Precipitous Delivery Protocol in Urgent Care

Unplanned precipitous deliveries in outpatient clinics pose significant challenges to healthcare systems, including the University of Utah healthcare system (UUHC). Despite their rarity, these events require an immediate and effective response to ensure the safety and wellbeing of both mother and newborn. The lack of preparedness among staff members in handling such deliveries has been identified as a critical issue. Local Problem: The UUHC system, encompassing various clinics in Salt Lake City, UT, has experienced approximately one unplanned precipitous out-of-hospital delivery per year in its outpatient clinics, leading to concerns about staff readiness and patient outcomes. Recent events 2 highlighted staff unpreparedness, necessitating the development of a standardized protocol and kit to manage such emergencies effectively. Methods: This Doctor of Nursing Practice (DNP) scholarly project utilized the Johns Hopkins evidence-based practice (EBP) model to adapt and implement a precipitous delivery protocol (PDP) and kit in the Sugarhouse Urgent Care (SHUC) clinic. The study involved pre- and postsurveys to assess staff members' confidence, ability, and preparedness regarding their current practice and the feasibility, usability, and satisfaction of an adapted protocol and kit. Interventions: The PDP and kit were developed through a phased approach involving literature review, multidisciplinary collaboration, protocol adaptation, and approval processes. The protocol outlined roles, responsibilities, and steps for managing a precipitous delivery while the kit contained necessary supplies. Training sessions were conducted for staff members, focusing on protocol implementation and kit utilization. Post-training evaluations assessed feasibility, usability, and satisfaction. Results: Pre- and post-surveys demonstrated significant improvements in staff members' confidence, ability, and preparedness regarding precipitous delivery management (n=18). Feasibility, usability, and satisfaction levels increased post-implementation of the PDP and kit. Qualitative data analysis revealed strong support for the new protocol, with suggestions for further improvement. Conclusion: Implementing the PDP and kit in the SHUC clinic effectively addressed the challenge of unpreparedness for unplanned precipitous deliveries. The project's success, evidenced by improved confidence, ability, preparedness, feasibility, usability, and satisfaction, underscores the importance of standardized protocols and training in outpatient settings. Future efforts could focus on expanding implementation to other urgent care clinics within the UUHC system and conducting further research to assess protocol effectiveness during unplanned OOH deliveries.

1 A Precipitous Delivery Protocol in the University of Utah Sugarhouse Urgent Care Daniel M. Fidler, Melissa Baker, Lisa Taylor-Swanson College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project March 31, 2024 Abstract Background: Unplanned precipitous deliveries in outpatient clinics pose significant challenges to healthcare systems, including the University of Utah healthcare system (UUHC). Despite their rarity, these events require an immediate and effective response to ensure the safety and wellbeing of both mother and newborn. The lack of preparedness among staff members in handling such deliveries has been identified as a critical issue. Local Problem: The UUHC system, encompassing various clinics in Salt Lake City, UT, has experienced approximately one unplanned precipitous out-of-hospital delivery per year in its outpatient clinics, leading to concerns about staff readiness and patient outcomes. Recent events 2 highlighted staff unpreparedness, necessitating the development of a standardized protocol and kit to manage such emergencies effectively. Methods: This Doctor of Nursing Practice (DNP) scholarly project utilized the Johns Hopkins evidence-based practice (EBP) model to adapt and implement a precipitous delivery protocol (PDP) and kit in the Sugarhouse Urgent Care (SHUC) clinic. The study involved pre- and postsurveys to assess staff members' confidence, ability, and preparedness regarding their current practice and the feasibility, usability, and satisfaction of an adapted protocol and kit. Interventions: The PDP and kit were developed through a phased approach involving literature review, multidisciplinary collaboration, protocol adaptation, and approval processes. The protocol outlined roles, responsibilities, and steps for managing a precipitous delivery while the kit contained necessary supplies. Training sessions were conducted for staff members, focusing on protocol implementation and kit utilization. Post-training evaluations assessed feasibility, usability, and satisfaction. Results: Pre- and post-surveys demonstrated significant improvements in staff members' confidence, ability, and preparedness regarding precipitous delivery management (n=18). Feasibility, usability, and satisfaction levels increased post-implementation of the PDP and kit. Qualitative data analysis revealed strong support for the new protocol, with suggestions for further improvement. Conclusion: Implementing the PDP and kit in the SHUC clinic effectively addressed the challenge of unpreparedness for unplanned precipitous deliveries. The project's success, evidenced by improved confidence, ability, preparedness, feasibility, usability, and satisfaction, underscores the importance