Proposing an Early Labor Lounge at the University of Utah Medical Center

Cesarean sections have become a common operating room procedure in the United States, with approximately one-third of American women delivering by cesarean. Organizations such as the World Health Organization and U.S. Healthy People 2020 have identified the need to reduce Cesarean section rates significantly. Early labor admission is associated with increased medical intervention and morbidity, including birth by cesarean. Early Labor Lounges are a promising solution to the problem of early labor admission to the hospital and its subsequent interventions. Currently, the University of Utah Health does not have an Early Labor Lounge. Although a preliminary proposal was made to create one, hospital stakeholders required more information to consider the proposal. The purpose of this quality improvement project is to propose the creation of an Early Labor Lounge to stakeholders at the University of Utah Health, using information from the literature and information obtained from interviewing hospitals with existing Early Labor Lounges. Three hospitals with an Early Labor Lounge were identified in the United States, and a semi-structured interview was performed to gather information on the hospital implementation process, challenges, protocol, billing, and staffing. The collected data was presented to stakeholders in a scheduled meeting. Stakeholders were individuals that could make ELL implementation possible, including a Certified Nurse Midwife and the OB Medical Director who drafted the initial ELL proposal for the hospital. Other individuals included the Nurse Manager, Clinical Nurse Coordinator, and OBES lead 2 triage provider. Stakeholders were surveyed after the presentation to assess next steps to implement the recommendations at the University of Utah Health.The hospital interviews revealed significant challenges in implementing Early Labor Lounge. The challenges included the patient's admission status, billing, unclear responsibilities of staff, staff resistance, risk management issues, and underutilization concerns. Due to the barriers to successful implementation experienced by existing Early Labor Lounges, the project recommendation to stakeholders was actually not to create an Early Labor Lounge, but instead, to implement various elements of existing Early Labor Lounges to support women in early labor. The post-presentation survey results indicate that the presentation was valuable in demonstrating the many challenges associated with implementing an Early Labor Lounge. However, three out of five stakeholders stated that the University of Utah Health could overcome the barriers faced by other hospitals by acquiring a more significant buy-in from hospital staff and launching a pilot study. Two out of five stakeholders did not want to pursue Early Labor Lounge, though they did wish to implement the alternative recommendations. However, all stakeholders stated that the intervention helped them view the challenges more clearly. This project was successful in gathering and then presenting to key stakeholders at University of Utah Health the available information on Early Labor Lounges, including information on billing, protocol, staffing, and the significant implementation challenges faced by existing Early Labor Lounges. The project also met its overarching goal toward the creation of an Early Labor Lounge, as the University of Utah Health will now pursue a pilot Early Labor Lounge.

Erminia Martinez The University of Utah College of Nursing 1 Abstract Background: Cesarean sections have become a common operating room procedure in the United States, with approximately one-third of American women delivering by cesarean. Organizations such as the World Health Organization and U.S. Healthy People 2020 have identified the need to reduce Cesarean section rates significantly. Early labor admission is associated with increased medical intervention and morbidity, including birth by cesarean. Early Labor Lounges are a promising solution to the problem of early labor admission to the hospital and its subsequent interventions. Currently, the University of Utah Health does not have an Early Labor Lounge. Although a preliminary proposal was made to create one, hospital stakeholders required more information to consider the proposal. The purpose of this quality improvement project is to propose the creation of an Early Labor Lounge to stakeholders at the University of Utah Health, using information from the literature and information obtained from interviewing hospitals with existing Early Labor Lounges. Methods: Three hospitals with an Early Labor Lounge were identified in the United States, and a semi-structured interview was performed to gather information on the hospital implementation process, challenges, protocol, billing, and staffing. The collected data was presented to stakeholders in a scheduled meeting. Stakeholders were individuals that could make ELL implementation possible, including a Certified Nurse Midwife and the OB Medical Director who drafted the initial ELL proposal for the hospital. Other individuals included the Nurse Manager, Clinical Nurse Coordinator, and OBES lead 2 triage provider. Stakeholders were surveyed after the presentation to assess next steps to implement the recommendations at the University of Utah Health. Results: The hospital interviews revealed significant challenges in implementing Early Labor Lounge. The challenges included the patient's admission status, billing, unclear responsibilities of staff, staff resistance, risk management issues, and underutilization concerns. Due to the barriers to successful implementation experienced by existing Early Labor Lounges, the project recommendation to stakeholders was actually not to create an Early Labor Lounge, but instead, to implement various elements of existing Early Labor Lounges to support women in early labor. The post-presentation survey results indicate that the presentation was valuable in demonstrating the many challenges associated with implementing an Early Labor Lounge. However, three out of five stakeholders stated that the University of Utah Health could overcome the barriers faced by other hospitals by acquiring a more significant buy-in from hospital staff and launching a pilot study. Two out of five stakeholders did not want to pursue Early Labor Lounge, though they did wish to implement the alternative recommendations. However, all stakeholders stated that the intervention helped them view the challenges more clearly. Conclusions: This project was successful in gathering and then presenting to key stakeholders at University of Utah Health the available information on Early Labor Lounges, including information on billing, protocol, staffing, and the significant implementation challenges faced by existing Early Labor Lounges. The project also met its overarching goal toward the creation of an Early Labor Lounge, as the University of Utah Health will now pursue a pilot Early Labor Lounge. 