Labor and delivery patient safety bundle associated with improved outcomes

1. Implementation of a labor and delivery patient safety bundle was associated with reduced incidence and severity of delivery-related adverse events, as measured by 2 objective indices.

2. Improvements were seen in high-risk pregnancies only.

Evidence Rating Level: 2 (Good)

Study Rundown: Increasingly, efforts are being made to identify ways to decrease medical errors and prevent adverse outcomes. Strategies that have been employed include individual and group trainings, use of technology, simulations, protocols, and checklists. While childbirth accounts for 4 million hospitalizations in the U.S., there has been limited evaluation of strategies to improve outcomes associated with childbirth. Three indices, the Adverse Outcome Index (AOI), Weighted AOI (WAOI), and Severity Index (SI), were previously developed to measure the incidence and severity of delivery-related adverse events including maternal or neonatal death, uterine rupture, birth trauma, unplanned operative procedure, 5 minute-APGAR score <7, maternal blood transfusion, third or fourth degree perineal laceration, and maternal or neonatal ICU admission. In the present work, the authors evaluated the impact of a labor and delivery patient safety bundle on delivery-associated outcomes and found and association with improvements in the M-WAOI and M-SI indices.

Strengths of the study included a large and diverse patient population, exclusion of data from the implementation/transition period, and stratification by pregnancy risk. The study was limited by retrospective design and low incidence of certain outcomes, including HIE. Additionally, the impact of the intervention may be overestimated, as the trend for M-WAOI and M-SI appear skewed by outlier values during the pre-intervention period. A process evaluation to determine validity, adherence to and effect of individual bundle components is merited.

Click to read the study in AJOG

Relevant Reading: Impact of a comprehensive patient safety strategy on obstetric adverse events

In-Depth [retrospective cohort]: This study evaluated the effects of a labor and delivery patient safety intervention consisting of 24-hour attending presence, communication training, mandatory use of a labor partogram, fetal heart rate tracing interpretation training, and regular feedback on delivery-associated outcomes pre- (n = 2349) and post- (n = 2856) intervention. These outcomes were measured using adapted versions of the AOI, WAOI, and SI indices that included HIE. AOI was the number of patients with ≥1 of these outcomes divided by the number of deliveries; the WAOI was the total weights of the adverse outcomes divided by the number of deliveries; and the SI was the total weights of the adverse outcomes divided by the number of deliveries with an adverse event. The primary outcomes of interest were these modified measures: the M-AOI, M-WAOI, and M-SI. Cesarean delivery was the secondary outcome.

There were more high risk pregnancies during the post-intervention period (p < 0.001). Between the pre- and post- intervention periods, there was a decrease in the M-WAOI (p = 0.0497) and the M-SI (p = 0.01). There were no differences in mode of delivery.

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