11/2/2015. Increasing Access to Epidural Analgesia for Labor through Education: A Collaborative Endeavor. Aim Statement.

Transcription

1 Increasing Access to Epidural Analgesia for Labor through Education: A Collaborative Endeavor Clinical Safety & Effectiveness Session 14 DATE Aim Statement The primary purpose of this quality improvement project is to improve access to epidural analgesia in low and moderate risk laboring women by: 1. Completing an anesthesia pre operative evaluation on admission to the Labor and Delivery Unit. 2. During anesthesia pre operative evaluation provide consistent, non biased, scripted education on pain management options for laboring women and their families. We will show an 10% increase in epidural rates from 47.6% over a 4 month period of time in low to moderate risk patients. Team Members Team Members Jerry Green, DO, Anesthesiology & Pain Management Janice Lankford, RN, CNM, DNP, Parkland Midwifery Service Susan Chew, RN, CNM, MSN, Parkland Midwifery Service Sponsor Brian Casey, MD, Maternal & Fetal Medicine Thank you To L&D Anesthesia Staff, Nurses, and Nurse Midwives for their willingness to give feed back, help with the project, and support an optimal patient experience 1

2 Measures 2015 Pre Pilot Epidural Rates 60.0% 55.0% 4 Month Pre Pilot 50.0% 45.0% 40.0% 35.0% Jan Feb Mar Apr 2015 Epidural Rates Pre Project was 47.6%, n 1149, 547 epidurals Measures Data obtained from L&D East patient log book on low/moderate risk midwifery unit. 60.0% 55.0% 2014 Epidural Rates 50.0% 45.0% 40.0% 35.0% Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 2014 Epidural rates were 46.8%, n 3844, 1800 epidurals Measures National epidural rate across the country is 63.40% (Osterman & Martin, 2011; Padilla, 2015) Hispanic Epidural rate is 44.7% (CDC, 2015; Osterman & Martin, 2011; Padilla, 2015) The target epidural rate for this project is 57.6% for a 10% increase over the 4 months of the quality improvement project 2

3 Additional Information Hispanic s represent approximately 82% (2014) of women who present in labor at Parkland Hispanic women have reported that fear and mistrust of hospitals, lack of understanding of pain options, language barrier, and fear of permanent back pain as the reason for not choosing epidural analgesia in labor (Castro & Singer, 2004; Padilla, 2012; Passel & Gloste, 2008; Polley & Glosten, 2004; Rompen, 2012);. Fishbone Diagram: Honing in on a significant test variable Development Plan Part 1: Testing the Script Script modeled from preoperative assessment experiences. These conflicted directly with common wisdom. PP Patient agreed to be interviewed by team Had chosen IV sedation to manage her labor pain Agreed to participate in trialing our educational script and give feed back regarding content Had a positive reaction to the script. 3

4 Development Plan Part 1: Testing the Script Scripted labor pain management options: Benefits, risks, & side effects Myth/rumor debunking. Patient s feedback: She wanted to try the epidural with her next baby More beneficial to hear the options early. Development Plan Part 2 Pre Project Staff Education Anesthesia Staff and leaders Nurse Midwifery Staff Nursing Timeline and Population Time Line: May 1 st to August 31, 2015 Population: Low risk to moderate risk midwifery patients (Others excluded) All epidurals used for labor was included. Epidurals placed in OR were excluded, since we were looking specifically at labor analgesia. Neuraxial analgesia is already the standard for cesarean sections. 4

5 Project Protocol START Data Was Epidural Pre op & Epidural placement ordered? Epidural Order time Epidural Start Time Yes Epidural No in Midwifery Log END IV Medication No Pain relief Results Overall Epidural Results 2014 to 2015 Epidural Rates 60.0% 55.0% Percentage 50.0% 45.0% 40.0% % Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Series1 46.2% 49.1% 52.5% 51.9% 47.8% 45.7% 45.6% 40.9% 44.6% 46.3% 46.8% 46.1% 45.9% 47.7% 51.1% 45.4% 57.7% 57.8% 59.1% 57.2% 5

6 Project Results Pre and Post Pilot Epidural Rates 65.0% 60.0% S T A R T 55.0% 50.0% 45.0% 40.0% 35.0% Jan Feb Mar Apr May Jun Jul Aug A paired sample t test was calculated to compare the pre pilot epidural rate with the post pilot epidural rate. The mean on the pre pilot was (sd = 2.57), the mean on the post pilot was (sd =.8103),. A significant increase From pre test to post test was found (t(3) = , p = 001). Results: Outcomes Impact The numbers are simply a measureable proxy for more important outcomes. Improvement of the process is the rising tide that lifts all boats, particularly safety. Improvement of pain control can have more significant impacts in the longer term, such as mother baby bonding and exclusive breast feeding. Results: Outcomes Impact Decreased risk of emergent general anesthetics. Therapeutic effect on pre eclampsia and bleeding by lowering pressure. Decreased chaos: when we need to act, the knowledge and consent are already there. What s good for mom is good for baby: decreased anxiety, better communication and cooperation. 6

7 Results: Patient Satisfaction Epidural Wait Times: Order to Start Time Parkland Move 0.3 Minutes May 1: Project Start Jan Feb Mar Apr May Jun Jul Aug Results: Revenue/Cost Impact Grant for Increased Epidural Rates: Increased Epidural Rate Grant: Network Access Improvement Program (NAIP) for $1,100,000 if rates increase from March 1 to August 31 st 2015 (Obtained) $1, Million additional money if rates increase from Sept 1 through August 31 st Cost of incremental project epidurals = <$32,699> Net gain for hospital is $1,067,301. Enhanced patient satisfaction: Priceless Project Challenges Internal culture and biases within institution Pending move to new facility Peak patient volume during pilot Staffing issues Staff to patient ratios Resistance Inconsistency with using educational scripting tool. 7

8 Next Steps Just Beginning Automate Data Collection and Reporting Convert epidural script to video format in Spanish and English (completed) for consistency and decreased labor cost. Deploy video upstream both to clinics and upon admission. Maintain universal anesthesia pre operative assessments upon admission to facilitate more timely placement of epidurals. Track residual barriers to timely epidural placement. Key Take Home Principles The enemy is usually looking at you in the mirror; its our problem, not the patient s. Don t get distracted. Pushback is frequently more than anticipated. Perceived complexity of barriers tends to increase exponentially. Do the right thing and keep that front and center. Knowledge and pain control, for example in this project, are simple concepts. Just do it now. Avoid analysis paralysis. Thank you 8