3 Keywords: Early Labor Lounge, early labor admission, cesarean section, stakeholders 4 Introduction Problem Description Cesarean sections (C-section) have become one of the most common operating room procedures in both developed and developing countries (World Health Organization [WHO], 2015). When the rate of birth by C-section was first measured in 1965, the United States cesarean birth rate was 4.5% (National Partnership for Women & Families, 2016). Since then, this rate has risen precipitously. The 2018 U.S. National Vital Statistics Reports reported that approximately one-third of American women deliver by C-section (Osterman & Martin, 2015; Paul et al., 2017). This rate is higher than the U.S. Healthy People 2020 C-section target rate of 23.9% for low-risk, full-term, singleton pregnancies in vertex presentation and significantly higher than the World Health Organization (WHO) recommended ideal C-section rate of 10-15% (Betran, Torloni, Zhang, & Gulmezoglu, 2015; Spong et al., 2013). According to the WHO (2015), at a population level, C-section rates higher than 10% are not associated with reductions in maternal and newborn mortality. Nevertheless, the overall C-section delivery rate in the U.S. continues to hover around 32% (Paul et al., 2017; Martin, Hamilton, Osterman, & Driscoll, 2019). Additionally, the U.S. has the most expensive births of any developed nation. The high national C-section rate is a contributing factor (Betran et al. 2015; Martin et al., 2019). In 2018, the U.S. had a total of 3,791,712 births registered, with 1,208,176 of those births delivered by C-sections (Martin et al., 2019). The principle source of 5 payment for the delivery of births continues to be either private insurance or state-funded Medicaid, which paid for 42.3% of births in 2018 (Martin et al., 2019). The average cost of a C-section in the U.S. is around 51 thousand dollars (Elfein, 2019; Truven Health Analytics MarketScan Study, 2013). While lower in cost, vaginal delivery still costs an average of 32 thousand dollars in the U.S. (Elfein, 2019; Truven Health Analytics MarketScan Study, 2013). However, these high costs and increased cesarean delivery rates have not yielded better birth outcomes, as U.S. maternal and neonatal health has not increased significantly since the 1980s (Marowitz, 2014). Several studies have shown that early labor admission is associated with increased rates of C-section and other medical interventions, both of which are associated with increased morbidity and cost (Paul et al., 2017; Spong et al., 2013; Marowitz). Early labor admission can be defined as admission before active labor (Mikolajczk, Zhang, Grewal, Chan, Petersen & Gross, 2016; Marowitz, 2014). Research has shown that early labor management is a critical time for cesarean prevention because the timing of when a woman is admitted to the labor ward significantly influences the interventions she will receive during labor and ultimately, her birth outcomes (Neal et al., 2014; Paul et al., 2017). An Early Labor Lounges (ELL) in the hospital setting has been proposed as a possible solution to avoid early labor admission and its subsequent interventions (Paul et al., 2017). An Early Labor Lounge is a structured space for low-risk women and their support people to use during early labor without returning home, which is sometimes very distant from the hospital (Paul et al., 2017). It is a space located within the hospital 6 with the aim to provide maternal support, educate women, instill confidence, and reduce anxiety for laboring women reluctant to return home after arriving at the hospital (Paul et al., 2017). The University of Utah Health is a large regional hospital that serves patients from a wide geographic area, including multiple counties and surrounding states. It is a tertiary facility that provides maternity care to women of diverse ethnic and socioeconomic backgrounds. Currently, the hospital does not have an Early Labor Lounge. While a preliminary proposal has been made to create one, hospital stakeholders required more information to consider the proposal. Available Knowledge The evidence is clear that admitting women in active labor is associated with better birth outcomes for both the mother and the baby (Neal et al., 2014; Marowitz, 2014; Mikolajczyk et al., 2016; Gams, Neerland, & Kennedy, 2019; McNiven, Williams, Hodnett, Kaufman, & Hannah, 2001). A randomized controlled trial found that those admitted in active labor had lower rates of epidural use, lower need for augmentation and subsequently, lower rates of oxytocin use, higher patient satisfaction, and overall less time on the labor ward than those admitted prior to active labor (McNiven et al., 2001). On the other hand, observational studies have found early labor admission to be associated with increased medical intervention and higher C-section rates (Rahnama, Ziaei, & Faghihzadeh, 2006; ACOG, 2017). Delaying admission until the woman is in active labor can be challenging for both the family and the provider, as active labor is difficult to diagnose prospectively (Neal et 7 al. 2014). Many women tend to arrive at the hospital before they are in active labor and are discouraged when sent home by hospital staff. Updates have been made to the clinical definition of active labor to assist providers in diagnosing it, but despite this effort, active labor continues to be challenging to accurately identify (Paul et al., 2017). In order to promote admission only during active labor, it has been recommended to keep women