of standardized protocols and training in outpatient settings. Future efforts could focus on expanding implementation to other urgent care clinics within the UUHC 3 system and conducting further research to assess protocol effectiveness during unplanned OOH deliveries. Keywords: nursing, precipitous delivery, protocol, unplanned labor A Precipitous Delivery Protocol in the University of Utah Urgent Care Problem Description The University of Utah healthcare system (UUHC) is one of the largest healthcare systems in the western United States. This system serves individuals from Utah, Nevada, Wyoming, Colorado, and Idaho. Since 2020, UUHC has experienced, on average, one unplanned precipitous out-of-hospital (OOH) delivery in its outpatient clinics per year. The most recent event occurred in April 2023, when a precipitous delivery occurred in the Sugarhouse Urgent Care (SHUC) clinic's main lobby in Salt Lake City, Utah. This was neither the first nor the last time a precipitous delivery occurs in the outpatient setting. It was found that the staff who responded to the event in April were unprepared to care for the mother and newborn infant. While many outpatient clinics provide services to obstetric patients, the clinics do not have a simple process to care for an unplanned precipitous delivery. By definition, an unplanned precipitous delivery can happen at any time and any location. Community clinics, as well as urgent care clinics, must be prepared in the event of a precipitous delivery in their clinic. Svedberg et al. (2020) found that most women who plan on giving birth in a hospital are not prepared to give birth outside of a hospital, and doing so can be a tumultuous and traumatizing event. They also found that women who experience an unplanned out-ofhospital delivery have increased pain and suffering and higher levels of physical and emotional stress, potentially leading to a disconnect between the mother and newborn infant (Molloy et al., 4 2021). Beaird et al. (2023) found that many complications can arise from unplanned outofhospital deliveries, such as hypothermia, perinatal morbidity, and mortality. They also found that when clinics are prepared, the risks of these complications decrease significantly. The best and most effective way to prepare for these unplanned emergencies is to perform training with staff members and have the needed supplies to enable healthcare providers to perform to the best of their abilities (Prescott et al., 2020). Available Knowledge The prevalence of unplanned OOH deliveries in the United States is higher than one might imagine. In 2018, emergency medical services (EMS) responded to nearly 108,000 obstetric emergencies in the United States (Cash et al., 2021). They found that of the almost 108,000 emergencies, 3,489 were unplanned OOH deliveries. These patients were cared for and transported to the nearest birthing facility. Of the unplanned deliveries, nearly half (1,504) were pre-term. This study demonstrates the need for continued research in obstetric emergencies as EMS continues to care for these patients daily. Current research demonstrates that healthcare providers in community clinics feel unprepared and need more skills and knowledge to handle an unplanned precipitous delivery (Hill et al., 2023). Additionally, EMS personnel (EMTs, paramedics, and specialized registered nurses) need more training to care for these unique situations (Hill et al., 2023; Persson et al., 2019). Qualitative data from all three of these studies found common themes. The study participants, whether pre-hospital or in-hospital, felt they lacked the skills, confidence, knowledge, and sometimes the tools necessary to handle an unplanned precipitous delivery. They all desired additional training to help prepare them to encounter this unique situation. 5 In the study conducted by Chang et al. (2020), it was established that newborns are often underweight in unplanned OOH deliveries, making them 11 times more susceptible to infections compared to infants born of an average birth weight. Furthermore, the research highlighted that infants with low birth weight face an elevated risk of postpartum infections. Additionally, Engiom et al. (2017) discovered that when births occurred outside of traditional medical institutions, such as community clinics or urgent care facilities, they exhibited a mortality rate three times higher (8.4 per 1000) compared to births within healthcare institutions (2.4 per 1000). The study did not report the exact cause of the increased mortality rate. However, their findings underscored how the social determinants of health influenced the ability of participants to choose adequate perinatal care and birthing locations. Specifically, living farther from a hospital or clinic was associated with reduced access to adequate perinatal care, leading to an increased risk of postpartum mortality. Rationale The evidence-based practice (EBP) model selected for this project is the Johns Hopkins model. This EBP model focuses on a systematic and collaborative approach to making decisions in healthcare. It consists of many steps. However, the overarching theme includes five steps: asking a clinical question, obtaining evidence, appraising the evidence, applying evidence in a clinical setting, and evaluating the outcomes. This model allows for powerful problem-solving and decision-making through interprofessional teamwork. These steps will ultimately bring lasting change in urgent care for future