incidence of PPH, quantitative blood loss and use of secondary uterotonic agents.
    • Postoperative Cesarean Section Outcomes Following Standardized Oxytocin Dosing: Rule of Three’s

      Sanchez, Miguel; Pellegrini, Joseph (2020-05)
      Problem & Purpose: Currently there is no standardized guidelines for the administration of oxytocin during a cesarean section to prevent uterine atony, which has led to anesthesia providers administering varying doses of oxytocin to prevent postpartum hemorrhage (PPH). Oxytocin that is delivered at high rates of infusion have been associated with myocardial depression through hypotension, tachycardia, and myocardial ischemia. The literature has shown that the use of regimental low dosed oxytocin like the “Rule of Three’s” improves its efficacy. The purpose of this quality improvement (QI) project is to overcome the lack of standardization with the delivery of oxytocin during a cesarean section by developing a clinical practice guideline (CPG) for low dose oxytocin administration following the “Rule of Three’s” algorithm. This manuscript will highlight the development with a primary concentration on the post-cesarean section oxytocin administration. Methods: The CPG was developed through 4 phases. The first phase involved stakeholder recruitment along with the development of the CPG using the AGREE II tool to evaluate it. During the second phase the CPG was appraised by the chief anesthesiologist for initial approval. The third phase consisted of a formal presentation to the anesthesia staff that was based on oxytocin management. A Provider Feedback Questionnaire (PFQ) was used to evaluate providers response to CPG. During the fourth stage, approval for the use the CPG was granted by the chief anesthesiologist for use. The data was analyze confidentially using both inferential and descriptive statistics. Results: The CPG was assessed using the AGREE II Tool resulting in an overall average of 93%, which was indicative of a high-quality guideline recommended for clinical use at the facility. The PFQ (n=12) assessed the CPG’s quality, acceptance, applicability, value, and outcome had an overall agreement of 80.7%. Conclusion: The “Rule of Three’s” was proven to be the optimal dosing regimen during cesarean section and throughout the postoperative period. During the postoperative period the prevention of uterine atony is vital to reduce the incidence and severity of PPH, which is effectively achieved when using the “Rule of Three’s” CPG. A limitation of the quality improvement (QI) project was anesthesia provider were resistant to changing their practice. The next phase of the QI project will include reducing provider resistance and monitoring quantitative blood loss during surgery.
    • Reducing Hemodynamic Variations from Oxytocin Administration during Cesarean Sections: Clinical Practice Guideline

      Hyde, Ashton R.; Pellegrini, Joseph (2020-05)
      Problem & Purpose: Oxytocin is administered during cesarean sections to prevent uterine atony; however, oxytocin’s adverse side effects include decreased systemic vascular resistance, reflex tachycardia, arrhythmias, bradycardia, transient asystole, myocardial ischemia, and ST segment changes. In the 1990s and early 2000s, intravenous bolus doses of 10 units were commonly administered, which have led to significant hemodynamic effects and, in some cases, patient demise. Similar cardiovascular effects have been observed in the five-unit bolus dosing range. Currently, oxytocin is administered as an unregulated infusion with the potential for 20-30 units in a minimum of ten minutes. Methods used in clinical practice vary profoundly and no widely accepted oxytocin uterotonic management guideline exists. The purpose of this Quality Improvement (QI) project is to develop a Clinical Practice Guideline (CPG) that examines administration methods to reduce variable hemodynamics. Methods: This project consisted of four phases, which included: formation of a stakeholder team and CPG development using AGREE II tool feedback, dissemination of a formalized presentation, revision of the CPG using the responses elicited via the Practitioner Feedback Questionnaire (PFQ), and a confidential data analysis. Although improvements in hemodynamics were observed in clinical practice, this data was not collected or analyzed. Results: The AGREE II had high quality scoring for the overall guideline (93%). Key stakeholders recommended use of the CPG in practice. PFQ indicated an 80.7% (n=12) agreement among the questionnaires for quality, recommendation acceptance, recommendations applicability, comparative value, and outcome variables. Providers and students subjectively reported reductions in hemodynamic variability and the lack of definitive data precluded a formal analysis. Conclusion: Circumventing practice variation will mitigate hemodynamic instability and communication failures. Practitioners deemed the CPG as high quality and easily translatable to practice; however, resistance persists for widespread clinical implementation. Future recommendations include reducing these institutional barriers, performing data analyses of hemodynamic changes pre and post utilization of the CPG, and evaluating the extent of improved patient outcomes.