under observation before admission to the labor unit to determine labor status (Neal et al., 2014). During this time, the use of non-pharmacologic comfort measures is appropriate to support women as they transition into active labor (Breman, Stoor, Paul, LeClair & Johantgen, 2019; ACOG, 2017). Early Labor Lounges may provide a safe and secure place for this non-pharmacologic therapy as women transition into active labor prior to formal hospital admission (Paul et al., 2017). A space for women in early labor to receive support is endorsed by the American College of Obstetricians and Gynecologists (ACOG). In Committee Opinion Number 766, ACOG (2017) states that the: care of women in latent labor may be enhanced by having an alternative unit where such women can rest and be offered support techniques before admission to labor and delivery…. Techniques such as education and support, oral hydration, position of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial. (p. e166) Women report that one of the various reasons they came to the hospital prematurely is that they found early labor to be challenging to manage alone at home (Carlsson, 2016). Women also state that latent labor is complicated and stress-provoking 8 and a time when they need reassurance from hospital staff (Carlsson, 2016). Many women who are sent home from the hospital describe feeling vulnerable, unsupported, anxious, and as though their preferences were not met (Barnett, Hundley, Cheyne & Kane, 2018; Carlsson, 2016). An Early Labor Lounge may offer the reassurance and support that women desire. New research indicates many benefits of Early Labor Lounges (ELL). The current data shows that women using Early Labor Lounges feel supported by the hospital staff during their labor process (Breman et al., 2019). There is also an increase in birth satisfaction scores with Early Labor Lounge use (Breman et al., 2019). In an observational study of Early Labor Lounges, women also stated that they felt more supported by their partners with ELL use (Breman et al., 2019). Rationale The Stakeholder Theory is a valuable approach to understanding how change might affect or influence an individual or organization (Crane & Ruebottom, 2011). This is critical when attempting to implement a new project, such as the Early Labor Lounge, as there are multiple perspectives to consider. A thorough stakeholder analysis was done to help ensure greater acceptance, adoption, and implementation of the Early Labor Lounge (Crane & Ruebottom, 2011). The Early Labor Lounge has many potential benefits; it also poses certain risks and barriers that stakeholders may have difficulty in overcoming (Crane & Ruebottom, 2011). Identifying, understanding, and addressing stakeholders' concerns regarding the ELL is the key purpose of this project. Thus, the stakeholder's opinions, ideas, and feelings were adopted into the ELL interview questions 9 to assure greater acceptance of the project. Specific Aims The purpose of this project is to present a proposal to stakeholders for the development of an Early Labor Lounge at the University of Utah Health, utilizing information from the literature and existing hospital-based labor lounges. The overall goal is for the creation of an alternative physical space for low-risk women in early labor to feel comfortable, safe, and have access to evidence-based, non-pharmacologic pain relief measures as they transition into active labor. The first objective of this project was to gather information on protocols, billing, risk management, staffing, and implementation barriers from existing labor lounges in the United States. Using this information, a presentation for stakeholders was developed with protocol recommendations. To create this project presentation, members from multiple disciplines were consulted, and their ideas and expertise were incorporated into the final project. Lastly, the project surveyed stakeholders for remaining questions, needed information, potential barriers, and next steps to implement a labor lounge at the University of Utah Health. Methods Context This quality improvement project was conducted at the University of Utah Health, a large, urban, research and teaching hospital located in Salt Lake City, Utah. It serves as a regional referral center for Idaho, Wyoming, Montana, Nevada, and New Mexico (University of Utah Health, n.d.) and provides medical care to more than 10% of the 10 continental United States (University of Utah Health, n.d.). It houses a busy labor and delivery unit doing approximately 4,500 deliveries per year and serving both high and low-risk patients ("Epic", 2020). The University of Utah Health C-section rate is approximately 22.6% (Jones, 2014). The hospital contains its own obstetric triage unit that has eight triage beds as well as the labor and delivery unit with fourteen labor and delivery rooms and three operating rooms. This project primarily focuses on the Obstetrics Emergency Services (OBES) unit, which includes labor triage services. The current process at OBES is that low-risk women who do not meet the criteria for active labor admission are offered the option to return home or to ambulate on hospital grounds for one to two hours and return for reevaluation. At this time, OBES has eight triage beds, but the unit will be downsized to approximately five triage beds due to relocation. Currently, there are no dedicated private spaces outside of OBES in which women can labor as they transition into active labor. When women opt to ambulate for a few hours, their triage room is held for them, and these rooms are unable to be occupied by other incoming patients. Having space within the hospital where women can labor, such as an ELL, would help to free up rooms in OBES and offer an alternative space to women to continue labor progression. OBES also does not have a labor triage protocol in place to guide its providers with labor admissions. While there is an understanding among OBES providers that admission should wait until active labor, it is still difficult to know when to admit without a clear protocol in place. Given this, an alternative space in which women could labor may diminish any inclination toward generous cervical examinations that result in 11 admitting patients who are not yet in active