At Home Bed Rest - A Viable Option for Arrested Preterm Labor - Research Paper Example

 Design for change in practice The rise in health care expenses has forced physicians to design changes in medical management. Preterm labor problems of pregnant women is a medical condition in which hospitalized bed rest can be altered with a safe and well planned ‘at home bed rest’ after treatment for acute symptoms or signs have been completed. At home bed rest is a better method for pregnant women because expectant women and families need not go through the psychological effect of being in a hospital. Alternative approach to treat preterm labor emphasizes on effectiveness of ambulatory monitoring of uterine function, home monitoring of uterine and program implementation with or without the assistance of nurses. The aim of the research is to offer care and support in the less expensive home setting that is of advantage to the patient. A randomized clinical trial to compare maternal and neonatal outcome such as birth weight, gestational age, rate of preterm birth, number of infants at neonatal ICU and period of neonatal hospital stay for home versus hospital care indicated that there was no significant difference among the group of patients who underwent hospitalized bed rest and at home bed rest (Goulet, C., Gevry, H., Lemay, M., Gauthier, R., Lepage, L., Fraser, W., et al. 2001 p.986). A table showing the difference in outcomes between at home bed rest group and at hospital group of patients. Factors At home group At hospital group Mean gestational age at delivery 37.52 weeks 37.50 weeks Mean birth weight 974 g 3020 g Mean duration of first hospitalization was shorter for ‘at home bed rest’ group 3.8 days 6.1 days Mead duration of all maternal hospitalization was shorter for ‘at home bed rest’ group 3.7 days 5.0 days No significant difference for the two groups regarding the number of babies born before the actual time or the duration for neonatal hospitalization, hospitalization in intermediate care nursery or in NICU (Goulet, C., Gevry, H., Lemay, M., Gauthier, R., Lepage, L., Fraser, W., et al. 2001 p.985) Methods of analyzing patient outcomes for ‘at home bed rest’ Bed rest is recommended for pregnant women to avoid preterm birth. The option of at home bed rest requires patient education, risk assessment, increased prenatal visits, home nursing visits, case management and uterine contraction management. The objective of preterm birth prevention is (i) to offer early detection of symptoms and signs of preterm labor that permits effective tocolytic treatment to prolong pregnancy and (ii) to encourage antenatal management of patients outside the hospital. Various measures have to be taken while a patient is at home bed rest which include home uterine activity monitory and ensure availability of seven days a week, 24 hour access to perinatal and monitoring nursing services. Benefits of outpatient monitoring is to monitor and encourage the patient’s compliance to medications, ensure prescribed activity level and reduce stress level. A research and analysis on ‘at home bed-rest’ patients who availed pregnancy care services from Matria Healthcare, Inc for a fourteen year period from 1988 - 2002 yielded a detailed evidence. Data included the outpatient services offered by the physician and the medical history of patients without prior preterm labor problem, diagnosis and treatments, daily nursing assessment, daily biophysical data with respect to services availed and interventions, reason and frequency of physician contacts, change in treatment and medication and pregnancy outcome. It was found that the healthcare service provider had a detailed treatment plan, which included the patient’s physician setting up a uterine contraction threshold (normally at four contractions per hour). When the threshold exceeded or met or in case the patient reports subjective signs of preterm labor, nursing intervention is stepped up to the acute level. Acute nursing is followed by patient assessment and further treatment by instructing the patient about activity level, oral hydration, more rest and the prescription and administration of PRN tocolytic medication and the patient is asked to monitor uterine contractions. In case nursing intervention did not yield proper result to reduce uterine activity or signs of preterm labor persist, the physician is notified over phone. The physician recommends additional measures, visits the patient or recommends further evaluation at the hospital. Outpatient physician evaluation includes adjustment of oral / subcutaneous tocolytic prescription, change or initiation in tocolytic medication, physician office evaluation or additional outpatient uterine monitoring. If uterine activity persists, physician intervention is notified and usually results in hospital evaluation. Besides, the notification of a patient’s acute condition over telephone, written summaries are offered to the physician every week with data and details from the patients. This kind of routine analysis requires a patient’s daily uterine monitoring information linked to physician intervention, nurse intervention, pregnancy outcome tables and hospitalization