Smooth Transitions: Enhancing Interprofessional Collaboration when Planned Community Births Transfer to Hospital Care.

In Washington state, planned community births are attended by direct entry licensed midwives (LMs) and certified nurse-midwives (CNMs). The most recently published vital statistics data from 2018 reported that 3.6% of the 84,648 births in Washington occurred at home or in freestanding birthing centers. Approximately 16.2% of planned home birth and birth center clients experience intrapartum or early postpartum transfer to the hospital, while 1.8% of their newborns do. The safety of and satisfaction with these types of referrals depends on multisystem processes performed by a variety of health care professionals. Smooth Transitions is a quality improvement (QI) initiative in Washington state that was developed to enhance interprofessional collaboration between community-based midwives, emergency medical services (EMS), and hospital personnel to improve the quality of hospital transfers from planned community settings. Key interventions to date have included (1) information sharing to dispel misconceptions and provide context regarding community births and midwives; (2) co-creation of transfer guidelines; (3) regularly held interprofessional meetings to review transfers and build relationships; and (4) ongoing review of qualitative feedback that captures the perspectives of all involved. Responses on questionnaires and audits indicate that Smooth Transitions has had a positive impact on provider, staff, and patient experiences with hospital transfers. Future endeavors will include strengthening quantitative data collection processes to measure safety indicators, expanding relationships with EMS, and building a case review process that is legally protected. By engaging representatives of all stakeholder groups and addressing community-to-hospital transfers as a multisystems issue, replication of the Smooth Transitions QI Program nationally could promote increased community midwifery integration by enhancing the referral experience for both patients and caregivers.

Time from decision to incision for cesarean deliveries at a community hospital.

OBJECTIVE: To compare decision-to-incision times of cesarean deliveries for various indications, estimate the percentage of cesarean deliveries initiated within 30 minutes (defined as "efficient"), and assess the effect of performance improvement projects over time. METHODS: In 2004 (n=291) and 2006 (n=574) cesarean deliveries were prospectively tracked for decision-to-incision time. Information collected included indication, urgency, and reason for delay. Performance improvement addressed surgeon, anesthesiologist, operating room availability, nursing availability, and patient-related delays. RESULTS: Unscheduled cesarean delivery efficiency improved from 36% in 2004 to 59% in 2006 (P<.001). Emergency cases improved from 67% to 84% (P=.07). The "Other" category was most improved over time, from 18% efficient deliveries in 2004 to 49% in 2006 (P<.001). For patients with failure to progress, efficiency improved from 33% in 2004 to 54% in 2006 (P<.001). For patients with nonreassuring fetal heart rate tracings, efficiency improved from 56% in 2004 to 76% in 2006 (P=.02). The efficiency rate for cesarean deliveries varied significantly by indication in both study years (2004, P<.001; 2006, P<.001). CONCLUSION: Cesarean delivery efficiency varied by indication, but a data-driven hospital-based initiative successfully improved efficiency over time. Indication-based standards that address an institution's staff and structural capacity are needed to evaluate time from decision to incision.