Factors that influence the implementation and effectiveness of a patient safety bundle to reduce low-risk cesarean deliveries

美国剖腹产率高是一个令人迫切关注的问题，因为剖腹产是 与产妇发病率和死亡率风险增加有关。第一次剖腹产的妇女 增加严重并发症的风险，如子宫破裂、计划外子宫切除术和子宫内膜炎。 每一次剖腹产都会增加严重的产妇发病率和不良新生儿结局的风险。 送货。在过去的二十年里，剖腹产率的上升被认为是整体 同期孕产妇死亡率和发病率增加。降低剖宫产率 在首次怀孕的低风险母亲中，卫生资源和服务管理局是 目前支持通过州围产期协作实施“患者安全捆绑包”。 拟议的研究将利用在马里兰州实施剖腹产捆绑的现实世界。 围产期协作(MPC)，它是首批实施捆绑和 包括该州32家分娩医院中的31家。我们的研究团队，拥有实施科学方面的专业知识， 产科护理质量，以及混合方法和定性研究，将进行混合方法案例研究 参与货币政策委员会的医院的捆绑实施情况。这项拟议的研究将是第一次 剖宫产捆绑的实施研究，并将解决指南文献中的重要空白 在产科护理中的实施。为了我们的第一个目标，我们将对MPC领导人进行定性采访，并 利益相关者描述和分类每家医院的实施方法，并确定障碍和 实施捆绑包的促进者。访谈将涉及整合的五个领域 执行研究框架(CFIR)，并将有助于建立指南的证据基础 在产科护理中的实施。在我们的第二个目标下，我们将进行比较定性分析， 评估哪些实施因素是高度采用捆绑包的医院的常见因素(70% 捆绑做法)和低采用率(40%的做法)，以及剖腹产率较高的医院(每100人中30人 活产)和较低的比率(每100人中有20英镑)。对于我们的第三个目标，我们将评估捆绑EBP的维护， 以及任何新采用的EBP，通过在合作结束一年后对MPC领导人进行调查。这个 这项研究的结果将有助于制定R01提案，以测试实施支持 旨在改进捆绑实施和降低剖腹产率的一揽子计划。

High rates of cesarean delivery in the United States are a cause of urgent concern as cesarean delivery is associated with increased risks for maternal morbidity and mortality. Women with a first cesarean are at increased risk for serious complications such as uterine rupture, unplanned hysterectomy, and endometritis. The risk of severe maternal morbidity and poor neonatal outcomes increases with each subsequent cesarean delivery. The rise in cesarean delivery rates during the past two decades is a suspected driver of overall increases in maternal mortality and morbidity in the same time period. To reduce cesarean delivery rates among first-time mothers with low-risk pregnancies, the Health Resources and Services Administration is currently supporting implementation of a “patient safety bundle” through state perinatal collaboratives. The proposed study will leverage a real world implementation of the cesarean bundle through the Maryland Perinatal Collaborative (MPC), which is one of the first state collaboratives to implement the bundle and includes 31 of the state’s 32 birthing hospitals. Our research team, with expertise in implementation science, obstetric care quality, and mixed-methods and qualitative research, will conduct a mixed-methods case study of bundle implementation at hospitals participating in the MPC. The proposed research will be the first implementation study of the cesarean bundle, and will address important gaps in the literature on guideline implementation in obstetric care. For our first aim, we will conduct qualitative interviews with MPC leaders and stakeholders to describe and categorize each hospital’s implementation approach and to identify barriers and facilitators for implementing the bundle. Interviews will address the five domains of the Consolidated Framework for Implementation Research (CFIR), and will contribute to building the evidence base for guideline implementation in obstetric care. Under our second aim, we will conduct Comparative Qualitative Analysis to assess which implementation factors are common to hospitals with high adoption of the bundle (>70% of bundle practices) and low adoption (<40% of practices), and hospitals with higher cesarean rates (>30 per 100 live births) and lower rates (<20 per 100). For our third aim, we will assess the maintenance of bundle EBPs, and any new adoption of EBPS, through a survey of MPC leaders one year after the collaborative ends. The results of this study will contribute to the development of an R01 proposal to test an implementation support package designed to improve implementation of the bundle and reduce cesarean delivery rates.