We appreciate the interest in our study expressed by Dr Xu, Ms Sivarajasingam, and Dr Patil in their thoughtful letter. Performance improvement work always benefits from the exchange of ideas from different centers and practice environments. We are grateful for the opportunity to respond to their comments and consider their suggestions in our system.
We agree that emergent cesarean deliveries (CDs), with an expected decision-to-incision (DTI) interval of 30 minutes or less, would likely benefit most from improved communication in terms of patient outcomes. As the authors of the letter pointed out, the time-critical nature of these deliveries makes it challenging to balance communication and expediency. Our approach was to conduct the improvement effort, which involved frequent trials of a new process, in a less pressured setting. Not knowing a priori whether our interventions would improve outcomes or prolong the DTI, it seemed prudent to test our interventions in a clinical scenario unlikely to produce harm—nonemergent unscheduled CDs with a desired DTI of 60 minutes or less. We tracked a family of measures that included outcome (preventable general anesthesia and provider satisfaction rates), process (huddle completion rates), and balancing measures (DTI) while we ramped up testing of our huddle intervention and found these to be revealing. We learned that further improvement work will be necessary to decrease the huddle completion time so as not to unintentionally prolong the DTI for emergency CDs. We also learned that improving our communication process was not sufficient to decrease our general anesthesia rate. This learning clearly illustrates the value of using iterative testing while monitoring appropriate improvement measures to solve health care system problems. We do intend to carefully evaluate the best way to apply our learning to preoperative communication related to emergency CDs and hope to report our work in the future.
The authors of the letter make several excellent points that highlight the challenge of directly applying a performance improvement intervention to a different hospital with very different delivery volumes and staffing strategies. They described the anticipated challenges of implementing the huddle in a higher volume center where staff may not always be readily available. Our interventions are not meant to be universal solutions, but potential starting points to be adapted to other local practice environments using the performance improvement strategies described. We have experienced benefits from using checklists and huddles in other preoperative environments and feel that they are worth considering irrespective of potential staffing barriers. Their use in our main operating room led to a reduction in preoperative task completion failures as measured by a decrease in reported incidents. Our experience with preoperative huddles in both clinical environments demonstrated that additional time is needed to complete them. One reason for this is staff availability as the authors have suggested. Any effort to implement preoperative huddles should plan for this and consider how to best coordinate staff availability and minimize the time required to complete necessary discussions.
We agree that the differences in terminology used to describe the urgency of CDs in different health care systems are also notable. Unlike the Royal College of Obstetricians and Gynaecologists categorization of Cesarean Sections, the American College of Obstetrics and Gynecology does not have a similar well-defined categorization system. While various categorization systems have been proposed in the literature each hospital or health system generally defines their own categories and expected time intervals based on the literature, regulatory requirements, and local preferences. During the initial learning phase of our project, we identified that different staff interpretations of CD categories such as “stat,” “emergent” and “urgent” were a contributor to miscommunication on our unit. Because there are relatively undefined terms to describe the urgency of CDs in our system, we elected to address this formally for each case by discussing a specific time frame during the pre-CD huddle. This allowed us to communicate more clearly and take specific patient factors into account.
We did not include formal cardiotocography (CTG) interpretation in our pre-CD huddles but agree that they could add value to the preprocedural discussions. Given the time constraints previously discussed, this would need to be carefully tested to assess its value and the amount of time required. The patients in our labor unit have continuous CTG monitoring which is interpreted by the obstetricians who can interject information about clinically significant changes at any time during preparation for CD. We look forward to future reports that include this or other important huddle components that could add to this important process improvement.