One standard by which obstetrical practice is measured is the ability to achieve a time line of ≤30 minutes from decision for surgery to time of surgical incision for women in labor for whom a cesarean delivery is indicated due to fetal intolerance to labor. We reviewed our institution’s performance regarding this standard and identified an initial rate of 25% of cases actually meeting this standard. Using a program of continuous quality improvement, various systematic and individual barriers were identified and overcome resulting in a significant change in performance. This is a report of the various processes and identified areas of challenge encountered to improve on the ability to achieve this important standard of care.
For better or worse, one of the benchmarks for the quality of care provided in obstetrics is the so-called “30-minute rule.” This rule specifically relates to the allowable time from surgical decision for delivery to surgical incision in cases in which delivery is indicated for fetal intolerance to labor. Supported by many national organizations including the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Royal College of Obstetricians and Gynecologists, clear establishment of the value, biological plausibility, and clinical achievability of this commonly referenced legal standard has remained elusive as reported. Despite these factors and daunting clinical challenges, every modern obstetrical care unit is held to this standard and, when associated with adverse perinatal outcome, it has become a benchmark for adequacy of obstetric care in the medical-legal arena.
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In an effort to assess the ability to achieve this 30-minute standard in such indicated cases at our institution, a continuous performance improvement project was initiated. The hospital is a level III community health care center with >5500 births annually to both private and public patients. The hospital has a medical staff of some 40 board-certified obstetrical and gynecological practitioners and is closely affiliated with an academic teaching institution. Medical students, residents, and fellows in obstetrics and gynecology are in attendance at the hospital as part of their academic training and work closely with the clinicians in providing care to all the patients. There are designated obstetrical anesthesiologists and maternal-fetal medicine subspecialists in the labor and delivery unit at all times. Over a 3-year period we initially reviewed and then prospectively tracked our performance and implemented various changes in practice in an effort to measure and attempt improvement in our achievement of this 30-minute standard. These interdisciplinary efforts included the participation of all caregivers, a prospective collection of data for all cesarean births arising from laboring patients, and an attempt to identify medical, physician, nursing, space, logistical, and patient-related barriers and delays. Specific endpoints including indication for surgery, time line, surgeon, nurse, and anesthesiologist were collected and shared among all caregivers. In addition, discussion of the process on several occasions with the medical and nursing staff occurred and recommendations for change received consensus. Institutional review board approval was obtained as part of a data analysis study and performance improvement project. This is a report on that effort and its outcomes.
Materials and methods
We initially obtained data for a 6-month period of time for cesarean births arising from the labor and delivery unit for all indications (phase I). In this group there were 68 women delivered specifically for fetal indications of intolerance to labor related to concerning fetal heart rate monitoring. For these patients with fetal intolerance to labor, the time from clinical decision to surgical incision occurred in ≤30 minutes in only 17 (25%) of the cases. We shared this surprising finding with our physicians and nurses and held an instructional conference on this obstetrical standard and the various challenges identified in meeting the standard. Then for a 6-month period, data were prospectively collected on all cesarean births in laboring patients with open dialogue between nurses and physicians on each case regarding indications and time lines (phase II). A worksheet was completed and collected on all cases with both the physician and nurse signatures. During this time, efforts were made to have a second operating room made available for cases of emergency arising in laboring patients. Ongoing education with emphasis on the importance of achieving the standard of ≤30 minutes occurred. The third phase of this project occurred following the specific implementation of a new work flow for our center including specific changes. The new work flow simplified communication and emphasized teamwork to promptly transport the patient to the operating room where preoperative preparations were completed. Two anesthesiologists were made available at all times as well as 2 operating rooms designated specifically for cesarean deliveries arising from the labor and delivery unit. Following another 6 months of data collection, without acceptable progress, we elected to intensify data collection and reporting. We began tracking the time from decision to transport to the operating room in addition to decision to incision time and began posting monthly results in the physician and nurses lounges (phase IV). We graphically displayed progress and listed all cases with a fetal indication that met the 30-minute standard, including the names of the obstetrician, nurse, and anesthesiologist, and time required from decision to transport and decision to incision. For cases with a decision to incision time >30 minutes, the cases were listed along with the reasons for delay, but the medical personnel were not identified. In addition, every physician and nurse received a monthly summary electronically that included the posted information. For cases not meeting the 30-minute standard, each responsible obstetrician and nurse received individual notification along with reinforcement of the work flow and suggestions for improvement. The final phase of this process involved the institution of a “code green” identifier for cesarean deliveries with a fetal indication (phase V). Specifically, when a case of fetal intolerance to labor requiring cesarean birth occurred, an overhead announcement in the labor and delivery unit of “code green” with room identification was made. This provided for immediate attention and prioritization of the case, rapid communication with anesthesia and operating room staff, and the arrival of additional nursing personnel to transport the patient. The expectation was reinforced that the physician would remain with the patient and assist the nurses in facilitating transport to the operating room within 5 minutes of the decision for cesarean delivery. In the months following the implementation of the code green process, monthly tracking and posting of outcomes continued and ongoing reinforcement, clarification, and feedback was provided to physician and nursing staff based on daily review of individual cases. At the time of the decision for cesarean delivery, emphasis was placed on deliberate communication between the physician and nurse regarding the indication and the expected time line.
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