Evaluation of a clinical protocol for the management of fever in labor among pregnant women at term: A quality-improvement study

Abstract

Objective: To assess the impact of a quality-improvement initiative designed to increase diagnostic accuracy and adequate management of clinical chorioamnionitis (CC) at a tertiary center. Chorioamnionitis occurs in 1%–13% of term pregnancies and increases maternal and neonatal peripartum complications; often over-diagnosed, it leads to unnecessary investigations and treatments. Methods: This was an interrupted time-series study. In September 2017 two interventions were implemented: (1) staff training and (2) standardized clinical protocol for the management of fever in labor. All singleton term pregnancies were included. CC cases were reviewed in the pre-intervention (2015–2016, n = 179) and post-intervention (2017–2018, n = 142) groups. CC criteria based on the American College of Obstetricians and Gynecologists guidelines, antibiotics, maternal and neonatal outcomes, and pathology were compared. A cost–consequence analysis was performed. Results: Incidence of CC decreased from 8.2 to 5.6 per 10 person-year (P < 0.001). This was associated with a significant increase in diagnostic accuracy from 15.7% to 73.2% (P < 0.001). Weight-adjusted tobramycin dosage improved from 8.8% to 69.1% (P < 0.001). Maternal length of hospitalization and readmissions decreased significantly, without affecting neonatal sepsis rate. Interventions decreased yearly hospital costs associated with CC by 23.4%. Conclusion: Standardizing the management of fever in labor significantly increased the diagnostic accuracy of CC and decreased the misuse of antibiotics in term pregnancies. CC costs decreased by 23.4%.