A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.
By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).
ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.
However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).
The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.
The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.
An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.
Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.
With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.
“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.
The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.
Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.
“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.
Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.
“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.