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Two hospitals monitor high-risk moms-to-be
Lawrence General Hospital in Lawrence, MA, and Community Memorial Hospital in Menomonee Falls, WI, ran innovative case management projects recently that resulted in outstanding improvements. Both facilities initiated new models of care that targeted maternity care. They were focused on lowering cesarean section rates and improving access to care in the first trimester to reduce preterm births.
Some initial findings were common to both Lawrence General’s and Community Memorial’s projects:
• When pregnant women receive early prenatal care and concomitant screening for risk factors, preterm births are reduced. That’s where the case manager comes in. She follows high-risk patients and provides education so the mother-to-be can be on the alert for signs and symptoms of early labor. One way to identify pregnant women early so their monitoring begins early is to institute systematic follow-up procedures after a positive pregnancy test. Once contacted, the women can be referred to a case manager or prenatal care coordinator, who can then screen for risk factors. The case manager keeps in close contact with the women and their clinicians.
Getting patients more involved
• When women with modifiable risk factors such as smoking and substance abuse can be identified early in the pregnancy, they can be recruited into cessation programs, reducing preterm labor.
• With education, patients can be encouraged to take an active role in their own care. This is accomplished by using creative coaching strategies designed to influence how patients manage their daily needs.
• When physicians become involved in making decisions regarding change, such as determining when to perform a cesarean, rates go down. Peer-to-peer communication should be encouraged, and ongoing performance data feedback, both individual and aggregate, should be provided.
• When nurses play an active support role during labor, the time a woman is in labor is lengthened, sometimes allowing a vaginal birth.
• When mothers-to-be are educated about vaginal birth after cesarean (VBAC) and the choices open to them, VBACs tend to increase.
• There should be guidelines for the diagnosis and management of preterm labor.
Susan Leavitt, RNC, BSN, is now director of the maternity center and labor and delivery at Elliot Hospital in Manchester, NH, but at the time of Lawrence’s improvement project, she was nurse case manager and clinical coordinator of labor and delivery at 180-bed Lawrence, which is affiliated with Tufts Medical School. In May of 1995, Lawrence joined with other hospitals, including Community Memorial, to participate in the Institute for Healthcare Improvement’s (IHI) Breakthrough Series on cesarean reduction.
"Initially, this was a hospital effort," says Leavitt. "We’d been looking at our cesarean rates on a departmental level for a few years, but with no success. Then we joined with 28 other hospitals in IHI’s national project to do this in a year." Using an interdisciplinary approach including mother-to-be, physician, and nursing staff, they reinforced the expectation of a vaginal birth by providing support to help the patient learn to tolerate labor.
"We did achieve good results," says Leavitt. "We changed a lot of patient care practices that had been going on here for a long time." The team accomplished five major changes to their regular procedures:
1. With the participation of physicians, they developed and implemented guidelines to prevent admissions for false labor. They now do not admit patients until they are actively in labor.
2. They encouraged walking during labor by reducing unnecessary fetal monitoring and IV lines.
3. They increased pain management through support and pharmaceuticals.
4. They encouraged nurses to support patients more. The role of the nurses changed and they were empowered to take ownership of patients and their care.
5. They educated women about VBACs at 20 to 24 weeks (formerly, that information was given at 30 to 36 weeks). They also educated physicians about appropriate indications for VBAC.
Educational inservice training was performed on an ongoing basis. Gains that were accomplished were reviewed monthly and continually recognized and celebrated.
"What made this project work," says Leavitt, "was that the vice president of nursing, the chief of obstetrics, and I met four times a year at a site away from the hospital. The facility allocated significant resources for those trips, and that gave us time away when we could concentrate on planning the initiative." She says a larger quality improvement committee then met to work on the project.
Planning legwork done in weekly meetings
"We met weekly for six months at the hospital," says Leavitt. "For each session, we had goals to accomplish, such as changing policies and educating people about the changes. It was good that we met weekly rather than waiting for monthly department meetings to take on the project, because we were able to do a lot of the legwork during those sessions." Everything was done by the time the monthly meetings rolled around, and all those participants had to do was agree on issues.
"It was quite a different process than we were used to," Leavitt says. Her team utilized IHI’s rapid PDSA (plan-do-study-act) cycle. She says all the concepts they were working on had already been backed up with research in the literature. "But they hadn’t been implemented in most obstetrics departments," she says. "Since they had already been documented, we implemented the concepts in the units, brought people on board, and educated patients, staff, and physicians." Leavitt says Lawrence’s project has been copied in other facilities across the country.
She says case management has a major role in the application of research to reality. "Getting facilities to be proactive in patient treatment is an important part of case management. We have to educate these patients so they know they have options like VBACs and vaginal deliveries instead of cesareans."
