Issues Addressed/Background: Urgent and emergent cesarean deliveries remain an important intervention to reduce maternal and neonatal morbidity. Recent studies suggest that initiatives to reduce the decision-to-incision time (DTI) can improve neonatal outcomes without compromising maternal outcomes. Presently at UCSD, documentation of the DTI is inconsistent, which limits our ability to track and evaluate this metric. A preliminary analysis of cesarean deliveries between August-October 2022 showed that only 185 out of 380 (49%) of non-scheduled cesareans were appropriately documented in the medical record. Therefore, we aim to develop and implement a DTI protocol to streamline communication, team-based roles, and improve documentation for cesarean deliveries at UCSD.
Description of Project: Multidisciplinary Cesarean Practice Guidelines were developed to define categories for cesarean deliveries: 1) Emergency, 2) Urgent, 3) Non-emergent/indicated, and 4) Scheduled cases. Goal DTI timeframes and communication steps are specified for each category, including documentation of the DTI and reasons for any case delay. A web-paging team was created to promptly alert all team members (obstetric, anesthesia, surgical technicians, primary and charge nurses) of an urgent cesarean delivery. The protocol includes a preoperative huddle to confirm surgical timing and other clinical considerations. For emergency cases, the current “Code Pink” system was enhanced with additional role assignments for nursing, physician, and technician team members. Operating room posters specific to Hillcrest and Jacobs Medical Centers were created to outline roles and responsibilities in emergency cesarean deliveries. Hands-on simulations for emergency deliveries were conducted prior to implementation.
Lessons Learned/Expected Outcomes: The protocol was fully implemented on March 13, 2023. Pre- and post-implementation variables to be assessed include: DTI, proportion of non-scheduled cesarean deliveries with DTI appropriately documented, number of cases with delays charted, and reasons for delay. We also plan to analyze the proportion of cesareans in each category that achieve designated time targets, i.e. urgent cases < 60min, emergency cases < 10min. We anticipate that improved communication and role clarification outlined in the protocol will improve our ability to expedite non-scheduled cesarean deliveries and conduct processes improvement for the unit.
Recommendations/Next Steps: Data will be collected and analyzed for the above variables for the 4-month period before and after protocol implementation. Labor & Delivery leadership will review the analysis to identify ongoing areas for improvement. Future analysis could explore the impact of the protocol on clinical outcomes such as NICU admission, APGAR scores, umbilical cord gasses or maternal morbidity. In addition, measures of team communication and efficiency metrics (i.e. reasons for case delay) can provide valuable data for systems improvement.
