Early Elective Delivery (EED)

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Early Elective Delivery (EED)
Quality metric below national/ recommended levels

Background
EED puts both mother and baby at significant risk for complication, while offering no benefits.  According to the American Journal of Obstetrics and Gynecology, 10–20 percent of all deliveries are induced labor or C-section before 39 weeks that are not medically required1. Multiple national quality organizations, including The Joint Commission (TJC), National Quality Forum (NQF), and The Leapfrog Group (LFG), identified elective deliveries prior to 39 weeks (induction of labor and cesarean section) as a key quality indicator for obstetric hospital care.

Unless medically necessary, elective delivery of an infant before 39 weeks’ gestation is discouraged, since the last few weeks are critical to a baby’s health and organ development. Elimination of early elective deliveries requires efforts on behalf of physicians, nurses, and hospital leaders2. Successful implementation of a 39-week induction program can only come from a commitment to providing care that is patient centered and safe. Suggested strategies for lowering the rate of EEDs include reducing demand and availability through education and policy. Implementation of a policy to decrease the rate of non-medically indicated deliveries before 39 weeks can decrease these deliveries and improve neonatal outcomes. Clinician and patient education and awareness of the risks involved can lower demand for EED that arises out of a desire for convenience3.

The joint commission recommends the following for improving elective delivery performance measures:

  • Adopt a hospital wide policy that establishes criteria for performing early term medical and cesarean sections.
  • Require a review of all requests that do not meet the established criteria.
  • Obtain clear, concise documentation from clinicians about important information (such as gestational age at the time of delivery and any medical complications) to help coders identify conditions.
  • Provide updated coder education as needed.

Lessons learned at Memorial Hermann Healthcare System

Our dashboard reported that we were at 20% for elective deliveries <39 weeks.  However, because this data was summarized from a random sampling of patients, we felt it was likely  too high an estimate and did not take into account the high-risk patients in our hospital who have legitimate reasons for delivery prior to 39 weeks. Thus, step 1 was to investigate whether a compliance issue truly existed.  We surveyed 1-month data at Children’s Memorial Hospital (CMHH) for January 2018.  A Maternal Fetal Medicine (MFM) specialist reviewed the charts.  Of 460 deliveries that month:

  • 184 were non-spontaneous <39 weeks.
  • 176 (96%) fit under approved JACHO guidelines for medically indicated deliveries.
  • 8 (4%) did not fit under guidelines but were special circumstances for which delivery was approved by MFM specialists.
  • Only 1 case (0.5%) had poor documentation that did not support the need for delivery <39 weeks.

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:

  1. Organizational Enabling Factors
    1. Leader commitment & prioritization of safety
      The Memorial Hermann System has made avoidance of elective delivery <39 weeks a priority. The hospital reviews indications for delivery, and if the indication is not on the approved list, further clarification is necessary. Commonly, a note from MFM explains why the delivery is indicated.  The hospital is committed to compliance with this guideline, and it has been successful due to the implementation of a structured and uniform method of scheduling indicated deliveries.However, this is also a barrier for indicated deliveries <39 weeks that may not fall under traditional guidelines.  Physicians may have an indication for delivery <39 weeks, but because the indication does not fall under the general umbrella of approved indications, the physician may have pushback at the organizational level to proceed with delivery.
    2. Policies and resources for safety
      The policies and review process in place for scheduling an indicated delivery have successfully prevented the scheduling of deliveries that don’t meet the qualifications for i delivery <39 weeks.
  2. Group Enabling Factors
    1. Cohesion
      Originally each hospital in the Memorial Hermann System was working in its own silo. The relationships between hospitals has improved due to 2 factors:

      1. The Maternal Levels of Care is now being implemented in Texas. Each hospital involved in deliveries must apply for a designation I-IV (I representing a hospital taking care of basic, low-risk obstetrics, with IV being a hospital that can care for the high-risk gravida and can provide MFM and subspecialty care).  This is akin to the levels of care assigned to trauma units or NICU.  One of the requirements in the Maternal Levels of Care for level IV institutions is that they are involved in outreach with hospitals of low designations, which has fostered teamwork among the hospitals.
      2. The Texas Aim Collaborative is a working group of 204 hospitals throughout Texas working to decrease maternal morbidity and mortality. These quarterly workshops along with weekly-monthly phone calls help keep clinicians from different hospitals in touch and improve cohesion.
    2. Psychological safety
      There seems to be a lack of psychological safety among physicians regarding the 39-week rule in a way that perhaps was not intended. Physicians are reluctant to deliver women <39 weeks, even if a medical indication exists, for fear of punitive action from the hospital.
  3. Individual Enabling Factors
    1. Safety knowledge & skills
      Publicity as well as explanations by medical personnel have increased awareness among both physicians and patients that unindicated delivery <39 weeks may not be safe.
    2. Sense of control
      Physicians do recognize that the action of an unindicated delivery <39 weeks can lead to increased risk of NICU and neonatal morbidity.
    3. Individual commitment & prioritization of safety
      Physicians are committed to safe delivery practices and most are motivated to practice within the framework of the 39-week rule.