labor. Intervention The first step of this project involved gathering information on labor lounge protocols, billing, risk management, staffing, and implementation barriers from existing Early Labor Lounges in the United States. Hospitals were identified via published literature, multiple search terms, and use of content expert Julie Paul, who is the creator of the first Early Labor Lounge in the U.S. Three different facilities in the U.S. were identified and contacted for interviews. There is potentially a fourth hospital with an ELL, but upon further discussion with personnel in their hospital system, no information on the ELL was identified. A semi-structured telephone interview was conducted with hospital personnel at existing ELL facilities. Interview questions (Appendix A) were developed with the help of one of the stakeholders, Brett Einerson who is a qualitative research expert in Maternal-Fetal Medicine, as well as Rebecca Wilson a University of Utah College of Nursing Assistant Professor with expertise in qualitative research. The interviews aimed to identify common themes from existing labor lounges, as well as elicit valuable information on how facilities developed and implemented their ELL. The thirty-minute interviews were transcribed and analyzed for common themes. The second step of this project was to develop a presentation for the University of Utah Health stakeholders. The presentation included information gathered from the literature review and from interviews with hospital personnel at existing ELL. The presentation aimed to demonstrate a need for ELL at the University of Utah Health through evidence from the literature. It also addressed information from the interviews 12 regarding protocols, billing, risk management, staffing, and challenges encountered. The third step of this project was to present the information to the stakeholders on Early Labor Lounges (Appendix B). This included information gathered from the literature and existing hospital-based Early Labor Lounges. The presentation objectives included sharing with stakeholders the findings from interviews with existing ELLs and to discuss recommendations for supporting women in early labor at the University of Utah Health. Stakeholders were identified with the help of the Labor and Delivery Nurse Manager. Stakeholders were individuals that could make ELL implementation possible, including a Certified Nurse Midwife and the OB Medical Director who drafted the initial ELL proposal for the hospital. Other individuals relevant to ELL implementation included the Nurse Manager, Clinical Nurse Coordinator, and OBES lead triage provider. The presentation meeting was organized with the help of the Women and Children's Administrative Assistant. The thirty-minute PowerPoint presentation was held at the Women & Children's conference room at the hospital. The fourth step of this project was to survey stakeholders for remaining questions, needed information, potential barriers, and next steps to implement the recommendations at the University of Utah Health. Survey questions (Appendix C) were developed with the help of a qualitative research expert and designed to elicit open-ended answers. The survey aimed to highlight the next steps towards implementation to help women during early labor. Study of the Intervention This qualitative improvement project used a semi-structured interview with open- 13 ended questions to gather information from existing ELLs. The presentation was given to a total of five University of Utah Health stakeholders, and the impact of the presentation was measured using a final stakeholders survey. Measures Interview questions (Appendix A) were designed specifically to gather data on existing ELL protocols, billing, risk management, staffing, and implementation barriers. Interview and survey questions were approved prior to initiating the project by a qualitative research expert in Maternal-Fetal Medicine, who is also a stakeholder, and a University of Utah Nursing Assistant Professor with expertise in qualitative research. The final post-presentation survey was designed to gather stakeholders' responses to the presentation and to identify next steps for supporting women in early labor at the University of Utah Health. The survey was given to stakeholders for them to complete by hand immediately following the presentation. The responses from the paper surveys were collected and manually transcribed for content analysis. Administration of paper surveys at the time of the presentation ensured completion by these busy stakeholders. All collected data from interviews and surveys was analyzed for common themes with the help of a qualitative research specialist to ensure accuracy of analysis. Analysis The semi-structured interviews of ELL facility personnel produced qualitative data on existing Early Labor Lounges. A descriptive analysis of the semi-structured interviews was conducted. Questions were organized into categories and categories then were further sorted into themes. An expert in qualitative data analysis assisted with this 14 process. For assessing the stakeholders' feedback following the presentation, a descriptive analysis of the open-ended survey questions was conducted. The stakeholder's responses to the open-ended question were analyzed to identify common themes regarding the next steps, remaining information to be gathered, potential barriers, and lingering questions. The same expert in qualitative data analysis assisted with this process as well. Ethical Considerations This quality improvement project involved minimal risk in obtaining data on Early Labor Lounges. The project was reviewed by the University of Utah Institutional Review Board and was deemed a quality initiative. Informed consent was not required for this project. Results The first hospital interviewed was South Shore Hospital, located in South Weymouth, Massachusetts. South Shore Hospital created the first ELL in the U.S. in an attempt to improve its primary C-section rate and to decrease early labor admission by supporting women in early labor. South Shore's ELL is a 20 ft by 12 ft room located outside its obstetric triage unit (Paul et al., 2017). It consists of six stations with various non-pharmacologic activities, including