providers, staff members, and patients (Vera, 2023). The first step of the model includes asking a clinical question. This question was asked after multiple community clinic precipitous delivery events were witnessed over three years within the UUHC system. At that time, there was no plan or direction to help the staff members with unplanned OOH deliveries. Second, an evidence review of the literature was conducted within 6 the past five years. Rapid appraisal of the literature occurred during this step, and key search terms were used to obtain studies relevant to the topic. Third, an in-depth appraisal was completed on the evidence obtained. This appraisal ensured that only high-quality studies were utilized to adapt the protocol, kit, and training provided. Fourth, the evidence was applied clinically through multiple training sessions given to staff members at the SHUC. Fifth, the protocol, kit, and training outcomes were evaluated using quantitative and qualitative data analysis. The final portion of the Johns Hopkins model focuses on reflection. Training participants were allowed to provide feedback and suggest improvements. The information obtained from these participants can be used to make further process improvements for future practice. It allows for the continued application of the Johns Hopkins model by asking a new clinical question, finding current evidence, and implementing that evidence into practice. Specific Aims This Doctor of Nursing Practice (DNP) scholarly project aims to adapt and implement an evidence-based precipitous delivery practice change consisting of a protocol and kit in the SHUC (see Appendix C and D). Four specific objectives guided this purpose. First, we aimed to assess the ability of staff members to care for an out-of-hospital delivery. This was completed using a survey with specific questions concerning their current confidence level, ability, preparedness, and knowledge of supplies needed to handle a precipitous delivery. Second, we utilized current research and worked with content experts to adapt a protocol and kit to aid unplanned OOH delivery in the clinic. Third, a practice change was implemented through the training given to staff members concerning the new process. The training included how and when to use the protocol, supplies in the kit, and the new flow process. Fourth, after the participants had received 7 the training, we evaluated the feasibility, usability, and satisfaction of the protocol, kit, and training using multiple surveys. Methods Context As briefly mentioned above, the SHUC is part of the UUHC system. It is located in a centralized urban area near downtown Salt Lake City, Utah. This healthcare system contains five hospitals and 12 community healthcare centers in the United States' western region. The UUHC’s geographical network covers Nevada, Wyoming, Idaho, Colorado, and Utah and serves as the flagship healthcare system for smaller rural hospitals mentioned in the states above. Due to its central location, this urgent care serves a diverse population encompassing individuals from various ethnicities, education levels, and socioeconomic backgrounds, primarily focusing on providing service and treatment to those affected by the social determinants of health. The SHUC treats anywhere between 100-150 patients per day. The symptoms and severity of these patients are mainly mild to moderate. However, severe and life-threatening conditions can potentially present to urgent care, upon which these patients are promptly transferred to the closest emergency department. The staff required for daily operation requires a multidisciplinary approach encompassing approximately 150 providers (Medical Doctors, Physician Assistants, and Nurse Practitioners) who rotate regularly through SHUC. Additional staff includes one nurse manager, a nurse educator, approximately 15 registered nurses, and approximately 40 medical assistants. The clinic houses seven patient rooms, and daily operation requires 4-5 providers, two registered nurses, and six medical assistants. Intervention(s) A precipitous delivery protocol (PDP) was adapted from published evidence-based protocols, along with a precipitous delivery kit containing the necessary supplies to aid in 8 unplanned OOH delivery. Approval from the manager was sought and received to ensure the adapted protocol aligned with the urgent care needs. Following approval, a team of nurses and nurse educators specializing in urgent care and obstetrics was charged to adapt the protocol to meet the specific needs of the urgent care. After that, a phased approach was used to adapt and implement the intervention. Phase one involved four steps. In step one, an in-depth literature review was conducted on current practices of emergency departments, specifically at the University of Utah, Georgetown University, and University of Maryland emergency departments. These departments were not chosen for any specific reason; instead, they had current evidence-based literature on their department protocols. In step two, a multidisciplinary team involving urgent care providers and content experts was used to adapt a specific protocol for use at the SHUC. This protocol included items such as the team responding to the delivery, their roles and responsibilities during the delivery, items in the delivery kit, and instructions on how and when to use them. It also provided simple step-by-step instructions on delivering the baby and providing postpartum care. Step three instructed