Use of Antenatal Steroids

Use of Antenatal Steroids
Quality metric meeting national benchmarks

Background
For decades, the use of antenatal corticosteroids (ACS) has been well established as an intervention to minimize morbidity for neonates delivered preterm. Until spring of 2016, the utility ACS was not thought to be significant after 34 weeks, or the late preterm period. A multi-center randomized controlled trial to assess this question, published by ALPS, demonstrated a statistically significant reduction in morbidity when administered to steroid naive singleton pregnancies with anticipated preterm delivery after 34 weeks.

Clinical suspicion arose at Memorial Hermann that the new guidelines were not being implemented in practice, even in an academic medical center. We examined one year of late preterm births after publication of the ALPS data and found that the rate of ACS administration was only 40%. The majority of patients between 36 and 37 weeks did not receive ACS when they met criteria. Furthermore, 15% of patients received ACS inappropriately. These findings prompted us to evaluate our compliance not only with the Perinatal Core Measures (which was 100% for patients less than 34 weeks), but also with the evolving recommendations. We looked at how we could improve administration of ACS after 34 weeks.

Approval is pending from the MHHS (Memorial Hermann Hospital System) to construct and implement an electronic medical record (EMR) tool, or flowsheet, that incorporates the inclusion and exclusion criteria used in the evidence-based protocol, to adhere to safest practice. Any changes to the EMR requires committee approval from all departments and disciplines impacted. After we gain all approvals and launch the new process, we will compare the before and after data to measure impact.

Looking at the each of the enabling factors in the framework and definitions, we identified the following gaps, barriers and/or facilitators that have led to success, failures and lessons learned:

Lessons learned at Memorial Hermann Healthcare System

Looking at the each of the Safer Culture enabling factors, we identified and learned from the following gaps, barriers and/or facilitators that have led to both success and failure:

Organizational Enabling Factors
1. Leader commitment & prioritization of safety
  The MHHS has made compliance with core measures a priority. While compliance with ACS prior to 34 weeks has always been successful, the adoption of new guidelines has lagged. In recent months, as dashboards have expanded across the system, satellite hospitals have begun analyzing their data for late preterm steroid administration, demonstrating physicians’ and leadership’s expanded commitment to the practice of evidence-based medicine.
2. Policies and resources for safety
  A policy is in place to order ACS for premature infants (25–33 6/7 weeks). With the results of the ALPS data, best practice now includes infants 34–36 6/7 weeks. MHHS data showed that this new guideline was not uniformly adopted. Antepartum, PTL and PPROM admission order sets have traditionally included orders as part of the MPP (Master Power Plan) for antenatal steroids. These order sets are often used for late preterm patients as well; however, if they are admitted with a specific indication that necessitates delivery, they may be admitted under a different MPP that may not include antenatal steroids as an option, thus necessitating a separate order from the catalog. Further, when the order is generated from the catalog, the appropriate obstetric dosing is amongst all available dosing. The order is available as an opt-in, opening the possibility that it will be inadvertently omitted. Thus, the impetus to change the MPP to reflect current best practice, in a convenient and safe manner for the ordering physician.Part of the institutional commitment to safety involves committee approval at the level of physicians and nurses to ensure all concerns are addressed. This approach has had the unintended consequence of delaying the start of the initiative because institutional personnel and processes were modified after our initial submission, and all committees and disciplines must have approval.
Group Enabling Factors
1. Cohesion
  As we’ve shared the results from our previous study and the intentions for the current initiative with other hospitals in the MHHS and with various physician groups, we have received enthusiasm and approval.
2. Psychological safety
  Physicians are more apt to administer ACS rather than withhold, due to the potential neonatal ramifications of inadvertent administration. This leads to “indication creep,” or the administration of late preterm steroids for women in whom there may be less benefit, for example women with diabetes, multiple gestations, or delivery at 37 weeks.
Individual Enabling Factors
1. Safety knowledge & skills
  ALPS has been presented at national perinatology meetings, and academic societies published committee opinions on the issue. However, they stopped short of recommending the practice, rather advising clinicians just to consider late preterm steroids. Due to the lack of strong recommendations, physicians may not be aware of the guidelines for implementation and there may be a learning gap.
2. Sense of control
  Physicians may not recognize that the unnecessary administration of ACS when unindicated may lead to unintended consequences, such as neonatal hypoglycemia.

Individual commitment & prioritization of safety
Physicians are committed to safe practices and are motivated to adopt new practices that are evidence-based and that benefit their patients.