yoga, rebozo, shower, and meditation (Paul et al., 2017). South Shore Hospital has eligibility protocol for its ELL use with explicit inclusion and exclusion criteria. In general, women have to be low-risk for obstetric complications to utilize the ELL (Paul et al., 2017). They must have a normal contraction pattern, be afebrile, mobile, term, vertex, singleton, and have a National Institute of Child 15 Health and Human Development (NICHD) Category 1 tracing, may have intact or ruptured membranes, but need to be Group B Strep (GBS) negative (Paul et al. 2017). Patients are not admitted to the labor unit; instead, they have an outpatient status. Women in ELL are reevaluated by triage staff every two hours or as needed (Paul et al., 2017). The ELL implementation cost was minimal as it was incorporated into the hospital renovation. The total cost went towards ELL supplies and décor, which was approximately 500 dollars (Paul et al., 2017). Supplies included posters, labor balls, rebozos, and massage tools (Paul et al., 2017). South Shore Hospital published an article on the implementation challenges they faced when launching ELL. Six implementation barriers were clearly identified: infection control and housekeeping concerns, legal issues surrounding admission status, buy-in from hospital staff and administration, space constraints and privacy concerns, lack of research to support the model, and resistance to change (Paul et al., 2017). South Shore Hospital formed a multidisciplinary team and had a monthly meeting to address these challenges. The greatest challenge they faced was buy-in from the hospital and staff, which was resolved through regular committee meetings. They addressed the legal concerns surrounding admission by changing their policy to keep the laboring woman's status as an outpatient without the need for close supervision. South Shore Hospital also identified facilitators and barriers to implementing ELL from the clinical perceptive by conducting staff interviews. The staff interviewed included registered nurses, physicians, and midwives. Facilitators to ELL use included the clinician's belief in supporting the American College of Obstetricians and 16 Gynecologists (ACOG) change in active labor definition. Overall, the majority of the clinicians identified one positive feature of the lounge (Breman et al.,2019). The lounge was seen as a safe choice to calm anxiety. It was also seen as a transitional area for women to declare themselves in labor (Breman et al., 2019). Barriers to ELL use included that women wanted to be admitted despite not being in active labor (Breman et al., 2019). Additionally, physicians did not see themselves as responsible for the lounge and primarily viewed it as the triage provider and triage nurse's role (Breman et al., 2019). The most significant barrier encountered in ELL use was time. Orientation to the lounge required time by triage staff, and available staff time was dependent on the number of triage patients. Time was identified as a challenge by 80% of clinicians (Breman et al., 2019). Another barrier encountered was that registered nurses were not confident in their ability to support women in early labor (Breman et al., 2019).In all the staff interviews, the influence of the triage nurse was mentioned, and ELL was clearly seen as a nursing intervention (Breman et al., 2019). Clinicians also acknowledged that time was required to orient women and their families to the activities in ELL, and this required confident, skilled staff (Breman et al., 2019). The second hospital interviewed with an ELL was the University of Minnesota Masonic Children's Hospital located in Minneapolis, Minnesota. It is the hospital most similar to the University of Utah Health with a similar triage unit and labor and delivery rooms. The University of Minnesota Masonic Children's Hospital ELL is equipped with a labor bed, chair, labor ball, laminated educational diagram, essential oils, and a yoga mat. The triage staff is responsible for discussing comfort measures, encouraging 17 hydration and nutrition, and educating women and their families on the space. The University of Minnesota Masonic Children's Hospital does have a protocol for its ELL use. Women must be low-risk and between 37-42 weeks' gestation with a reactive nonstress test (NST). Unlike South Shore Hospital, women are required to have an intact membrane to use ELL. Any women requiring continuous monitoring or requiring intravenous fluids are excluded from ELL. Women in the lounge also have an outpatient status. Challenges encountered by University of Minnesota Masonic Children's Hospital include that ELL users are still in Epic, the electronic health records, and therefore are not entirely out of the staff's care. Registered nurses are required to monitor fetal heart tones intermittently and oversee maternal vital signs, consequently making ELL users feel similar to other triage patients. The smallest triage room is converted into an ELL by rearranging the furniture. When the hospital is short on triage rooms, the ELL is converted back to a triage room, therefore, removing ELL as an option for a patient. When hospital housekeeping cleans the ELL, the furniture is often rearranged back to a triage room, thus requiring time and energy from staff to rearrange the furniture back to the ELL. Due to the many challenges, registered nurses stated they often forget the ELL is an option for their patients, resulting in underutilization of the space. The third organization interviewed was Blooma, which is an external prenatal organization located in Minnesota. Midwives approached Blooma from Woodwinds Health and St. John's Hospital to fund their hospital ELL. Blooma provided the equipment and supplies, and the hospital provided the space. It was a way for Blooma to 18 show their support for laboring women and have a direct relationship with the hospital. Woodwinds Health ELL had four private closed-off sections near its triage center. The ELL contained a nutrition station and offered various non-pharmacologic amenities, including labor balls, blankets, yoga mats, posters, décor, and diagrams. The cost was approximately 2,000 dollars and primarily went towards supply purchases. There was no staffing available in the ELL, and there were a total