Abstract: It has been noted that on Labor and Delivery unit, there are patients who deliver their baby within 90 minutes of epidural placement. Having a neuraxial block placed later in labor not only decreases the amount of pain relief time a laboring patient has, since an epidural can take 20-30 minutes to attain its full effect, it also significantly increases the risks of an epidural placement. Patients in a later stage of labor are often less able to hold still, which can possibly increase the number of attempts as well as risk of a “wet tap” or dural puncture. They may also be at higher risk of having “block failure” due to malpositioning of the epidural catheter once it is threaded. The purpose of this quality improvement study is to determine the causes for delayed epidural placement in laboring patients to identify areas for process improvement.
Methods: Data was collected from medical records retrospectively. We looked at all of the epidurals from April 2016 through Jan 2017 and included the epidurals that were placed within 90 minutes of delivery. Epidural placement was determined by the time of test dose from the anesthesia chart. We then evaluated patients for their original documented preference to receive an epidural or not. We also looked at possible causes of delay which included; time of labs drawn, documentation of HTN/pre-eclampsia/eclampsia, delay in anesthesia availability, late admission to the hospital (defined as arriving within 2 hours before the epidural placement), and possible fetal issues.
Results: We found that about 1 in 25 patients (59 out of total 1376 patients) received an epidural within 90 minutes of delivering. Of those 59 patients only 11 of them were delayed because of arriving to the hospital late, Of the remaining 48 patients 40% of them did not have a preference documented in the chart (Process Improvement Area #1), For those in this group who stated no to initial epidural screening 33 % received pain medication prior to questioning (Process Improvement Area #2). Finally, for those who reported an interest in epidural placement, 22 % may have had a delay in provider availability (Process Improvement Area #3). Full details of these patients are shown in the process map, with the highlighted areas indicating topics of future process improvement (Figure 1).
Conclusion: This quality improvement initiative has identified several target areas for improvement to reduce the number of delayed epidural placements. Currently, implementation strategies are being developed to improve patient epidural screening during admission. Similarly strategies are being developed to improve communication with the Obstetrics department (nurses, attendings, and residents) as well as develop anesthesia support teams to facilitate availability.
Figure 1: Quality Improvement Process Map: Factors Impacting Delayed Labor Epidural Placement
