research design
This is a practical implementation of quality improvement measures using educational videos for patients scheduled for IOLs. This is a single-center study at Eskenazi Hospital, a county hospital in Indianapolis, Indiana. In 2021, 2,547 births occurred, approximately 25% were planned IOL deliveries and 16% were first-time caesarean deliveries. The pre-implementation survey was conducted over a four-week period from June to July 2021 and from September to November 2021. To allow video to be implemented into clinic workflows, there was a delay in completing pre- and post-implementation collections.
Eligibility criteria
Patients must be 18 years of age or older, admitted to a puerperal unit, able to read English or Spanish, and regularly receive medically indicated IOLs (for 37 weeks or older) or elective IOLs (if patient is 39 years of age or older). (desired) were eligible for the study. week). Patients were excluded if they were admitted for IOL from triage or directly from the clinic because they did not have time to watch the video. The study instructions explicitly stated that completion of the study signified the participant’s informed consent. This study was approved by the School of Medicine’s Institutional Review Board and the Hospital’s Research Committee.
Participants were screened by reviewing the induction schedule and assessing eligibility criteria. Research team members distributed questionnaires to eligible participants while they were admitted to the puerperal ward 24 to 72 hours after delivery. Postpartum patients are typically admitted approximately 48 hours after vaginal delivery and 72 hours after cesarean section. Written instructions provided participants’ implied consent and explained data extraction and confidentiality procedures. Patients could withdraw from the study at any time. Questionnaires were collected before discharge, and responses were anonymized and then entered into the REDCap database. Incomplete studies were omitted. Paper copies were securely destroyed in accordance with the Federal Patient Information Privacy Act.
intervention
At our hospital, obstetricians, family physicians, and women’s health nurses provide IOL counseling. There is no standardized counseling process or form. The videos used in this study were evaluated in a 2019 randomized trial [11]. A Spanish version was then created by that team and approved for use in this study. Permission to use the videos in this study was obtained from the authors. This video uses animation to explain the reasons for IOLs, common durations, mechanisms of available IOL drugs, and indications for cesarean delivery (Appendix A). It is approximately 3 minutes long and ends with advice for patients preparing for an IOL. According to previous trials, informal feedback was obtained from nurses, patients, and obstetric providers during design. 67% of trial participants said they would recommend this video to others [11].
Our hospital has eight obstetric outpatient clinic locations. Providers were notified of the intervention initiation via email or verbally at a staff meeting. A bilingual handout with instructions and a QR code to the video was provided to clinic managers and medical assistants and distributed with checkout documentation to patients scheduled for IOLs (Figure 1). Staff were required to encourage all scheduled patients to watch the video, regardless of whether they met study eligibility criteria. The research team also sent an electronic version of the video handout to scheduled patients one week in advance via the patient provider’s messaging application.
Figure 1
QR code for English IOL education video with explanation
A bilin 14-item survey was developed to assess the study objectives. To our knowledge, there are no validated knowledge assessments regarding IOLs. Therefore, the two questions regarding drug used and duration were written by the authors and have not been externally validated. The post-administration survey included a question about whether participants watched the video. These questions were translated by a certified Spanish interpreter and back-translated into English to ensure fidelity (Appendix B).
The next survey section consists of the Revised Birth Satisfaction Scale (BSS-R). This is a 10-question psychometric survey that has been validated in multiple languages, including American English and Spanish. [13, 14]. The study was written at a 6th grade reading level and was validated for use during the first 10 days postpartum. An item from the “Listen to Mothers” questionnaire asking whether respondents would choose induction in future pregnancies was used. Finally, there is a free text area where participants can comment on anything they wish they had known before arriving.
result
To assess knowledge of IOL medications used, we compared patient selection on the list of induction medications to those documented as administered in the electronic medical record. The BSS-R is scored on a 0-4 Likert scale. The BSS-R is scored out of a total of 40 points, with higher scores indicating greater satisfaction. BSS-R has three subsets. The stress experienced during childbirth (items 3, 4, 9, 11), the woman’s personal attributes (6, 10), and the quality of care (5, 7, 8, 12). There is no standard score set for ‘satisfied’ and ‘unsatisfied’, it is a global perception of care. [13]. The item listening to mothers’ stories about future recruit choices was scored on a 0 to 3 Likert scale.
Other measures and variables
Age, preferred language, race and ethnicity, BMI at admission, parous, indication for induction of labor, first dilation, comorbidities, method of delivery, duration of labor, analgesic use, infant Apgar, postpartum ED. Baseline demographic characteristics including perinatal depression were collected. Scale scores (regularly collected during postpartum inpatient treatment). This information was collected by a member of the research team and entered electronically into REDCap using a research identification number to maintain confidentiality.
sample size
We modeled the expected degree of change from previous randomized controlled trials using this tool. This study found a mean difference of 0.6 based on a 1-5 Likert score scale response with a standard deviation of 0.9. Extrapolating this difference to the BSS-R score results in an increase of approximately 4 points. To take advantage of this difference, we required at least 20 participants in each group. Considering the actual implementation design, we chose to enroll at least 30 participants in each group, provided the differences in study means were small. Based on our hospital patient population, we estimated that approximately 30 patients could be enrolled in each group over a 6- to 8-week collection period.
statistical analysis
The primary objective of this study was to compare the change in satisfaction as measured by the mean total BSS-R score between pre- and post-implementation groups, which is reported as a continuous value from 0 to 40 . The secondary outcome of IOL agent knowledge, rather than total accuracy, was assessed by each agent individually. This analysis was chosen to assess who accurately identified the drugs that were not used and accounted for the different combinations that patients might receive. Continuous variables are reported with the mean and associated standard deviation. Baseline categorical characteristics were compared with chi-square tests, and continuous baseline characteristics were compared with Mann-Whitney U tests. Knowledge items were assessed using chi-square analysis, and satisfaction items were assessed using t-tests. Alpha was set at 5% for all tests and SPSS was used for analysis. Sub-analyses were used to compare postgroup differences, delivery method, and participant language between those who watched the video and those who did not.
