54: SAFE PASSAGES implementation reduces perineal trauma

In 2013 the Dept. of Defense (DoD) participated in the Partnership for Patients (PfP) program to reduce iatrogenic patient harm. The incidences of 3rd & 4th degree perineal lacerations after operative vaginal delivery (Patient Safety Indicator (PSI) 18) and vaginal delivery without instruments (PSI 19) were addressed. Prior to PfP implementation, baseline rates were measured in Military Treatment Facilities (MTFs) in each of the 3 DoD Medical Services (Army, Navy, Air Force). One Service, (Service X) developed a specific program for harm reduction - SAFE PASSAGES (SP). The other Services (Y and Z) encouraged reduced rates but did not provide specific programmatic recommendations for reduction. The SP program included a specific set of interventions associated with reduced perineal injury (Figure 1). We evaluated the effectiveness of SP training on the incidence of perineal trauma in the DoD. We used a prospective cohort design. Baseline PSI 18 and 19 rates for each of the DoD Services were established using year 2010 delivery data (n = 272,161). Implementation occurred in 2012. Baseline rates were compared to post implementation (2013 through 3rd quarter 2014) rates (n = 451,446). All but 1 MTF in Service X received SP training either as a 4-hour on-site workshop or an interactive webinar. For PSI 18, Service X showed the greatest reduction in the rate (63.6%) while Service Y showed some improvement (15.5%) and Service Z had a non-significant worse rate (-12.6%) - Table 1. Overall, there was an improvement in PSI 18 (19%; p < 0.01) and a trend to improvement for PSI 19 (5.8%; p = 0.066) across the services. For PSI 19, again Service X showed the greatest improvement (41.8%). For Service X MTFs that received on-site training, PSI 18 rates decreased from 18.5/1000 to 6.0/1000--a 309% improvement (p = 0.012). All but one Service X MTF with webinar training showed some improvement. The one Service X MTF without SP training had increased rates of PSI 18 and 19. Notably, Service X cesarean delivery rates decreased by 1.63% while neonatal morbidity did not change during the study period. Standardized training can be used to reduce perineal trauma rates without increasing cesarean or neonatal trauma rates. Implementation of the SAFE PASSAGES program may be a useful tool for broader implementation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)