Optimizing antenatal corticosteroid administration for women at risk of preterm birth: a quality improvement project

Introduction: Preterm birth at less than 37 weeks’ gestation occurs in approximately 8% of pregnancies in Canada and is associated with perinatal morbidity and mortality, long-term health consequences and socioeconomic burden. Administration of antenatal corticosteroids (ANCS) within 7 days of delivery significantly reduces adverse outcomes related to prematurity including perinatal and neonatal death, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis and mechanical ventilation. Antenatal corticosteroids administered outside of this window are associated with reduced benefit and potential risks. The Canadian Preterm Birth Network has found substantial variability between sites in the rate of ANCS administration in the week preceding preterm delivery. This project aims to develop and implement a decision making tool to increase the percentage of infants born prematurely who receive antenatal corticosteroids within 7 days prior to delivery.

Methods: Evidence-based Practice for Improving Quality (EPIQ) methods were used to engage a multidisciplinary team to a develop an evidence-based decision making tool to guide the administration of ANCS. The tool was implemented on labour and delivery, triage and antepartum wards at a tertiary care centre after educational presentations were offered to Obstetricians, Maternal Fetal Medicine Specialists, NICU, residents and nursing staff and feedback from these stakeholders was incorporated. The Plan-Do-Study-Act (PDSA) cycle was used as a template to evaluate the change in practice.

Results: A PDSA cycle was completed from July 27-August 6 2020. During this period, 66 eligible patients were assessed with the tool used for 33 patients resulting in a 50% uptake of the tool. 11 out of the 33 patients received ANCS. 6 of those 11 patients delivered with the 7 day window of ANCS administration. The nursing staff gave feedback on the increased clinical workload required to implement this tool.

Conclusion: The use of a decision tool was effective in guiding decision making on whether to administer ANCS. The next PDSA cycle aim to increase uptake of the tool from 50% to 80%. The data sheet will be streamlined in response to feedback and involves an audit card to ask whether steroids are indicated or not, and whether the tool was used to guide decision on ANCS administration.