Does the Presence of a Condition-Specific Obstetric Protocol Lead to Detectable Improvements in Pregnancy Outcomes?

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In attempt to improve patient safety and outcomes, protocols for treatment of a specific complication have been suggested in various studies and encouraged by government regulation and malpractice carriers. However, evidence that condition-specific protocols improve obstetric outcomes is lacking. Studies that have shown improved outcomes because of these protocols have been primarily limited to single centers. This study examined if risk-adjusted patient outcomes would be better in hospitals with condition-specific obstetric protocols in place compared with hospitals without protocols. This study was a secondary analysis of the data set from a cohort study at 25 hospitals that was performed between 2008 and 2011, the Assessment of Perinatal Excellence (APEX) study. Participating hospitals submitted all protocols for labor and delivery quarterly and included the dates that those protocol were in effect. Patients were categorized by whether they delivered in the presence of a protocol. Data were analyzed to find whether the outcomes, adjusted for risk, related to specific complications were associated with condition-specific protocols used during deliver. Data from 115,502 patients were collected. The rate of hemorrhage was significantly higher in hospitals with a hemorrhage protocol. Hospitals without preeclampsia protocols had significantly higher rates of intensive care unit admissions for preeclampsia (odds ratio, 0.28; 95% confidence interval, 0.18–0.44), and preeclampsia-specific protocols were also associated with fewer cases of severe hypertension (odds ratio, 0.86; 95% confidence interval, 0.77–0.96). Protocols for postpartum hemorrhage were associated with an increased rate of postpartum hemorrhage and not associated with a lower rate of cases with more than 1000-mL estimated blood loss. Protocols for shoulder dystocia were not associated with a change in the rate of shoulder dystocia or rate of shoulder dystocia maneuvers used. There was not a consistent relationship found between condition-specific protocols and the severity of those complications. The adjustment for risk in these data was important for determining results. The different results found between preeclampsia protocols and hemorrhage protocols may be explained by the fact that preeclampsia is a more frequently occurring complication, and providers may be more familiar with that protocol. In conclusion, the results suggest whether a protocol is in place does not matter. More research is necessary to better understand high-quality protocol.