Establishing gold standards for System-Level Measures: a modified Delphi consensus process.

OBJECTIVE: To establish aspirational 'gold standards' for a suite of System-Level Measures (SLMs) being used by Counties Manukau Health (CM Health), a New Zealand (NZ) District Health Board. DESIGN: This study employed a multi-stage, multi-method modified Delphi consensus process. SETTING: The Delphi consensus process involved virtual (email) communication between participants (Round 1) and a structured face-to-face meeting (Round 2) held in Auckland, NZ. PARTICIPANTS: Participants comprised of health professionals, managers, academics and quality improvement experts with an interest in the use of SLMs. INTERVENTIONS: Participants in the first round received a letter requesting their participation in an anonymous Delphi. The second round involved national and international health system experts taking part in a structured, facilitated face-to-face meeting. Participants reviewed 15 SLMs in total. The SLMs all related to the three domains of the Triple Aim: Population Health, e.g. life expectancy at birth; Patient Experience of Care, e.g. rate of adverse events; and Cost and Productivity, e.g. healthcare expenditure per capita. MAIN OUTCOME MEASURES: For a proposed gold standard to be agreed and established for each SLM. RESULTS: Twelve participants took part in Round 1, with 19 participating in Round 2. The process established agreement on a gold standard for each of the 15 reviewed SLMs. CONCLUSION: We demonstrated that the Delphi consensus process can be used to establish gold standards for a suite of SLMs used by a NZ Health Board (CM Health).

Audit and feedback using the Robson classification to reduce caesarean section rates: a systematic review.

BACKGROUND: In most regions worldwide, caesarean section (CS) rates are increasing. In these settings, new strategies are needed to reduce CS rates. OBJECTIVES: To identify, critically appraise and synthesise studies using the Robson classification as a system to categorise and analyse data in clinical audit cycles to reduce CS rates. SEARCH STRATEGY: Medline, Embase, CINAHL and LILACS were searched from 2001 to 2016. SELECTION CRITERIA: Studies reporting use of the Robson classification to categorise and analyse data in clinical audit cycles to reduce CS rates. DATA COLLECTION: Data on study design, interventions used, CS rates, and perinatal outcomes were extracted. RESULTS: Of 385 citations, 30 were assessed for full text review and six studies, conducted in Brazil, Chile, Italy and Sweden, were included. All studies measured initial CS rates, provided feedback and monitored performance using the Robson classification. In two studies, the audit cycle consisted exclusively of feedback using the Robson classification; the other four used audit and feedback as part of a multifaceted intervention. Baseline CS rates ranged from 20 to 36.8%; after the intervention, CS rates ranged from 3.1 to 21.2%. No studies were randomised or controlled and all had a high risk of bias. CONCLUSION: We identified six studies using the Robson classification within clinical audit cycles to reduce CS rates. All six report reductions in CS rates; however, results should be interpreted with caution because of limited methodological quality. Future trials are needed to evaluate the role of the Robson classification within audit cycles aimed at reducing CS rates. TWEETABLE ABSTRACT: Use of the Robson classification in clinical audit cycles to reduce caesarean rates.

Rising rates of caesarean deliveries at full cervical dilatation: a concerning trend.

OBJECTIVES: To audit caesarean sections performed at full cervical dilatation over a three year period in a tertiary referral centre in Ireland. To evaluate (i) the rate of caesarean deliveries in the second stage of labour, (ii) the indication for delivery and (iii) the associated fetal and maternal morbidity in this cohort of women. STUDY DESIGN: This cohort study was carried out in the University Hospital Galway (UHG). Medical records of 136 consecutive women with singleton cephalic pregnancies at term, identified from the hospital database, who underwent a second stage caesarean section (CS) between 1 January 2006 and 31 December 2008, were reviewed retrospectively and demographic and outcome data were collected. RESULTS: During the study period 2801/10,202 (27.5%) babies were delivered by CS. One hundred and thirty six CS (4.8%) were performed at full dilatation. The rate of CS during the second stage increased from 0.9% in 2006 to 1.8% in 2008. The majority of women were nulliparous (76.5%) and in spontaneous labour (64%). 44.1% of women had a second stage CS without a trial of instrumental delivery. 41.3% of public deliveries were attended by a consultant. The majority of babies (54%) were delivered because of a prolonged second stage with a mean duration of 146 min from full dilatation to delivery. Twenty-four of 59 primiparous women (40.7%), who underwent CS because of a prolonged second stage, did not receive oxytocin. 13.2% of babies were admitted to the neonatal intensive care unit. Estimated blood loss was documented in 67% of cases (n=91); 14.3% of women (n=13) had a postpartum haemorrhage greater than or equal to 1000 mls. 23% of these women (n=3) required a blood transfusion. The overall blood transfusion rate was 2.2%. 50% of women had a hospital stay of greater than four days. CONCLUSIONS: There is a worrying rise in the overall rate of CS at full dilatation. Audit of the second stage CS rate is a useful measure of clinical standards. Strategies for improved care include increased consultant presence, meticulous documentation and ongoing training of junior obstetric staff to ensure safe intrapartum care. CONDENSATION: The increase of second stage caesarean sections requires urgent strategies for improved care including increased consultant presence, meticulous documentation and training of junior obstetric staff.