In 1993, 153-bed Community Memorial Hos pital, near Milwaukee, developed a prenatal case management program called "Right from the Start." Hospital Case Management asked Kathy Seamandel, RN, a case manager in the obstetrics unit of Community Memorial, what the case managers’ role was in the prenatal project. "One of our roles was educating the patient about risks of repeat cesarean — risks of surgery rather than vaginal delivery," she explains. The case managers had an integral role and worked closely with the physicians and staff nurses. The case managers perform the following functions:
• contact women with first pregnancies, previous cesareans, referrals from the physicians, or other high-risk factors and actually assess every pregnant woman (all low-risk women who have had a previous delivery are sent a self-assessment tool; those who have risk factors are reassessed with a phone call);
• make referrals to social service agencies;
• contact women one month prior to their due date to assess, do pain evaluation, and review labor support;
• review each case during the postpartum hospitalization and prepare for discharge;
• call the new mother at home within 48 hours of discharge.
Cesarean rate falls in program’s first year
"Our hospital was very successful in reducing our cesarean rate," says Alice Maki, RN, director of obstetrics and women’s health at Community Memorial. The facility’s cesarean rate had been 14.4% in 1994. Within a year, it was reduced to 9%; in 1998 it went up to 10.2%. "We all think those rates went back up a bit due to the fact that there had been some information in the consumer media regarding VBACs and how they may not be as safe as thought in the past," says Seamandel. "I’ve never seen evidence of it here, but patients have the right to accept or decline VBACs."
In conjunction with its Right from the Start program, Community Memorial also became involved in IHI’s first collaborative for reduction of cesareans in 1995. "It was a wonderful experience," says Maki. "Our prenatal project and the IHI project seemed to be made to go together."
Seamandel says there were 11 staff nurses who acted as case managers between 1993 and 1995. "Then we revised the program because we weren’t meeting our goals of getting patients called in a timely manner," she says. "In 1995, three of us became exclusively case managers. That way, we can devote our time to the high-risk patients."
For the IHI collaborative, a team comprising physicians, nurses, and a quality assurance specialist focused on two high-risk groups: women with a history of cesareans and women with dystocia. Physicians and nurses used evidence-based research and practice in providing medical and nursing care.
Now physicians send a woman’s clinical history and physical at 16 weeks to the case managers with an indication of any high-risk factors. Their office staffs distribute binders with descriptions of the care program. "Our patients are very compliant," says Maki. "They bring that binder with them to prenatal education classes and to the hospital when they come in to give birth."
She says, "When we started looking at cesar ean reduction in 1993, we were looking at 24-hour inpatient care for OB patients. Nationwide, the standard had gone from 48-to-72-hour lengths of stay [LOS] to 24 hours." (The 24-hour LOS after birth has now reverted to 48 hours nationwide.)
"But we knew there was no way we could send mothers out of the hospital prepared for their new parenting experience within 24 hours of their birth," Maki continues, "so a group of nurses and case managers sat down and brainstormed. It took us nine months to implement the prenatal continuum of care program." They decided that all patients needed to be assessed prior to coming to the hospital for their baby. Case managers now develop the plan of care while patients are still pregnant. When the mothers-to-be come to the hospital, the labor and delivery nurses have a care plan developed by the case manager and the patient at their fingertips.
"When the labor and delivery nurses have a patient in active labor, they know everything about her, including what her wishes are," says Maki. The case managers developed a pain assessment tool, and they talk with each patient about the types of pain she has experienced and what she expects her childbirth to be like.
"We needed a great deal of cooperation from the physicians’ offices to do those prenatal assessments," she says. "We have two large multispecialty clinics nearby the hospital, and those physicians nearly all practice at our hospital. So we have good cooperation with them and their office staffs." At 16 weeks of gestation, the physicians send the case managers all the clinical information they have collected on each of their patients. The case managers take over and do another complete assessment then, and again right before delivery.
Seamandel and Maki agree that a key to their program’s success was the cooperation among the physicians’ office staffs, the labor and delivery staff, and the case managers, who all attended meetings and discussed new ideas. Community Memorial’s orthopedics and gynecology departments have adapted ideas on prehospital assessment from obstetrics case management.
For more information, contact the following sources quoted in this article:
Susan Leavitt, RNC, BSN, director, maternity center and labor and delivery, Elliot Hospital, Manchester, NH. Telephone: (603) 669-5300.
Kathy Seamandel, RN, case manager, obstetrics unit, Community Memorial Hospital, Menomonee Falls, WI. Telephone: (414) 251-7766.
Alice Maki, RN, director, obstetrics and women’s health, Community Memorial Hospital, Menomonee Falls, WI. Telephone: (414) 532-3502.