WSHA Disaster Readiness Conference Wenatchee, Washington May 29, 2013.
Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety...
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Transcript of Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety...
![Page 1: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/1.jpg)
Algorithm & Checklist PDSA Trials
Dale Reisner, MDMedical Director of Obstetrics Quality
and SafetySwedish Medical Center
WSHA Safe TableSafe Deliveries Roadmap
November 19, 2013
Presented at Washington State Hospital Association Safe Table 11/19/2013
![Page 2: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/2.jpg)
InductionFetal and Maternal Assessment Appropriate
for Induction
Unfavorable Cervix(Bishop Score < 8)
Medically Indicated Only
Mechanical or Pharmacological Cervical Ripening
Favorable Cervix (Bishop Score > 8)
Initiate Oxytocin
Cervical Change
Cervical Change
Cervix > 6 cm**may observe for spontaneous labor
Repeat with Different Method
Home or Cesarean
No ResponseOxytocin Trial?
Continue Oxytocin or AROM
Assess Cervical Change
Cervix < 6 cm, Unable to AROM, or no Cervical Change with 24 Hours
Oxytocin
Proceed to Cesarean
No Change• Adequate contractions
for > 4 hours•Inadequate contractions
for 6 hours
Second Stage Arrest
Failed Induction
No Cervical Change
No Cervical Change
If Elective, Consider Home
See Spontaneous Labor Algorithm
Draft
Presented at Washington State Hospital Association Safe Table 11/19/2013
DRAFT
![Page 3: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/3.jpg)
Labor Induction Checklist - DRAFT
Type of Induction:
Medical ___________________________ Non-medical/Elective
Pre-procedure:
Consent form discussed with patient and signed, and on chart (medical and non-medical)
Non-medical Induction:
Not done prior to 39 weeks gestation. Gestational age: wks_________ days__________ Between 39 – 40 6/7 weeks gestation, Bishop score is 8 or greater confirmed by 2 examiners (no
cervical ripening)
Medical Induction:
Done for accepted medical inductions w/i evidenced-based or National association guidelines (ACOG, SMFM, etc) for definition and most appropriate gestational age for delivery.
Consultation for indication not on above lists Cervical ripening for unfavorable cervix
Failed Induction (assuming stable mother and fetus) – parameters to use when not entering active labor (> 6 cms):
Either: failure to achieve uterine contractions every 3 minutes with cervical change after 24 hrs of Pitocin and with AROM (if no contraindications), or, uterine contractions every 3 min x 24 hrs without entering active phase if initial Bishop score was less than 8 or if cervical ripening was used.
Inadequate response to a needed, clinically appropriate, second cervical ripening agent Membranes have ben ruptured with inadequate progress (assuming feasible and no contraindications
to AROM) Pitocin has been given per hospital protocol if inadequate frequency and/or intensity of contractions
occur after cervical ripening alone If ROM, Pitocin given x 12 hrs without regular contractions resulting in cervical change If Failed Induction:
Options discussed regarding further management: consideration of risks, benefits, and alternatives of all options (i.e. discharge home with plan to return versus Caesarean Section, depending on clinical situation)
Presented at Washington State Hospital Association Safe Table 11/19/2013
DRAFT
![Page 4: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/4.jpg)
TRIAGE
Cervix < 4 cm Cervix 4 cm or More
Maternal or Fetal Indication
for Admission
Admit to L&D
Vaginal Delivery
Induction Algorithm
Spontaneous Labor > 37 wks and < 41 wks
Stable Mother and Baby
Operative Vaginal or Cesarean
Depending on assessment; Home, AROM and/or Oxytocin,
or Cesarean
Inadequate Progress
First Stage Adequate Progress
First Stage First Stage Arrest
Inadequate Progress
Second Stage
Adequate Progress
Second Stage
Second Stage Arrest
Inadequate Progress
Second Stage
Adequate Progress Second
Stage
Home Walk and Reassess
Draft
Presented at Washington State Hospital Association Safe Table 11/19/2013
DRAFT
![Page 5: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/5.jpg)
Spontaneous Labor Checklist - DRAFT
First Stage: Admission delayed for (all conditions met for discharge):
Cervix less than 4 cm Membranes intact Reactive NST/FHR category I (if uterine contractions present). Confirmed by 2 practitioners (RN,
MD, DO, CNM) Pain control adequate with appropriate outpatient interventions as needed
Admitted to Labor and delivery (delay admission criteria not met) Discharged home for:
Cervix 4-5 cm without change x 2-4 hrs < 80% effacement Reactive NST/FHR category I (if uterine contractions present) Contractions less than 3/10 minutes
Further observation for: Cervix 4-5 cm without change x 2-4 hrs 90 – 100% effacement Membranes intact Reactive NST/FHR category I (if uterine contractions present) Contractions less than 3/10 minutes
Cesarean delivery for (all criteria present) Cervix 6 cm or greater Membranes ruptured (if feasible) Uterine activity
>200 Montivideo untis x 4 hrs, or every 3 minutes palpabley strong contractions x 4 hrs when not feasible to rupture membranes
OR<200 Montivideo units or <3/10 minute contractions x 6 hrs despite Oxytocin administration per protocol
Second Stage: Assessment of decent and position of presenting part at least every 1-2 hrs Operative vaginal delivery or Cesarean delivery for (if presenting part not on perineal floor: +4 or lower) Time from complete dilation*/**
Nulliparous with epidural - 4 hrs Nulliparous without epidural - 3 hrs Multiparous with epidural - 3 hrs Multiparous without epidural – 2 hrs
OR Total time from complete dilation 5 hours or greater > 2 hrs, adequate pattern, no descent
*Passive decent (laboring down) is included in these time periods**Each may need an additional hour if occiput posterior position and rotation of greater than 45 degrees toward anterior has been previously achieved
Presented at Washington State Hospital Association Safe Table 11/19/2013
DRAFT
![Page 6: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/6.jpg)
PDSA on 4 Campuses Nov 2013Both sets of Algorithms & Respective
Checklists
• 29 Algorithms/Checklists evaluated • 27 RNs or LIPs
Common ThemesWhat to do for <4cms with pain4-5 cms but not in laborDo we suggest the amt of walk & reassess time??SROM: Induction vs AugmentationShould we note effacement, station?Are there separate considerations based on parity?Can a little more guidance be put into algorithms but still keep them easy to follow?Presented at Washington State Hospital Association Safe Table 11/19/2013
![Page 7: Algorithm & Checklist PDSA Trials Dale Reisner, MD Medical Director of Obstetrics Quality and Safety Swedish Medical Center WSHA Safe Table Safe Deliveries.](https://reader035.fdocuments.net/reader035/viewer/2022080914/56649d1b5503460f949f13b4/html5/thumbnails/7.jpg)
TRIAGE
Cervix < 4 cm Cervix 4 cm or More in Labor
Maternal or Fetal Indication for Admission either in
Labor or Needs Induction
Admit to L&D
Vaginal Delivery
Indication for Induction see Induction Algorithm
and Checklist
Spontaneous Labor > 37wksStable Mother and Baby
Assess Exam and Pain
Depending on assessment; Home vs AROM and/or Oxytocin vs Cesarean
Inadequate Progress
First Stage Adequate Progress
First Stage First Stage Arrest
Second Stage Arrest
Inadequate Progress
Second Stage
Adequate Progress Second
Stage
Home Walk and Reassess
Draft
NewNew
Operative Vaginal or Cesarean
DefinitionsExamples:•Adequate progress•reVITALize
New
Presented at Washington State Hospital Association Safe Table 11/19/2013
DRAFT