the team on how and when to contact emergency medical services to transport the patient to a birthing facility. The multidisciplinary team then utilized published research to identify basic supplies needed to perform a precipitous delivery safely. These supplies were then purchased and placed into a kit for future use. Step four, the PDP and kit were presented to the nurse manager and clinic supervisors for final approval before implementation. Phase two covered implementation. During this phase, staff members were trained during the monthly urgent care meetings. If staff could not attend the monthly meeting, they could pick a future day to be trained. Most training was provided via an oral PowerPoint presentation, with supplemental training given via a mock precipitous delivery. During the mock delivery, staff members could utilize a practice kit, get hands-on experience, and ask questions concerning the 9 kits and protocol. Handouts were provided to trainees, and additional training resources were uploaded to the staff webpage. The protocol and contents of the kit were laminated and placed inside the delivery kit for staff member reference. Training was also provided to healthcare providers. However, that training is beyond this project's scope and is not reported here. Study of the Intervention(s) A precipitous delivery in a community urgent care is rare and unpredictable. Because of its rarity, obtaining data using the implemented protocol was not possible during this study. However, change statistics were analyzed regarding training provided to staff members. After the initial implementation of this project, stakeholders determined that this training should take place annually for all staff members and when a new registered nurse (RN), medical assistant, or emergency medical technician (MA/EMT) is hired. The impact of the intervention was evaluated through a set of surveys given pre- and posttraining. The pre-survey was administered approximately two weeks prior to protocol training and implementation. The same survey was administered to RNs and MA/EMTs to assess their confidence, ability, preparedness, and knowledge of precipitous delivery practices before protocol implementation (see Appendix A). Following their training session, post-surveys were distributed to all participants (see Appendix B). Questions in the post-survey (see Appendix B) included the same questions from the pre-survey (see Appendix A) regarding the participants’ confidence, ability, preparedness, and knowledge of the precipitous delivery practices, along with additional questions addressing the training they had received. The overall responses in the pre-survey (see Appendix A) were then analyzed and compared against those in the post-survey (see Appendix B). During the post-survey, participants were allowed to provide qualitative data through standardized questions. Their responses were then analyzed for future improvement and training of the protocol. 10 Measures The assessment of the intervention included evaluations of feasibility, usability, and satisfaction concerning the training, adapted protocol, delivery kit, and overall process. Assessments were administered as pre- and post-surveys. The surveys featured a combination of questions concerning participant demographics and questions addressing the current status of participants' ability to care for a precipitous delivery. Likert questions were given with a range of response options, including: "1-uncomfortable, 2-somewhat uncomfortable, 3-neutral, 4somewhat comfortable, and 5-comfortable." The post-survey mirrored the pre-survey questions and incorporated additional questions specifically aimed at gauging the feasibility, usability, and satisfaction associated with the protocol, delivery kit, and training. These questions were labeled with the measures they assessed (feasibility, usability, and satisfaction) to help facilitate data analysis. Responses in the post-survey utilized the same Likert scale ratings from the pre-survey and included additional open-ended questions. Feasibility was measured in the pre-survey through participants' personal feelings of preparedness and ability to care for a precipitous delivery in the clinic. Post-survey feasibility was measured by using additional questions concerning the staff member's perceptions of the training and mock precipitous delivery to increase their level of preparedness. With structured training and protocols, the hope is that participants will have increased confidence, skill, and preparedness to care for a precipitous delivery in urgent care. Three questions in the pre-survey addressed current feasibility, while one additional question in the post-survey addressed the feasibility of the training provided (see Appendices A and B). Usability pertains to staff members' intent to utilize this newly adapted protocol and delivery kit. With a simple protocol and delivery kit in place, the hope is that the RN or MA/EMT will feel more confident in their ability to perform their role during a precipitous 11 delivery. They will be able to recall the training they received or quickly refer to the guide in the delivery pack and assist the provider in performing the delivery. The use of the protocol should be easy to follow and provide a benefit to all individuals who utilize the new process. One question in the pre-survey and one additional question in the post-survey specifically addressed the usability of the protocol and delivery kit (see Appendices