Hard stop cuts deliveries before 39 weeks

Leaders at Summa Akron (OH) City Hospital took a hard look at elective inductions a couple years ago and didn't like what they found, says John Hutzler, MD, FACOG, division chief of obstetrics and chairman of obstetrics peer review. There was an inordinate number of women being induced early for a prolonged time, which carried an increased risk of morbidity and mortality for mother and baby. And there was a high number of C-sections at less than 39 weeks.

Hutzler himself was skeptical about whether there was much difference between a delivery at 38 weeks and 39 weeks, but a study of the literature convinced him. To address the issue, Hutzler and his colleagues started educating residents and physicians about a new "39 week hard stop" program for elective induction of labor and elective C-sections. At first the program was strictly educational, but then Hutzler, who heads the peer review program in obstetrics, put some teeth into it.

On Jan. 1, 2009, the hospital began requiring documentation of gestational age and refusing to schedule elective deliveries before 39 weeks, and it implemented a new standardized consent form that prohibited the early deliveries. "If they don't follow those guidelines, and if they managed to sneak through an induction or C-section before 39 weeks, it will go to our peer review process, and they will get negative standards of care for that," Hutzler says. "That's sort of a whip we've got to instigate better quality of care."

The benefits of the hard stop program are clear, says Tiffany Kenny, RN, MSN, CEFM, obstetrics informatics administrator at Summa Akron (OH) City Hospital. There have been only three elective inductions that slipped through the system, and those happened with the first version consent form that allowed a procedure to be scheduled before all supporting documentation was provided. The form has since been revised to require the documentation before the procedure can be scheduled.

The policy was not popular at first with physicians or patients, Kenny says. The most common reason cited for early induction or C-section was maternal discomfort, she says, and it was difficult to convince patient and physician to wait, she says. "One thing we have found useful is to provide reports to all the physician groups on their rates of early inductions and C-sections, and their corresponding complications, broken down individually and by group," Kenny says. "We've found that you can count on a little bit of competitiveness between physicians when they see someone else in their practice has a better rate or another practice has better numbers."

Sources

• John Hutzler, MD, FACOG, Division Chief of OB and Chairman of OB Peer Review, Summa Akron (OH) City Hospital. Telephone: (330) 375-3000.

• Tiffany Kenny, RN, MSN, CEFM, OB Informatics Administrator, Summa Akron (OH) City Hospital. Telephone: (330) 375-3000.