背景:引产很常见;但是,引产的最佳临床策略尚不清楚。与引产相关的临床实践的变化可能导致并发症增加和引产时间延长。
目的:本研究旨在分析基于证据的标准化护理路径的实施是否能改善与引产相关的临床结局。
方法:这是一个批准的质量改进项目,实施临床护理路径引产。此外,这是一项回顾性队列研究,对护理路径实施前(2018年1月至2018年5月)5个月和实施后(2018年8月至2019年9月)14个月的引产情况进行调查.主要结果是从入院到分娩的时间。从入院到分娩的时间按分娩方式分层。次要结局包括绒毛膜羊膜炎,子宫内膜炎,新生儿重症监护室入院,剖宫产,产后出血,和一系列意想不到的结果(绒毛膜羊膜炎,子宫内膜炎,新生儿重症监护室入院,剖宫产,和产后出血)。此外,分析了途径的依从性。对连续数据使用双尾t检验,对分类数据使用Fisher精确检验和卡方检验分析结果。倾向评分匹配用于评估潜在协变量的混杂。
结果:共审查了1471项引产,实施护理路径前引产392例,实施护理路径后引产1079例。该途径与从入院到分娩的时间减少1.2小时(从23.4小时减少到22.2小时;P=.08)相关。方案实施前(28.2小时)和后(28.8小时)剖宫产时间无显著增加(P=.71)。方案实施后,阴道分娩的分娩时间显着减少了1.7小时(从22.2到20.5小时)(P=0.02)。绒毛膜羊膜炎有显著下降(从12.5%下降到6.0%;比值比,0.44;95%置信区间,0.29-0.67),子宫内膜炎显着降低(从6.9%降至2.6%;比值比,0.36;95%置信区间,0.20-0.65),综合非预期结果显著下降(从56.9%降至36.6%;赔率比,0.46;95%置信区间,0.34-0.56)实施护理路径后。产后出血没有显着差异(从7.9%到6.1%;比值比,0.76;95%置信区间,0.48-1.22),新生儿重症监护病房入院(从18.1%到14.0%;赔率比,0.74;95%置信区间,0.54-1.02),或剖宫产(从19.6%到20.1%;比值比,1.03;95%置信区间,0.76-1.40)实施护理路径后。途径依从性各不相同,从50%到89%不等。
结论:采用标准化引产途径与从入院到分娩的时间减少1.2小时和改善妊娠结局相关,包括减少感染和意外结果。通过增加对护理途径的依从性,可以实现临床结果改善的进一步机会。
BACKGROUND: Induction of labor is common; however, the optimum clinical strategy for induction of labor is less clear. Variations in clinical practices related to induction of labor may lead to increased complications and longer induction of labor times.
OBJECTIVE: This study aimed to analyze whether the implementation of an evidence-based standardized care pathway improves the clinical outcomes associated with induction of labor.
METHODS: This was an approved quality improvement project implementing a clinical care pathway for induction of labor. Moreover, this was a retrospective cohort study of inductions of labor for 5 months before (January 2018 to May 2018) and 14 months after (August 2018 to September 2019) the implementation of the care pathway. The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. The secondary outcomes included chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, and postpartum hemorrhage). In addition, pathway adherence was analyzed. The outcomes were analyzed using 2-tailed t tests for continuous data and the Fisher exact test and chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates.
RESULTS: A total of 1471 inductions of labor were reviewed, with 392 inductions of labor before the implementation of the care pathway and 1079 inductions of labor after the implementation of the care pathway. The pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours (from 23.4 to 22.2 hours; P=.08). There was a nonsignificant increase in the time to cesarean delivery before (28.2 hours) and after (28.8 hours) protocol implementation (P=.71). There was a significant decrease in the time to delivery by 1.7 hours for vaginal deliveries (from 22.2 to 20.5 hours) after protocol implementation (P=.02). There was a significant decrease in chorioamnionitis (from 12.5% to 6.0%; odds ratio, 0.44; 95% confidence interval, 0.29-0.67), a significant decrease in endometritis (from 6.9% to 2.6%; odds ratio, 0.36; 95% confidence interval, 0.20-0.65), and a significant decrease in composite unanticipated outcomes (from 56.9% to 36.6%; odds ratio, 0.46; 95% confidence interval, 0.34-0.56) after the implementation of the care pathway. There was no significant difference in postpartum hemorrhage (from 7.9% to 6.1%; odds ratio, 0.76; 95% confidence interval, 0.48-1.22), neonatal intensive care unit admissions (from 18.1% to 14.0%; odds ratio, 0.74; 95% confidence interval, 0.54-1.02), or cesarean deliveries (from 19.6% to 20.1%; odds ratio, 1.03; 95% confidence interval, 0.76-1.40) after the implementation of the care pathway. Pathway adherence varied, ranging from 50% to 89%.
CONCLUSIONS: The introduction of a standardized induction of labor pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours and improved pregnancy outcomes, including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.