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

在美国，剖腹产的高比率是一个紧迫的问题，因为剖腹产是 与孕产妇发病率和死亡率风险增加有关。第一次剖腹产的妇女在 严重并发症的风险增加，如子宫破裂、计划外子宫切除术和子宫内膜炎。 随着每次剖宫产，产妇严重发病率和新生儿不良结局的风险增加 交付.在过去的二十年中，剖宫产率的上升被怀疑是整体死亡率的驱动因素。 同期孕产妇死亡率和发病率的增加。降低剖腹产率 在低风险怀孕的第一次母亲中，卫生资源和服务管理局正在 目前正在通过各州围产期协作机构支持实施“病人安全包”。 拟议的研究将利用真实的世界实施剖宫产束通过马里兰州 围产期协作（MPC），这是第一个国家协作，以实现捆绑， 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，混合方法和定性研究，将进行混合方法的案例研究 在参与MPC的医院中捆绑实施。这项研究将是第一个 剖宫产束的实施研究，并将解决指南文献中的重要空白 在产科护理中的实施。对于我们的第一个目标，我们将与MPC领导人进行定性访谈， 利益相关者描述和分类每家医院的实施方法，并确定障碍， 实现捆绑包的促进者。访谈将涉及综合战略的五个领域， 实施研究框架（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采用捆绑包的医院所共有的（>70%的 捆绑实践）和低采用率（<40%的实践），以及剖宫产率较高的医院（>30/100 活产）和较低的比率（<20/100）。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EBPS的情况，通过在合作结束一年后对MPC领导人的调查。的 本研究的结果将有助于制定R 01提案，以测试实施支持 旨在改善捆绑包的实施并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.