Doyle, J., Kenny, T.H., Burkett, A.M., & von Gruenigen, V.E. (2011), A performance improvement process to tackle tachysystole, Journal of Obstetric, Gynecologic, and Neonatal Nursing, 40(5), 512-9.
Name of Agency/Organization/Institution
Summa Health System Akron City Hospital, a level III perinatal center in Akron, OH with an annual delivery volume of approximately 3,000. In 2008, the hospital joined the Premier Perinatal Safety Initiative, an obstetric quality collaborative of 16 hospitals nationwide.
Project Aims and Goals
As part of a larger program to achieve zero preventable birth injuries, this project’s goal was to avoid tachysystole or appropriately intervene when tachysystole occurred. Tachysystole is defined as more than 5 contractions in 10 minutes, averaged over a 30-minute window, and is often associated with induced or augmented labor.
Approach and Activities
The project used the Plan, Do, Study, Act approach to quality improvement. First, the improvement team, which consisted of nurses, doctors, and administrators, reviewed existing oxytocin administration policy and the relevant literature and collected baseline data for benchmarking against other hospitals. Then an evidence-based algorithm for oxytocin administration was developed, outlining physiologic and safety guidelines for oxytocin administration. The algorithm included the definition of tachysystole and described appropriate interventions for addressing tachysystole whether in the presence or absence of fetal heart rate changes (e.g., changing maternal positioning, decreasing or discontinuing oxytocin drip).
The algorithm was vetted and eventually adopted as policy. All clinical staff received education about the new policy, which featured case examples and a review of communication/chain of command procedures when nurses encountered physician resistance to following the algorithm. The laminated algorithm was posted in every labor and delivery room at the bedside. Adherence to the algorithm was audited monthly and nurses doing well were acknowledged among their peers. Nurses not following the algorithm received a peer review letter and had the opportunity to review the case. When communication issues were identified, a multi-disciplinary team with obstetrician oversight reviewed the case and made recommendations.
The improvement team calculated the percentage of maternal-fetal dyads where uterine tachysystole was avoided or managed according to the algorithm each month. Results reached the goal of 100% at month 13 (August 2009) and remained at 95% to 100% since, with the exception of 2 months.
The researchers state, “Uterine tachysystole is more recognized and acted upon as a result of this performance improvement process. Nurses state a keen awareness of ongoing quality audits targeting oxytocin administration…Nurses also report more respectful and evidence-based discussions of [fetal heart rate monitoring] interpretation and oxytocin administration real-time at the point of care. Instead of having the baby ‘declare itself,’ meaning waiting for signs of fetal decompensation before intervening, our nurses are quicker to turn the oxytocin off for category II or III patterns or one half the dose if category I in the presence of tachysystole. Nurses and resident physicians have mentioned feeling ‘backed’ by policy when challenged clinically.”
BLUEPRINT AREA(S) ADDRESSED
- Performance measurement and leveraging of results
- Scope, content, and availability of health professions education
- Improved functioning of the liability system