Sustaining and spreading quality improvement: Decreasing intrapartum malpractice risk

The effects of the intrapartum care model given in line with the recommendations of the World Health Organization (WHO) on the mother's maternal behavior towards her baby, breastfeeding self-efficacy, breastfeeding success, and hospital discharge readiness: a randomized controlled trial

BACKGROUND

A woman's experiences of childbirth, which represents a significant transition in the journey towards motherhood, encompass a range of factors that can influence breastfeeding, parenting behaviors, and readiness for discharge. However, research exploring the intrapartum and postpartum care aspects of the WHO-developed intrapartum care model remains scarce, particularly with regard to breastfeeding, parenting behaviors, and the readiness of the mother in the early postpartum period.

AIM

The objective of this study was to examine the impact of the intrapartum care model that adheres to the guidelines set forth by the World Health Organization (WHO) on several key outcomes, including the mother's maternal behavior towards her infant postpartum, breastfeeding self-efficacy, the success of breastfeeding, and the mother's readiness for hospital discharge.

METHODS

The study was a randomized controlled trial. The study was conducted with 128 primiparous pregnant women (intervention group n = 64, control group n = 64) admitted to the maternity unit of a training and research hospital in a province in the Central Anatolia region of Turkey. The pregnant women in the intervention group were provided with intrapartum care in accordance with the WHO recommendations following the achievement of cervical dilatation reaching 5 cm. The control group was provided with only standard intrapartum and postpartum care. The data were collected using a personal information form, a postpartum parenting behavior scale, a breastfeeding self-efficacy scale, a breastfeeding charting system and documentation tool (LATCH), and a hospital discharge readiness scale.

RESULTS

The mean scores for parenting behavior and breastfeeding self-efficacy of the women in the intervention group who received intrapartum care in accordance with the World Health Organization (WHO) recommendations were found to be significantly higher than those of the women in the control group (p < 0.001). Additionally, the mean LATCH score of the women in the intervention group (9.6 ± 0.8) was higher than that of the women in the control group (8.4 ± 1.6) and no breastfeeding problems were observed (p < 0.001). The women in the intervention group exhibited a higher level of readiness for hospital discharge (176.3 ± 10.7) compared to the women in the control group (149.6 ± 13.7). The mean score for the subscale "expected support" on the readiness for hospital discharge scale was found to be 9 ± 7.2 in the intervention group, which was considerably lower than the mean score of the control group (15.2 ± 8.4). It was determined that women in the intervention group who received the intrapartum care model required less support in the postpartum period compared to women in the control group (p < 0.001).

CONCLUSION

The intrapartum care model provided in line with WHO recommendations increases mothers' parenting behavior, breastfeeding self-efficacy, and breastfeeding success, and supports them to be more ready for discharge from the hospital.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Knowledge translation strategies to support the sustainability of evidence-based interventions in healthcare: a scoping review

BACKGROUND

Knowledge translation (KT) strategies are widely used to facilitate the implementation of EBIs into healthcare practices. However, it is unknown what and how KT strategies are used to facilitate the sustainability of EBIs in institutional healthcare settings.

OBJECTIVES

This scoping review aimed to consolidate the current evidence on (i) what and how KT strategies are being used for the sustainability of EBIs in institutional healthcare settings; (ii) the reported KT strategy outcomes (e.g., acceptability) for EBI sustainability, and (iii) the reported EBI sustainability outcomes (e.g., EBI activities or component of the intervention continue).

METHODS

We conducted a scoping review of five electronic databases. We included studies describing the use of specific KT strategies to facilitate the sustainability of EBIs (more than 1-year post-implementation). We coded KT strategies using the clustered ERIC taxonomy and AIMD framework, we coded KT strategy outcomes using Tierney et al.'s measures, and EBI sustainability outcomes using Scheirer and Dearing's and Lennox's taxonomy. We conducted descriptive numerical summaries and a narrative synthesis to analyze the results.

RESULTS

The search identified 3776 studies for review. Following the screening, 25 studies (reported in 27 papers due to two companion reports) met the final inclusion criteria. Most studies used multi-component KT strategies for EBI sustainability (n = 24). The most common ERIC KT strategy clusters were to train and educate stakeholders (n = 38) and develop stakeholder interrelationships (n = 34). Education was the most widely used KT strategy (n = 17). Many studies (n = 11) did not clearly report whether they used different or the same KT strategies between EBI implementation and sustainability. Seven studies adapted KT strategies from implementation to sustainability efforts. Only two studies reported using a new KT strategy for EBI sustainability. The most reported KT strategy outcomes were acceptability (n = 10), sustainability (n = 5); and adoption (n = 4). The most commonly measured EBI sustainability outcome was the continuation of EBI activities or components (n = 23), followed by continued benefits for patients, staff, and stakeholders (n = 22).

CONCLUSIONS

Our review provides insight into a conceptual problem where initial EBI implementation and sustainability are considered as two discrete time periods. Our findings show we need to consider EBI implementation and sustainability as a continuum and design and select KT strategies with this in mind. Our review has emphasized areas that require further research (e.g., KT strategy adaptation for EBI sustainability). To advance understanding of how to employ KT strategies for EBI sustainability, we recommend clearly reporting the dose, frequency, adaptations, fidelity, and cost of KT strategies. Advancing our understanding in this area would facilitate better design, selection, tailored, and adapted use of KT strategies for EBI sustainability, thereby contributing to improved patient, provider, and health system outcomes.

Sustaining Improvement Initiatives: Challenges and Potential Tools

Like many implemented organizational changes, quality improvement (QI) projects demonstrate frequent decline after implementation. Factors associated with successfully sustained change are leadership, change characteristics, system capacity for changes and the resources required, and processes to maintain, evaluate, and communicate results. This review uses lessons from change theory and behavioral sciences to discuss change and sustainment of improvement efforts, to list models to support maintenance, and to provide evidence-based practical suggestions to enable the sustainability of QI interventions.

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION

Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.

METHODS

Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.

RESULTS

Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.

CONCLUSIONS

Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.