details in the relational database The daily monitoring activity must include the reason and need for physician intervention, nurse intervention or hospital evaluation. Every hospitalization of the patient was reported with the duration of stay, outcome of hospitalization and the use of tocolysis. Evidence At the Matria Healthcare, Inc the analysis was conducted on 10660 women with a uterine monitoring data that spanned 307249 days. The patients used preterm labor management services after diagnosing for preterm labor. Patients required a mean of 59.6 + 45.2 hours of monitoring more than the average of 28.8 + 21.4 days. Increased uterine symptom or contraction required nursing intervention for 9092 (85.3%) patients at least once. Additional acute nursing intervention was required for patients on an average of 5.0 + 5.7 monitored days. Nursing intervention resolved symptom of preterm labor in majority of the cases and the patient resumed usual monitoring. Physician intervention was required only for 4011 patients and hospitalization was ever lesser with only 2367 pregnant women (22.2%) needing at least one hospital evaluation (Morrison, J., Roberts, J., Jones, J., Istwan, N., Rhea, D & Stanziano, G 2004 p.103). Interventions by monitored days (n = 307 249) Interventions required by patients No of times Percent Days with nurse intervention 53 665 17.5 Days with physician intervention 6303 2.0 Number of physician calls 7316 Days with hospital evaluation 3163 1.0 Number of hospital days 9049 (Morrison, J., Roberts, J., Jones, J., Istwan, N., Rhea, D & Stanziano, G 2004 p.104) Model for Change Step 1: Assess the need for change The need for potential change is stimulated by the awareness about patient dissatisfaction and preferences, improvement data, evaluation data, practitioner queries or new research information. On finding the need, a multi-disciplinary or discipline specific practitioners or administrators must discuss the issue through brainstorming, multi-voting and flow-charts (Rosswurm, M.A. & Larrabee, J.H. 1999 p.318). Step 2: Associate problem with interventions and results The problem has to be defined and then associate the problem with different types of interventions and outcomes. The problem has to be classified because it facilitates communication between practitioners and assists in the identification of required resources. Patient outcomes are always related to physician intervention and therefore the intervention of multiple providers enhances the extent of care. Step 3: Synthesize Best Evidence The interventions and outcomes must be refined based on evidence using contextual data and clinical judgment. The problem, intervention prospects and desired outcomes are the crucial variable for research. Therefore, the topic must be clarified to find out the criteria for evaluation by pointing the strengths and weaknesses of various researches. The feasibility and benefits of findings must be used to arrive at the best methods of intervention (Rosswurm, M.A. & Larrabee, J.H. 1999 p.319). Step: 4 Design a Change in Practice After finding the best evidence, practitioners process the sequence of care activities in the form of a procedure, protocol or standard. While designing a change the feedback of stakeholders are significant. Less complex protocols gain more acceptance among stakeholders (Rosswurm, M.A. & Larrabee, J.H. 1999 p.320). Step: 5 Evaluating and Implementing Change in practice A pilot study / implementation of the protocol becomes successful if the coordinator monitors the process efficiently and is ready to answer related questions. The decision to adopt, adapt or reject a change depends on the feedback from pilot coordinators and managers. Step: 6 Integrate and sustain change in practice If the pilot study is successful, the change is integrated to the existing standards of care. When change is brought about to an existing method, stakeholder may find it disruptive. Care should be taken to implement new process in a smooth manner in every step of implementation with suitable monitoring to create an acceptance to the change (Rosswurm, M.A. & Larrabee, J.H. 1999 p. 321). Expected outcome It may be concluded that a change in practice from hospitalized bed rest to at home bed rest yields successful results if operated and monitored according to a well defined procedure by the stakeholders involved in care. Reference Goulet, C., Gevry, H., Lemay, M., Gauthier, R., Lepage, L., Fraser, W., et al. (2001). A randomized clinical trial of care for women with preterm labour: home management versus hospital management. CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne, 164(7), 985-991. Retrieved from MEDLINE with Full Text database Morrison, J., Roberts, J., Jones, J., Istwan, N., Rhea, D & Stanziano, G (2004) Frequency of nursing, physician and hosptial interventions in women at risk for preterm delivery. The Journal of Maternal-Fetal and Neonatal Medicine, 16, 102- Retrieved from MEDLINE with Full Text database. Rosswurm, M.A. & Larrabee, J.H. 1999 A model for change to evidence-based practice. Journal of Nursing Scholarship Iss.31 No.4. pp. 317-322 Retrieved from MEDLINE with Full Text database. Read More