of two participants in the year it was opened. ELL users had a discharged status. Blooma Early Labor Lounge mentioned many challenges with its ELL. First, the ELL was open for less than a year and had only two patients use the space in the time it was opened. The first ELL was opened at Woodwinds Health, and then the midwifery practiced moved to St. John's Hospital, and as a result, they took their ELL with them. Regardless, both of the ELLs were closed due to underutilization, the hospital's concern regarding liability, and too strict of an inclusion and exclusion protocol. Staff also stated confusion with the patient's discharge status because reevaluation required ELL users to be readmitted to the hospital as an outpatient. Readmission in an outpatient status permitted staff to document cervical exams on patients appropriately. The nurses saw this as an obstacle and found it more convenient to keep patients in triage than discharge them to the ELL. The common theme identified from interviewing hospitals with Early Labor Lounges is that the challenges begin with the patient's admission status. The patient's admission status determines the hospital's billing position, which influences staffing requirements. If staffing is required for ELL, then staff responsibilities must be clearly 19 defined. Unclear responsibilities may lead to staff resistance, as triage staff are already busy and therefore, resistant to additional responsibilities. Risk management concerns can also contribute to additional responsibilities for staff and to the admission status. All of this ultimately leads to underutilization. The other results collected during this project were results of a brief survey following the presentation to stakeholders (Table 1). Three out of five stakeholders stated that they still wish to pursue ELL for the University of Utah Health despite the information presented and recommendation otherwise. These three stakeholders believe the University of Utah Health can overcome the challenges experienced by other ELLs by acquiring more significant buy-in from hospital staff and administration. All three stakeholders stated a need for a pilot study in OBES before ELL implementation to determine hospital challenges. Two out of five stakeholders did not want to pursue ELL due to the many challenges presented, though they do wish to implement all recommendations presented, including the use of volunteer doulas in OBES and the creation of Walking Path. A Walking Path is an interactive planned route through the hospital that can be used in early labor for women to continue to ambulate and be mobile while remaining in the facility (Morelli & MacKeill, 2018). All (n=5) stakeholders stated that the presentation helped them view the challenges more clearly. Discussion Summary Results from the hospital interviews highlight the many challenges faced by existing ELLs. Although initially the project goal was to propose an ELL, due to the 20 many challenges faced by other hospitals, the project goal shifted, and an ELL was not recommended for the University of Utah Health at the stakeholder presentation. The stakeholder survey results following the presentation suggest that a majority of stakeholders are still interested in pursuing an Early Labor Lounge as an option for supporting women in early labor. The University of Utah Health stakeholders plan to pilot the project to determine challenges before employing it into the hospital renovation plans. Overall, this project was effective in gathering and presenting the information from the literature and existing hospital-based labor lounges. Interpretation The literature indicated many benefits to ELL use, such as a potential to decrease C-sections, but through the interviews, many significant challenges as well as underutilization were identified. This led to an unexpected change in recommendation for this project. While the objective of this project had initially been to propose an ELL for the University of Utah Health, the interviews were not convincing that this would benefit the University of Utah Health significantly. As well as the many challenges faced by other ELLs, this site also faces the issue of limited space for an ELL. Challenges appear to outweigh the benefits of ELL for University of Utah Health at this point, and many of the benefits of ELL can be implemented without an actual ELL. As a result, the presentation to the stakeholders was a recommendation against creating an Early Labor Lounge and instead a recommendation to implement elements of the ELL into the current system to better support women in early labor. Recommendations include offering women a variety of non-pharmacological options, such as a scripted Walking Path, 21 educating women about early labor via educational handouts, and adapting ACOG's change in active labor definition. Other recommendations include the use of volunteer doulas in OBES, hospital purchase of labor posters and balls, easy access to nutrition, developing an early labor coping menu checklist, and providing acupressure and meditation apps for women. The results of this project did not completely align with the limited research available on Early Labor Lounges. The literature focused on the many benefits of Early Labor Lounges, whereas the semi-structured hospital interviews highlighted the many barriers and challenges of ELL implementation, including underutilization. However, the challenges identified through semi-structured hospital interviews did align with the six implementation challenges that South Shore Hospital faced with implementing their ELL (Paul et al., 2017). South Shore Hospital published an article pinpointing the six implementation challenges their hospital encountered, and those challenges were mentioned throughout all of the semi-structured interviews (Breman et al., 2019). The six challenges include infection control and housekeeping concerns, legal issues surrounding admission status, buy-in from hospital staff and administration, space constraints and privacy concerns, lack of research to support the model, and resistance to change (Paul et al., 2017). The data collected from the hospital interviews informed stakeholders of the many barriers with ELL implementation. The presentation educated stakeholders to