Discussion
Significantly shorter time intervals from decision to delivery was observed after implementation of “code blue” protocol. As many as 80% of cases had DDI ≤30 minutes, and only 3.3% had DDI >75 minutes after implementation of “code blue” protocol, compared to 8% and 28.7% before “code blue”, respectively (p <0.001). The significant improvement was observed in every process after decision of cesarean section. Median DRI decreased from 25 to 8 minutes, DII decreased from 45 to 18 minutes and DDI decreased from 52 to 22 minutes (all p values <0.001). The improvements were observed in both during office and after office hours without significant differences between the different time of decision. This was different from previous reports from the same hospital that DDI was significantly shorter during after office hours 17,18 and confirms the success.
The results reflect the success of “code blue” protocol implementation as DDI was significantly shortened. This was similar to other previous studies which demonstrated that various quality improvement programs, including continuous education and team training course for obstetric and related staff with emphasis on the importance of achieving the standard of 30-minutes goal, can significantly shortened DDI and other processes. 16,19-21 Among many reasons for the success of “code blue” protocol was that the protocol was developed based on the evidence from previous studies in the same hospital and adjusted to the context of the hospital’s workflow. Involvement of multidisciplinary team members also helps making the protocol possible and achievable after implementation in the real situation. In addition, collaboration of all related staff results in protocol compliance after implementation.
Although majority of the women achieved the 30 minutes goal, it should be noted that the were still 5 cases with DDI of >75 minutes and all occurred during after office hours. The delay in these cases were due to limited resources during after office hours. Although with one extra operating room and extra staff team for “code blue” situation, all were occupied by other cases of similar but more serious conditions at the same time with these 5 cases. However, these cases were initially resuscitated and provided with close monitoring and ended up with favorable outcomes.
It can be observed that there was a shift in anesthetic methods from 28% general anesthesia to 94% after “code blue” which could partly help in reducing DDI, which was similar to a previous report that general anesthesia significantly shorten DDI compared to spinal anesthesia. 22 Nonetheless, a recent study reported that in optimized organization short DDI of ≤15 minutes was independent of the anesthetic technique performed. 23 However, adverse neonatal outcomes associated with general anesthesia should be aware of and early insertion of an epidural catheter should be considered whenever there is a potential concern of emergency cesarean section.
Whether short DDI improves neonatal outcomes is still controversial. A previous systematic review reported that among cesarean deliveries with immediate threat to life of the woman or fetus, no association was observed between 5-minute Apgar score <7, umbilical artery pH <7.1, and NICU admission and shorter delivery intervals.6 A more recent study also reported that decision-to-incision time of >30 minutes were not associated with worse maternal or neonatal outcomes. 8Previous studies from the same hospital also did not find such association between DDI and adverse neonatal outcomes.17,18 Similar results were observed in this study as well that no significant differences in adverse neonatal outcomes were observed even when DDI was shortened. However, there are many other factors that might not be measurable that are possibly related to adverse neonatal outcomes. Further studies are needed to evaluate such association.
The strengths of this study include that the intervention protocol was applied in the same setting and comparison group was selected from immediate years before the intervention that differences in other related care process should not vary significantly. Indications for cesarean section in comparison group were reviewed and only those with similar indications and diagnoses to the “code blue” protocol were included. Some limitations may include that contribution of actual component to the significant improvement as well as some other details related to the delay were not measured, e.g., transfer process details during different time of decision, anesthetic difficulties, differences between cesarean section indications, etc. Generalization of the results to other different settings might also be limited but similar quality improvement process is encouraged.
The results of this study showed that the implementation of “code blue” protocol can significantly shorten time to delivery in women requiring emergency cesarean section. However, to maintain and improve the performance of obstetric unit, the protocol needs to be audited and evaluated regularly to evaluate its performance and compliance as well as determine potential barriers that needs timely responses. Further studies are still needed to determine the rooms for improvement regarding cesarean section in cases with immediate threat to life of the woman or fetus, not only to shorten delivery time but also to improve maternal and neonatal outcomes.