Issue:

            The Society for Maternal-Fetal Medicine (SMFM), California Maternal Quality Care Collaborative (CMQCC) and the United States Preventative Task Force (USPTF) recommend low-dose aspirin (LDASA) for preeclampsia risk reduction in at-risk pregnancies. However, current evidence suggests that low dose aspirin (LDASA) prescribing practices for patients with risk factors for preeclampsia are inconsistent and preeclampsia risk screening practices vary. SMFM developed a checklist for preeclampsia risk factor screening and LDASA prescribing to make these practices more uniform. To our knowledge, there is no published literature of its use by prenatal care providers as it pertains to LDASA prescription patterns or medication adherence. The purpose of this intervention is to use electronic medical record (EMR) tools to increase appropriate preeclampsia risk screening and to increase evidence-based use of LDASA to reduce the risk of preeclampsia, particularly amongst patients with moderate risk factors² that may be inadvertently overlooked.

Description:

            Our project has the following aims: 1) incorporate the SMFM preeclampsia risk factor screening checklist as a smart phrase in the EMR during new obstetric care visits at our Women’s Health Clinic in Hillcrest and 2) increase risk-based LDASA prescribing to appropriate at-risk patients.

On September 6, 2022 we launched a system wide preeclampsia risk screen and LDASA eligibility smart-phrase within the EMR for use by all prenatal care providers (Figure 1). In addition, our new obstetric visit order set was modified to facilitate LDASA prescribing. Provider and patient educational materials were also developed. As part of the simultaneous LDASA initiative with CMQCC, we launched a department-wide campaign encouraging the use of the smart phrase to screen all new obstetric patients for preeclampsia. A retrospective chart review was performed of all new obstetric visits from September 6, 2022 – November 29, 2022 by all prenatal care providers at one prenatal clinic. Charts were reviewed for all the following: patient demographics, pre-eclampsia risk screen completion, risk factors met, eligibility for LDASA, prescription of LDASA and/or reason for why LDASA was not prescribed.

Results and outcomes:

            Of 158 new obstetric visits,12% (19/158) were seen by OB/MD providers, 41.1% (65/158) by NP providers, 7.6% (12/158) by CNM providers, and 39.3% (62/158) by MFM providers (Table 1). 37.8% (60/158) of new obstetric visits had the preeclampsia risk screen documented. The majority of preeclampsia risk screens were performed by NP providers 70% (42/60). 33% (20/60) of screened patients met eligibility criteria for LDASA by a high-risk factor alone, whereas 25% (15/60) met criteria for LDASA by two or more moderate-risk factors alone. BMI >30 (9/15), AMA (8/15), and Black race (4/15) were the most common moderate-risk factors present. 60% (9/15) of patients who met criteria by moderate-risk factors alone were prescribed LDASA, while 75% (15/20) of patients who met criteria by high-risk factors alone were prescribed LDASA. Of patients who met criteria for LDASA but were not prescribed medication at time of eligibility, 58.8% (10/17) declined, 17.6% (3/17) already had LDASA prescribed, and 23.5% (4/17) would obtain over the counter. Many patients who did not have the preeclampsia risk screen documented had LDASA prescribed by an alternative provider (36%, 35/98). Of the patients who met criteria for LDASA, 51% (18/35) received LDASA.

Recommendations:

Over one-third of new obstetric visits had a preeclampsia risk screen documented. Many of our patients were found to be at-risk by moderate factors alone, which demonstrates the importance of a thorough screening tool. In order to improve the consistency of our screening and documentation, we plan to perform additional provider education and plan to build the smart-phrase into more diversified clinic templates which may aid in uptake. We are expanding our audit of preeclampsia screening to all prenatal clinics. We plan to review obstetric deliveries, pre-eclampsia rates, and LDASA compliance rates following implementation of our intervention at UCSD Health through another EMR based smart-phrase that has been implemented.

Background:

 The incidence of induced labor has tripled from 9.5% to 31.4% between 1990 and 2020, due to an increase in the incidence of maternal and fetal indications for induction, as well as an increased recognition of the safety of induction of labor by maternal request at 39 weeks of pregnancy1,2,3. Induced labor has been shown to lead to decreased antepartum office visits and postpartum hospitalizations, with an overall neutral impact on healthcare utilization4,5. However, the increased time and number of interventions on labor and delivery for patients undergoing induction can be challenging for patients and the health care system.

 Induction of labor practices vary among physicians, midwives, and nursing staff, driven by both patient and provider preferences. Furthermore, UCSD cesarean birth rates for induced labor are higher than that for spontaneous labor. Given that induction itself is not thought to increase the risk of cesarean, this may be attributable to these patients’ comorbidities or differences in management practices during induction.

 There is a clear need to understand and increase the use of evidence-based labor induction practices that could decrease time to birth during inductions and decrease the rate of cesarean birth. 

Goals:

-Characterize patient characteristics, induction practices, and decisions leading to cesarean birth in birthing persons undergoing induction of labor

-Improve the implementation of provider and institution best practices for induction of labor and cesarean birth decisions

-Decrease the rate of cesarean birth in induced labor at UCSD

Interventions:

Implement an induction of labor education intervention consisting of evidence-based best practices for induction of labor. Educational talks and a handout on labor and delivery were rolled out in January 2024.

Preliminary Results:​

No apparent increase in cesarian rate since implementation of the labor checklist protocol. No apparent concerns for safety of interventions.

Next Steps:​

Granular data analysis of the impact on labor induction techniques with introduction of the labor checklist from Nov 23 – Feb 24. Analysis will include pre and post-intervention comparisons of:​

NTSV cesarean birth rate; ​Percentage of patients undergoing combination, individual, or staged approaches to cervical ripening​; Percentage of patients undergoing early amniotomy​; Maximum dose of oxytocin used; oxytocin discontinuation during labor​

Expected Outcomes:​

We expect that evidence-based induction of labor practices will increase in frequency in the period following the implementation of the checklist without an adverse impact on the cesarean delivery rate.​

Next steps:​

If evidence-based practices do not improve in frequency as expected, surveys of labor and delivery staff could be undertaken to identify challenges in implementing these practices and appropriate next steps.​