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.