Care bundles lower birth injuries, claims


Implementing evidence-based protocols related to vacuum-assisted delivery, early elective inductions, and labor augmentation helped reduce complications and liability claims in the first phase of a national perinatal safety initiative.

The Premier Perinatal Safety Initiative, which is a project of the Premier health care alliance, includes 14 hospitals from around the country that adopted team-based communications processes, participated in simulation training, and implemented evidence-based care bundles starting in 2008.

Susan D. DeVore

"We went to work on what would be an idealized design for perinatal care," Susan D. DeVore, president and CEO of the Premier health care alliance, said during a press conference to release the phase I results.

The results from phase I of the study (2008-2010) show that the interventions appear to be reducing maternal and neonatal harm.

Participating hospitals reduced birth hypoxia/asphyxia by 25%, dropping the instances of this type of neonatal injury from 1.6 per 1,000 deliveries in 2006-2007 to 1.2 per 1,000 during 2008-2010. Similarly, neonatal birth trauma fell from 1.8 to 1.4 per 1,000 deliveries in the same time periods, a reduction of 22%.

Postpartum hemorrhage, the most common cause of perinatal maternal death in the developed world, dropped 5.4% (from 30.0 to 28.4 instances per 1,000 deliveries) during phase I. Cardiac arrest and other cardiac complications resulting from administration of anesthesia during labor and delivery were reduced from 4.0 instances per 1,000 deliveries during the baseline period to 3.4 instances during phase I, a drop of 15%.

The study intervention also appears to be bringing down liability claims, though it sometimes takes 2 years or more following an injury before a claim is filed, Ms. DeVore said. Preliminary data show that the number of liability claims filed fell from an average of 18 during the baseline period to 10 in 2009; it is trending to be at 8 in 2010. Additionally, more claims were resolved without payment at the end of phase I than during the baseline period, according to Premier.

During phase I of the study, participating hospitals implemented three care bundles on elective induction, labor augmentation, and vacuum-assisted delivery. The hospitals had to show that they were providing all of the elements in the bundle to be considered adherent. For instance, the vacuum bundle requires that alternative labor strategies are considered, the patient is prepared, there is a high probability of success, the maximum application time and number of "pop-offs" is predetermined and documented, and cesarean and resuscitation teams are available at delivery.

Over the course of the study, adherence to the bundles has increased significantly. Compliance with the augmentation bundle rose from 33% at baseline to 72% at the end of phase I. Compliance with the elective induction bundle rose from 58% to 88%. And compliance with the vacuum bundle jumped from 9% at baseline to 51%.

Health care providers in the study also worked on improving communication throughout the labor and delivery team by adopting communication protocols used by the military, including TeamSTEPPS and Situation Background Assessment Recommendation (SBAR). They also performed simulations in which they role played worst-case scenarios using mannequins. "So, in real life, when some of these situations occur, it’s not the first time they’ve responded to it," Ms. DeVore said. "They’ve been through very serious simulations."

Phase II of the study, which will also look at the role of hospital culture in perinatal performance improvement, began in January 2011 and will be completed in December 2012. Premier expects to release final results from the project in the summer or fall of 2013.

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