The Benefits of a Standardized Approach to Identifying Women at Risk for Preterm Birth
With nearly 10 percent of U.S. babies born prematurely, it's imperative that obstetric nurses have access to standardized screening tools to provide the best perinatal care. After implementing a preterm labor assessment toolkit at the WellStar Health System, we helped to improve outcomes for both mother and baby while simultaneously lowering patient and hospital costs.
Nearly 10 percent of babies born in the U.S. are born prematurely and the rates of preterm birth are on the rise. Premature birth is the number one cause of death among babies and a leading cause of lifelong disabilities, with up to 50 percent of preterm births resulting in long-term neurologic impairment. In addition, the costs associated with prematurity are significant - estimated at more than $51,000 per premature infant. In order to reduce the occurrence and harmful effects of preterm birth, obstetric and perinatal nurses need to be able to intervene quickly for at-risk pregnant women, but this is only possible if screening protocols for expectant mothers with symptoms of preterm birth are standardized and reliable.
This is why I'm so passionate about implementing standardized triage assessments, like we've done at my hospital. The protocol we've developed allows for more appropriate selection of women who require hospitalization and treatments, such as tocolytic drugs to prolong pregnancy and antenatal corticosteroids to improve neonatal outcomes. Unfortunately, this isn't the case in most hospitals. Screening practices vary greatly across the U.S., but with a common theme: underutilization of available diagnostics, most notably the fetal fibronectin (fFN) test.
Many studies show that the use of fFN testing can help identify expectant mothers at imminent risk of preterm birth, versus those whose symptoms will resolve without hospitalization and treatment. However, there are no formal guidelines in place regarding the assessment of preterm labor and the role of routine fFN testing. This is unfortunate, given fFN testing has been shown to improve clinical outcomes for both mother and baby, as well as reduce costs.
For example, a recently published national study looking at Medicaid enrollees found that only 12 percent of more than 23,000 women with symptoms of preterm labor received an fFN test, and only 21.5 percent were assessed for cervical length. This was clearly insufficient, as 76 percent of the women triaged were not admitted to the hospital, and of these women, 20 percent ultimately delivered prematurely. Our patients deserve better care! These mothers would likely have benefited from continued monitoring and care within the hospital, where pregnancy might have been prolonged, and the risk of complications would have been lower. In fact, fFN testing better helped to identify these women who needed additional care, as the percentage of women who delivered within three days of being assessed in the emergency room was lower among women who had an fFN test alone (6.6 percent) than among those who were assessed by cervical length (21.6 percent) and was lowest among women who had both tests (4.7 percent).
This study suggests that routine administration of fFN testing, especially when done along with cervical length measurement, might have provided additional information that would have improved prenatal care for these expectant mothers. Why wouldn't we want to gather all the information possible to help inform how we care for our patients? In fact, implementing a nurse-led, preterm labor assessment toolkit at my hospital system - the WellStar Health System in Georgia - has allowed for more efficient allocation of our time and hospital resources. After implementing the toolkit at three hospitals, the number of patients who received an fFN test increased from 39-52 percent before the new protocol to 80-95 percent after. This led to a decrease in the average length of a nurse assessment from 40 minutes to 20 minutes and allowed for appropriate and prompt initiation of antenatal corticosteroids and tocolytics, as recommended by the American College of Obstetricians and Gynecologists. Through implementing this protocol, we were able to save costs from reduced unnecessary hospitalization, medical interventions and nursing hours, totaling more than $480,000. Now that's something I'm proud of!
Most importantly, this standardized, nurse-initiated screening protocol improves customer service, and therefore patient satisfaction and outcomes. The ability for nurses to quickly assess patients and admit those at imminent risk of preterm birth while discharging those for whom extended care is not needed, allows at-risk expectant mothers to receive the specialized care they need. For the majority of patients who were able to be discharged, we provide a brochure explaining their test results to foster an extra level of confidence that their symptoms have been evaluated carefully and correctly and that it's safe to go home. As healthcare providers, it's important that we are able to build trust and provide reassurance to expectant mothers worried about delivering their baby prematurely.
In recent years, we've seen a growing shortage of experienced labor and delivery nurses and an increase in the frequency of preterm birth. Given the resulting strain on healthcare systems, it is more important than ever to ensure not only that provider time and hospital resources are used efficiently, but also that streamlined procedures don't result in compromised quality of care that jeopardizes our patients' sense of well-being. To that end, fFN testing should be included as a standard test for at-risk women, due to its potential to improve care and patient satisfaction, reduce costs and ease the burden on nurses - the first line of care providers for these vulnerable patients.
About Lashea Wattie, MSN
Lashea Wattie has been practicing obstetrical nursing for over 20 years, with clinical and educational expertise in labor/delivery, antepartum and mother/baby areas. She currently works as the System Perinatal Clinical Nurse Specialist for a large health system in Georgia and was the lead facilitator to assist with the rising rate of maternal deaths across the state. She is an active AWHONN member, currently serving on both the National AWHONN Membership and Conference Committees, as well as a 2015 recipient of the AWHONN Award of Excellence in Community Service.
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