proceed cautiously, as there are many challenges with implementing an ELL. As a result, stakeholders determined that the hospital would benefit from a pilot study prior to 22 committing to an ELL in the renovation plans. The presentation to stakeholders was an effective approach to relaying the gathered information on Early Labor Lounges. The presentation was well received and appreciated by all stakeholders who attended. The information provided in the presentation proved to be valuable in demonstrating the challenges of implementing an ELL at the University of Utah Health. Many challenges to implementing an ELL were identified from the interviews of existing ELLs, and the project was useful in clearly highlighting those barriers for the stakeholders. Stakeholders are more likely to achieve success if they know in advance the potential challenges they will face in implementing an ELL successfully. Limitations A significant limitation of this project is the small amount of literature and research on Early Labor Lounges. Additionally, not all existing labor lounges were represented in this project's data, as there is potentially another ELL located in Pennsylvania. A main disadvantage of the telephone interview is that the length of the call is limited and not all hospital personnel were prepared to answer in-depth ELL questions. Lastly, due to scheduling, only five out of seven stakeholders were able to attend the final presentation, thereby leaving a gap in feedback and input from two crucial stakeholders. Conclusion The evidence is clear that avoiding early labor admission is essential to maternal and newborn health. One suggestion to avoid early labor admission is to create a space 23 within the hospital that promotes ambulation, hydration, nutrition, and nonpharmacologic labor activities. Early Labor lounges may be this space and are a possible solution to the problem of early labor admission. The University of Utah Health had a preliminary proposal for an ELL. However, more information was needed from the literature and existing labor lounges for stakeholders to consider ELL as an option. This project was successful in gathering and then presenting available information on Early Labor Lounges to key stakeholders. This project also met its overarching goal toward the creation of an ELL to support women as they transition into active labor, as the University of Utah Health will now pursue a pilot ELL. A considerable benefit of this project is that stakeholders with implementation power were invited to attend the presentation. This allowed for an initial multidisciplinary committee team to be formed for future meetings. The next step towards ELL implementation is a committee meeting to design an ELL pilot, starting with inclusion and exclusion criteria. The University of Utah Health will be utilizing the Imagine Perfect Care Study to design ELL space Mock-ups. As the hospital is going through the renovation, Imagine Perfect Care Resource Center will be vital for constructing the ELL space. There are plans for the future committee to meet to discuss the next steps to implementing Early Labor Lounge, ensuring that the work of this project continues. 24 References American College of Obstetricians and Gynecologists. (2017). ACOG Committee Opinion No. 766. Washington, DC: American College of Obstetricians and Gynecologists. Barnett, C., Hundley, V., Cheyne, H., & Kane, F. (2008). 'Not in labour': Impact of sending women home in the latent phase. British Journal of Midwifery, 16(3). Betran, A.P., Torloni, M.R., Zhang, J.J., & Gulmezolgu, A.M. (2015). WHO statement on cesarean section. BJOG. doi. 10.1111/1471-0528.13526 Breman, R.B., Storr, C.J., Paul, J., LeClair, M., & Johantgen, M. (2019). Women's prenatal and labor experiences in a hospital with an early labor lounge. NWH Journal. doi: 10.1016/j.nwh.2019.05.005 Carlsson, I. M. (2016). Being in a safe and thus secure place the core of early labour: A secondary analysis in a Swedish context. International Journal of Qualitative Studies on Health and Well-being. 11(1), 30230. doi: 10.3402/qhw.v11.30230. Center Intelligence Agency. (2015). Country comparison: Maternal mortality rate. The World Factbook. Retrieved from https://www.cia.gov/library/publications/theworld-factbook/rankorder/2223rank.html Center of Healthcare Quality and Payment Reform. (2013). The cost of having a baby in the United States. Truven Health Analytics Marketscan Study. Retrieved from http://www.chqpr.org/downloads/CostofHavingaBaby.pdf Crane, A & Ruebottom, T. (2011). Stakeholder theory and social identity: Rethinking 25 stakeholder identification. Journal of Business Ethics. 102:77-87 Elflein, J. (2019). Average bill charge by US hospitals for vaginal birth and C-section 2013. Statista. Retrieved from https://www.statista.com/statistics/801191/hospital-costs-vaginal-birth-vscesarean-section-in-the-us-on-average/ Gams, B., Neerland, C., & Kennedy, S. (2019). Reducing primary cesarean. An innovative multipronged approach to supporting physiologic labor and vaginal birth. J Perinant Neonat Nurs 33(1), 52-60. doi: 10.1097/JPN.0000000000000378 Hamilton, B.E., Martin, J.A., Osterman, M.J.K., Driscoll, A.K., & Rossen, L.M. (2017). Births: Provisional Data for 2017. National Vital Statistics Reports; 4. Hyattsville, MD: National Center for Health Statistics; 2018. https://www.cdc.gov/nchs/data/vsrr/report004.pdf. Marowitz, A. (2014). Caring for women in early labor: Can we delay admission and meet women's needs? Journal of Midwifery Women's Health 59(6). doi:10.1111/jmwh.12252 McNiven, P.S., Williams, J.I., Hodnett, E., Kaufman, K., & Hannah, M.E. (2001). An early labor assessment program: A randomized, controlled trial. Birth 1998: 25:5-10 Mikolajczyk, R.T., Zhang, J., Grewal, J., Chan, L.C., Petersen, A. & Gross, M.M. (2016). Early versus late admission to labor affects labor progression and risk of cesarean section in nulliparous women. Fronteirs in Medicine. doi: 10.3389/fmed.2016.00026 26 Martin J.A., Hamilton B.E., Osterman, M., Driscoll, A.K., Drake, P. (2019). Births: Final Data for 2016 by. Natl Vital Stat Reports. 2018;67(1):1-55. Morelli, E. & MacKeil, M. (2018). An early-labor walking path tool to reduce early admission and decrease primary cesarean birth rates. Retrieved from https://doi.org/10.1016/j.jogn.2018.04.005 Neal, J.L., Lamp, J.M., Buck, J.S., Lowe, N.K, Gillespie, S.L., & Ryan S.L. (2014). Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. Journal of Midwifery Women's Health 59(1), 28-34. doi:10.1111/jmwh.12160 Osterman, M.J.K. & Martin, J.A. (2014). Trends in low-risk cesarean delivery in the United States, 1990-2013. National Vital Statistics Reports; National Center for Health Statistics. 63(6). Paul, J. A., Yount, S. M., Breman, R. B., LeClair, M., Keiran, D. M., Landry, N., & Dever, K. (2017). Use of an early labor lounge to promote admission in active labor. Journal of Midwifery & Women's Health, 62(2), 204-209. doi:10.1111/jmwh.12591 Rahnama, P., Ziaei, S., Faghihzadeh, S. (2006). Impact of early admission in labor on method of delivery. International Journal of Gynecology and Obstetrics, 92 (3): 217-220. Spong, Y.C., Berghella, V., Wenstrom, K.D., Mercer, B.M., & Saade, G.R. (2013). Preventing the first cesarean delivery. Obstetrics & Gynecology, 120(5),1181-1193. doi: 27 Table 1. Stakeholder's Survey Response Questions Respondent 1 Respondent 2 Respondent 3 Respondent 4 Respondent 5 Given what you have learned about existing ELL is it still something you wish to pursue for UUH If Yes, how do you think our unit can overcome the challenges experienced by other ELLs? No No Maybe a remodel of this space could be incorporated Yes Yes Yes! A hybrid approach (adoption some aspects of ELL) is my preference. x x Bigger buy-in, current discussion being held about space planning Yes What other information do you think we need to gather to successfully implement an ELL? None, I feel that Erminia did a great job presenting the data x Data on current early labor admission Numbers of admission, Csection rates Stakeholder buy-in. Design by patients, CNMs, OBES (triage) staff, and doulas. Implementation as a pilot with frequent evaluation of use, safety, and efficacy. Institutional buy-in Flow and volume of OBES rooms- can we use one of these to pilot an ELL-like space? If No, which of the various alternatives options would you recommend that the implement? x Patient satisfaction for our unit Doulas in OBES + who can go with patient on walking path X X Still open. Need to provide more multidisciplinary education regarding early labor admission and c/s rate No What do patients want in an ELL? Survey of OBES providers for criteria to offer ELL. X Education/expectation management in clinic How has your perspective changed on the ELL? I feel like we need to path program in place to gather data I think the walking path would be amazing I love the concept! I think that individual implementation could be highly successful there seem to be too many barriers to pen a public ELL 28 I see the barriers more clearly 29 Appendix A: Early Labor Lounge Hospital Interview Questions Early Labor Lounge Hospital Interview Questions ⦁ ⦁ ⦁ Hospital Characteristics: ⦁ What is your facility's level of maternity care? ⦁ How many deliveries did your facility have in the last month and year? ⦁ Does your facility have a triage unit/department? How is triage done at your facility? Motive Questions: ⦁ Why did your facility create an Early Labor Lounge (ELL)? Was ELL designed to solve a facility problem, such as busy triage unit, high cesarean section rate, low patient satisfaction score etc.? ⦁ Who helped facilitate the ELL implementation? Implementation Questions: ⦁ How many years has your Early Labor Lounge been open? ⦁ How did you go about implementing an Early Labor Lounge at your facility? ⦁ What were some limitations/barriers you encountered when implementing ELL? ⦁ Is the ELL what you imagined it or planned it to be? 30 ⦁ Was there anything you wanted to do differently, but was limited by regulation or cost? ⦁ What did it cost to implement an ELL at your facility? Are you able to provide any breakdown of cost? ⦁ How did you address risk management concerns? ⦁ What are some things you might do differently now that your ELL is in place? ⦁ ⦁ ⦁ Were there any unforeseen advantages/disadvantages to the ELL? Protocol Questions: ⦁ Is there a protocol in place for the use of the Early Labor Lounge (ELL)? If so, what is your facility's protocol? Would you be willing to share a copy with me? ⦁ What do you consider when sending a women to the ELL versus admitting her or sending her home? ⦁ How are ELL patients reevaluated for labor? ⦁ Do you have a protocol in place for ELL users in case of an emergency? For example, cord prolapse, maternal seizure, or precipitous deliveries? ⦁ Is there a GBS protocol? If so, do you administer antibiotic treatment while they're using the ELL space, but not in active labor? ⦁ Have you noticed any trends with ELL users such as time spent on Labor and Delivery? Logistic of ELL: ⦁ Does your facility require staffing for ELL? If so, how is your facility 31 staffing it? (RN, MA, CNM, volunteer doulas etc?) ⦁ ⦁ Is documentation that goes into the EHR being done on patients using the space? ⦁ Does your facility bill patients for ELL use? Is so, how are you billing for it? ⦁ How many patients can use the ELL at one time? ⦁ Does your facility track ELL users? ⦁ How many patients used ELL in the last month? And for how long did they use the space? (1hr, 2hr, 3 hr, etc). ⦁ What's kind of services/amenities are provided in your ELL? ⦁ What is the most frequently used amenity? ⦁ What is the ELL patient demographics? Who is using it? ⦁ ⦁ ⦁ ⦁ Ethnicity/Race Insured Uninsured How far away from the hospital do ELL users live? Wrap up: ⦁ Can I contact you again for further questions? ⦁ What is the best way to contact you? (Email, phone, hours) 32 Appendix B: University of Utah Health Stakeholders Presentation 33 34 35 36 37 38 39 Appendix C: Stakeholders Survey Early Labor Lounge Presentation Survey ⦁ ⦁ Given what you have learned about existing Early Labor Lounges, is it still something you wish to pursue for the University of Utah Healthcare at this time? Y or N ⦁ If Yes, how do you think our unit can overcome the challenges experienced by other ELLs? ⦁ What other information do you think we need to gather to successfully implement an ELL? ⦁ If No, which of the various alternative options would you recommend that we implement? How has your perspective change on the Early Labor Lounge? 40 41