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Improving Decision-to-Incision Time in Unscheduled Cesarean Deliveries: Use of a Proactive Preoperative Huddle
Abstract Number: T1C-223
Abstract Type: Original Research
Background: Historical standards have called for 30 minutes or less to pass between the decision to perform an unscheduled cesarean delivery (CD) and the start of the case. More recent guidelines still specify a 30 minute target but allow more leeway, suggesting that the interval should “[incorporate] maternal and fetal risks and benefits.”(1) At our institution, while this interval is not routinely recorded, sample measurements showed that the 30-minute target was not consistently met. A process improvement project was undertaken to improve decision-to-incision time for unscheduled CD by addressing perceived deficiencies in organization, teamwork, and communication.
Methods: The intervention consisted of two elements. First, the unit’s preoperative huddle was redesigned to include an explicitly-stated target time for OR entry and opportunities for each team (obstetrics, anesthesiology, and nursing) to state remaining barriers to OR entry, resource needs, and anticipated timing. Secondly, the workflow sequence was inverted; rather than teams independently carrying out tasks first and later joining in a huddle as a final step, the huddle was accelerated to become the initial step following decision for CD. The primary outcome was time between case booking (a proxy for decision time) and time of OR entry. Data collection was continuous for four weeks prior to and four weeks following the intervention.
Results: Timing data was collected for 26 pre- and 31 post-intervention cases. Prior to intervention, the mean time between decision and OR entry was 33.5 minutes, median time was 33.5 minutes, and standard deviation was 16.0 minutes. Following intervention, the mean time was 18.0 minutes, median time was 17.0 minutes, and standard deviation was 11.2 minutes. Hypothesis testing for the mean time interval was carried out via Mann-Whitney U testing, with a U statistic of 639 and a two-tailed p-value of 0.0002.
Discussion: Through modification of a labor unit’s huddle tool to include explicit target times and a discussion of teams’ remaining tasks and needs, as well as redesign of the workflow for unscheduled CD to perform the preoperative huddle immediately, the mean latency between decision and OR entry was significantly reduced. Variability in timing also decreased. These improvements were likely due to facilitation of communication between teams, improved awareness of others’ remaining tasks, and increased goal orientation. In addition to patient care benefits, reducing this time interval benefits physicians by minimizing waiting, thus freeing time for other clinical tasks. Hospitals benefit through more efficient use of fixed facility resources. Future process improvement projects can focus maximizing efficiency and minimizing variability in the time period between OR entry and incision.
1. Riley LE, Stark AR, eds. Guidelines for Perinatal Care, 7th Ed. Washington: American College of Obstetricians and Gynecologists; c2012.