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235 - IMPROVING DOCUMENTATION OF OBSTETRICAL ANAL SPHINCTER INJURIES (OASIS) USING A STANDARDIZED ELECTRONIC TEMPLATE AT TWO UNIVERSITY AFFILIATED INSTITUTIONS

235

IMPROVING DOCUMENTATION OF OBSTETRICAL ANAL SPHINCTER INJURIES (OASIS) USING A STANDARDIZED ELECTRONIC TEMPLATE AT TWO UNIVERSITY AFFILIATED INSTITUTIONS

CHISHOLM, C. KILPATRICK, L. SWAIM, A. SELLNER, F. J. OREJUELA;
Obstetrics and Gynecology, Baylor Coll. of Med., Houston, TX.

Introduction: Adequate repair is vital to reduce the long term sequelae of OASIS. Sufficient documentation is necessary to reflect the quality of provided care, to provide information to guide future management, and to reduce medico-legal liability. Processes to evaluate current management of OASIS require a systematic recording approach. There is limited data regarding the utility of a standardized documentation template for OASIS repair. 1 With the advent of electronic medical records, proper method of documentation can be more easily disseminated and applied for general use.
Objective: To assess whether the documentation of OASIS management can be improved by introducing a standardized electronic operative report. Secondary objectives include rates of readmission due to complications and adherence to current practice guidelines.
Methods: A pre and post intervention study was conducted by auditing electronic medical records of patients affected by OASIS at two university affiliated labor and delivery units (county and private setting) between Jan 1 and Dec 31 2016. A standardized electronic template was introduced (fig. 1), and promoted in the labor units at both hospitals on July 1 2016. The use of electronic medical record template was encouraged by reminder e-mails and flyers displayed in the physician lounges at both units. The primary outcome was the quantification of the quality of repair documentation, by using a scale that included all relevant aspects of the repair (fig. 2). 2 The scale was evaluated by practitioners for face validity prior to its use. Data for the subsequent 6 months after the intervention introduction was collected in a similar fashion. Chi Squared and Student’s T test were used to compare categorical and continuous variables respectively.
Fig 1: Electronic Operative Template

Figure 2: Scale for Documentation Score

Specific Degree (3a, 3b, 3c, 4)

1

Rectal Exam Before

Repair

1

Location of Repair (in Delivery Room vs OR)

1

Suture type used for all levels

1

Technique of EAS Repair (Overlap vs End to End)

1

Rectal Exam After Repair

1

Use of Antibiotics

1

Total/Score

6-7 Good, 3-5 Moderate, 1-2 Poor


Results: Demographic information is shown in Table1 per delivery unit. The overall OASIS rate at Unit A was 2.0% and 2.9% in Unit B throughout the study period (p= 0.03). Analyzing both units separately, the level of training of the operator, rate of episiotomy and operative vaginal deliveries were similar throughout the study period. The quality of documentation measured by the scale score, proper use of antibiotics, and bowel regimen were significantly increased after the intervention at both units (Table 2). Unit A had a statistically significant higher documentation score during the study period.

Table 1. Demographic Characteristics Pre and Post Intervention by Unit

 
 

Unit A Unit B

 

 

Pre
N=25

Post
N=26

P Value

Pre
N= 60

Post
N=45

P Value

 

OASIS Inc.
no./total vaginal delivery (%)

25/1300 (1.92)

26/1225 (2.12)

0.7

60/1771 (3.39)

45/1724 (2.61)

0.2

 

Age, yr ± SD

22 ± 5

26 ± 6

<0.05

30 ± 5

30 ± 3

0.5

 

First vaginal delivery, no. (%)

20(80)

22(85)

0.7

43(72)

38(84)

0.1

 

Ethnicity, no. (%)
White
Hispanic
AA
Asian

2(8)
15(60)
6(24)
2(8)

0
17(65)
3(12)
6(23)

0.3

33(55)
6(10)
10(17)
11(18)

26(58)
10(22)
1(2)
8(18)

0.5

 

Training level, no (%)
Resident Year 1-2
Resident Year 3-4
Attending/Midwife

5(20)
18(72)
2(8)

2(8)
23(88)
1(4)

0.4

29(48)
7(12)
24(40)

23(51)
7(16)
15(33)

0.6

 

Type of delivery
Spontaneous, no. (%)
Forceps
Vacuum

12(48)
10
3

18(69)
4
4

0.1

37(76)
15
8

34(76)
6
6

0.2

 

Episiotomy
Total, no. (%)
Median
MDL

8(32)
5
3

8(31)
2
6

0.7

13(22)*
7
5

11(24)*
6
4

0.7

 

Epidural, no. (%)

20(80)

17(67)

0.7

46(77)

43(96)

<0.05

 

‡ 4 of 18 OASIS repairs performed and documented by upper level residents were consultations from midwife post delivery
* Episiotomy type not documented in one case for both pre and post intervention

Table 2. Outcomes Pre and Post Intervention by Delivery Unit

 
 

Unit A

Unit B

 

Pre 

 

N=25

Post 

 

 N=26

P Value

Pre 

 

N=60

Post 

 

N=45

P Value

 

Documentation QualityScore, Mean ± SD

2.6±1.5

5.3± 1.5

<0.05

2.0±1.6

3.7±2.0

<0.05

 

Readmission/ER Visit, no. (%)

0

0

 

2(3.3)

3(6.7)

0.4

 

Bowel Regimen, no. (%)

15(60)

24(92)

<0.05

10(22)

21(46)

<0.05

 

Antibiotic Use, no. (%)

1(4)

14(54)

<0.05

10(17)

15(33)

<0.05

 


Conclusions: The use of a standardized electronic operative template improves the documentation of OASIS repair and promotes implementation of best practice guidelines.
References: 1. Panagrahy R et al. A complete audit cycle management of third/fourth degree perineal tears. J Obstet Gynaecol. 2008, 28 (3):305-92
2. Green-top guideline No 29, June 2015. The management of third-and fourth- degree perineal tears