Improving Shoulder Dystocia Management and Outcomes with a Targeted Quality Assurance Program.
Improving Shoulder Dystocia Management and Outcomes with a Targeted Quality Assurance Program.
复制标题
通过有针对性的质量保证计划改善肩难产的管理和结果。
DOI：
10.1055/s-0037-1603819
复制
发表时间：
2017
影响因子：
2
通讯作者：
Satin,AndrewJ
中科院分区：
文献类型：
--
作者：
GurewitschAllen,EdithD;Will,SusanEBrown;Allen,RobertH;Satin,AndrewJ
背景一些研究人员在将通过模拟训练掌握的肩难产管理技能转移到临床实践方面取得了显着的成功。然而，其他研究人员尚未证明类似的益处，这对成功和不成功的干预措施之间的特定模拟方案、教学内容和附加质量保证措施的比较有效性提出了疑问。在我们的初步审查发现肩难产管理算法、记录和受伤新生儿及时随访方面存在差距后，我们制定并实施了五项干预措施，其中三项教育级别和两个系统级别，旨在改善肩难产管理。目的描述系统性质量改进计划对肩难产并发阴道分娩结局的临床影响。设置一个城市三级学术医疗中心，培训 36 名妇产科医生（每年 9 名），并提供全面的服务。每年约 2,000 次分娩的产科服务。研究设计我们使用 SQUIRE 2.0（卓越质量改进报告标准）来 (1) 描述我们的核心教学内容和基于模拟的实践，强调具体的规范性和规范性建议及其证据基础，以及 (2) 报告我们针对肩难产相关臂丛神经的系统质量改进计划的临床影响的中断时间序列评估结果 与基线（1993年6月至2004年12月）相比，约翰·霍普金斯医院（2014年1月至2015年12月）出生体重 ≥2,500 g的阴道分娩婴儿肩难产发生率从2.6%上升至4.6%（X2= 29.8； df = 1;p< 0.0001);此外，文件记录有所改进，直接胎儿操作有所增加，而使用会阴切开术治疗肩难产的情况有所减少。虽然干预前只有 65% 的臂丛神经损伤与肩难产相关，但干预后 100% 的新生儿臂丛神经损伤与肩难产相关（80/122 [65%] vs. 7/7 [100%]，X2= 3.66；df = 1；p= 0.055），这一趋势反映了人们对肩难产的认识同时增加。影响肩部并改善肩难产的整体治疗。最重要的是，肩难产并发症阴道分娩中臂丛神经损伤的发生率从基线的 31.6% 下降到 6.3% (X2= 27.9; df = 1;p< 0.0001)，绝对臂丛神经损伤率从每 1,000 名阴道分娩者 8.2 例下降到 2.9 例出生量 ≥2,500g，减少了64.5%（X2= 7.3；df = 1；p= 0.007）。 结论 具有具体规范性和规定性教学内容和管理建议的系统质量保证计划与改善肩难产的识别、管理和临床结果相关。
BackgroundSeveral investigators have achieved remarkable success in transferring shoulder dystocia management skills mastered with simulation training to clinical practice. However, other investigators have not demonstrated similar benefits, raising questions about the comparative effectiveness of specific simulation schemes, instructional content, and additional quality assurance measures between successful and unsuccessful interventions. After our initial review revealed gaps in following shoulder dystocia management algorithms, documentation and timely follow-up of injured neonates, we developed and implemented five interventions, three educational and two systems-level, aimed at improving shoulder dystocia management.ObjectiveTo describe the clinical impact of a systematic program of quality improvement on outcomes of vaginal births complicated by shoulder dystocia.SettingAn urban tertiary academic medical center that trains 36 obstetrics/gynecology residents (9 per year) and provides comprehensive obstetrical services for approximately 2,000 deliveries annually.Study DesignWe use SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) to (1) describe our core instructional content and simulation-based practice, emphasizing specific proscriptive and prescriptive recommendations and their evidence basis, and (2) to report an interrupted time series assessment of the clinical impact of our systematic quality improvement program targeting shoulder dystocia-associated brachial plexus injury.ResultsCompared with baseline (June 1993 to December 2004), the incidence of shoulder dystocia among vaginally delivered infants with birth weight ≥ 2,500 g at Johns Hopkins Hospital (January 2014 to December 2015) increased from 2.6 to 4.6% (X2= 29.8; df = 1;p< 0.0001); in addition, documentation improved, direct fetal manipulation increased, while use of episiotomy for the management of shoulder dystocia decreased. While preintervention only 65% of brachial plexus injury were associated with shoulder dystocia, 100% of neonatal brachial plexus injuries were associated with shoulder dystocia postintervention (80/122 [65%] vs. 7/7 [100%],X2= 3.66; df = 1;p= 0.055), a trend reflecting simultaneous increased recognition of impacted shoulders and improved overall management of shoulder dystocia. Most importantly, the incidence of brachial plexus injury among shoulder-dystocia-complicated vaginal deliveries has decreased from a baseline of 31.6 to 6.3% (X2= 27.9; df = 1;p< 0.0001), and the absolute brachial plexus injury rate declined from 8.2 to 2.9 per 1,000 vaginal births ≥ 2,500 g, a reduction of 64.5% (X2= 7.3; df = 1;p= 0.007).ConclusionA systematic program of quality assurance with specific proscriptive and prescriptive instructional content and management recommendations is associated with improved recognition, management, and clinical outcomes of shoulder dystocia.