Objective The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States.Study Design A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research.Results The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement.Conclusion This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists.

We sought to develop and implement an enhanced recovery after surgery (ERAS) pathway for cesarean delivery that would decrease postoperative opioid use in the inpatient setting while not compromising pain control. ERAS pathways have been adopted by other surgical fields but need more study in obstetrics. This is an IRB approved retrospective cohort study. Primary outcomes are postoperative, inpatient opioid use and patient reported postoperative pain scores. The ERAS pathway was started on 10/16/18 for all patients undergoing cesarean delivery. In-depth analysis included patients 3 months after the start of the ERAS pathway (n=267) compared to a historical control group 3 months prior at the same hospital (n=316). Data were collected via chart review of the electronic medical record. Opioid use, measured in morphine milligram equivalents (MME), was calculated using a validated analytics tool called Qlik Sense®. This tool was also used to track mean opioid use per patient on a monthly basis during ERAS implementation. Implementation of an ERAS pathway for cesarean delivery resulted in a significant decrease in opioid use per patient on each postoperative day and for the entire inpatient recovery period. After implementation of ERAS, median total postoperative opioid use was 30 MME (CI:27.5-37.5) per patient compared to 180.3 MME (CI:173-192.8) per patient prior to ERAS (p=0.028). With ERAS, 26% of patients never took an opioid during the postoperative recovery period. Before ERAS, 100% of patients took an opioid during recovery (p< 0.001). Median patient reported pain scores decreased with ERAS for postoperative days 1-3 (p< 0.001) and remained unchanged on day 4 (p=0.251). A 62% decrease in mean postoperative opioid use has been sustained for the past 8 months since starting ERAS compared to historical data for the past 2.5 years. An ERAS pathway for cesarean delivery significantly decreases postoperative opioid use in the inpatient setting while also providing better pain control. Patients undergoing cesarean delivery can benefit greatly from an ERAS pathway.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To evaluate maternal and neonatal outcomes following management of preterm premature rupture of membranes (PPROM) by two fetal assessment strategies.