Improving Care of High-Risk Obstetrics Patients By Creating an Evidence-Based Nurse-Driven Process
Holly A. Barbella, MSN, MBA, RN; Grant C. Walter; Ann F. McFadden
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Preterm birth complicates one out of every eight pregnancies in the US. A rural health system in north central Pennsylvania wanted to evaluate the most effective treatment modalities in trying to reduce preterm births. A collaborative interdisciplinary healthcare team, under nursing leadership was created to explore options. One additional aspect was the lack of process when identifying eligible high risk patients who might be eligible for intervention/treatment.
An evidence based practice (EBP) project utilizing the John’s Hopkins Model of EBP was initiated. The goal of the project was to evaluate the overall effectiveness of 17-P (an injectable progesterone medication initiated between 16-20 weeks’ gestation and given weekly until 37 weeks) as well as which high risk obstetric patients should receive the medication and its effectiveness at difference stages of the pregnancy. In addition, the project evaluated how to best reduce delays in treatment initiation. Literature was evaluated, specifically considering articles and publications that referred to clinical guidelines, clinical trials, medication information, and committee/expert opinions. All research articles and literature were evaluated per the Hopkin’s Model. Results demonstrated that use of 17-P does reduce preterm deliveries in varying degrees depending on gestational age of initiation and patient medical history. Additionally, the EBP project confirmed patient eligibility criteria included prior spontaneous, preterm, singleton delivery.
Based on results from the EBP project, the nurse led collaborative team was continued and the following additional goals were developed: administer 17-P at 16 weeks, educate staff and patients as to the benefits of 17-P and streamline a nurse driven process utilizing the Electronic Medical Record (EMR). Three screening questions were developed incorporating recommendations from findings identified from the EBP project and embedded in the EMR. The process also included nurses screening all new obstetric patients with the questions at the initial new OB visit. If the screening questions identified an eligible patient, providers then received an electronic notification alerting them of an at risk patient in order to provide counseling, order the 17-P and begin the precertification process for insurance. Staff communication, the development of staff and patient education, use of team meeting updates, and formal Grand Rounds were utilized.
To evaluate the patient identification process (nurses completing the screening questions) a monthly report was created. The report showed screening compliance by each department and was distributed to the nursing and leadership staff for evaluation. This feedback was marginally successful - raising overall system compliance from 40% to over 60%. It was determined that more targeted data was needed, and a report was additionally developed that provided individual nurse compliance with the screening process. This report was also electronically distributed on a monthly basis. Step by step instruction of how to properly perform and document the screening questions was also included as process reinforcement. Process compliance dramatically increased from 60% to over 85% in only a few short months.
In addition to screening compliance, initial injection data for eligible patients was also tracked. Before a screening process was created, the average gestational age for the first injection was 22.5 weeks, which was well over the recommendation of 16-20 weeks. Administration data from the latest quarter in 2016 shows the average initiation is now at 17.5 weeks’ gestation.
During reflection of the entire EBP project, the need for standardized work processes that are reliable across large service areas and multiple practices was recognized as the key for the improvement in outcomes. Transparent data shared regularly that were attributable to individuals provides a driving force for increased compliance. In addition, recognizing high performers and sharing success stories with other teams empowered team members to remain focused on improving patient outcomes.
The poster or oral presentation will explain the EBP project and results, the electronic and process improvements, details of education accomplished, graphs showing interventions and follow-up, and how other nurses/healthcare facilities could integrate the same project.
|Review Type||Abstract Review Only: Reviewed by Event Host|
|Keywords||Evidence based practice;
Nurse Driven Process in Obstetrics;
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