A and B). Satisfaction relates to how well the staff members perceive the new practice change and their ability to perform their roles during a precipitous delivery. In simple terms, these questions address how satisfied the participants are with the product. For this new protocol and process to succeed, SHUC stakeholder and staff member buy-in is critical. Two questions in the pre-survey and one additional question in the post-survey addressed this issue (see Appendices A and B). The validity of these measurements was determined through the approval of SHUC stakeholders, content experts, and the project chair. These groups reviewed every measurement, and feedback was provided during their creation. Analysis In this study, descriptive statistics were used to describe the study sample. Next, a MannWhitney U test was used to assess the difference between pre-intervention and postintervention. Finally, a content analysis of the summarized information was conducted on the open-ended survey questions. Anderson (2010) discusses how raw data should be compiled and analyzed, not just listed. This project followed their recommended method of data collection and analysis. Responses were read and re-read to become familiar with the content, and then the content was coded. Then, the responses were compiled into categories, organized, and summarized into themes. 12 Ethical Considerations This project focused on enhancing quality and did not fall under the purview of the University of Utah's Institutional Review Board. No conflicts of interest were associated with this project. Results This project involved two phases: the pre-survey phase and the post-survey phase. Furthermore, the surveys were split into two parts involving participant demographics and questions assessing feasibility, usability, and satisfaction (Table 1). These measures were assessed using Likert scales and an open-ended question for participant feedback. The Likert scales ranged from "1-uncomfortable/unconfident to 5-comfortable/confident." Pre- and postsurvey results were calculated to show mean and standard deviation. Additionally, a Mann-Whitney U test was used to estimate statistical significance between pre- and post-surveys (Table 2). A standardized measurement tool was not utilized in this project. Therefore, specific questions tailored for SHUC were created to assess the aforementioned measures. Overall, results from both surveys demonstrated improvement after implementation of the PDP, with statistically significant findings between pre- and post-survey data. Demographics Of the approximately forty RNs and MA/EMTs at SHUC, eighteen responded to the preimplementation survey, and fifteen responded to the post-implementation survey. The demographic data was gathered during both surveys, and information was reported concerning their age, role in urgent care, experience in healthcare, amount of time spent at SHUC, and prior involvement in a precipitous delivery. Of the eighteen staff that responded to the preimplementation survey, the majority (56%) were between ages 25-39, 45% of staff were RNs where 55% were MA/EMTs, 56% of staff members had 2-5 years of healthcare experience, 78% 13 of participants have worked at SHUC less than one year, and 72% have never been involved in a precipitous delivery (Table 1). Participants in both pre- and post-surveys were the same group of individuals. If a participant did not participate in the pre-survey but received the training, they were asked to refrain from participating in the post-survey. Feasibility Pre-survey results for feasibility among the SHUC participants ranked their ability to assist with a precipitous delivery with a mean response of 2.4 (SD = 1.29). In comparison, postsurvey results demonstrated a mean score of 4 (SD = 0.75). There was a significant increase in their ability to assist with a precipitous delivery between the pre-and post-survey (U = 49, p < 0.05) (Table 2). SHUC pre-survey responses about knowing the flow process when a precipitous delivery is paged in the clinic demonstrated a mean response of 2.4 (SD = 1.29). Post-survey results demonstrated a mean score of 4 (SD = 0.84). A significant increase was noted in knowing the clinic flow process between pre- and post-surveys (U = 47.5, p < 0.05) (Table 2). Finally, results from the pre-survey concerning participants' ability to care for a mother who just gave birth showed a mean score of 3 (SD = 1.24). The post-survey results showed a mean score of 4 (SD = 0.75). This change was significant between the two surveys (U = 71.5, p < 0.05) (Table 2). Usability Usability in the pre-survey inquired about the current practices in urgent care and staff members' use of a precipitous delivery kit, if any. Results from the pre-survey utilization of the precipitous delivery kit demonstrated a mean score of 2.1 (SD = 1.13). Post-survey results demonstrated a mean score of 3.7 (SD = 0.96). There was a statistically significant change between pre- and post-surveys (U = 41.5, p < 0.05) (Table 2). 14 Satisfaction Pre-survey results concerning staff members' ability to help deliver care for a newborn resulted in a mean score of 2.4 (SD = 1.09). Post-survey results for the same measure demonstrated a mean score of 4 (SD = 0.75). The change was significant between the two surveys (U = 36.5, p < 0.05) (Table 2). A second measure of satisfaction was used regarding the overall process of a precipitous delivery in the clinic. Pre-survey results showed a mean score of 2.1 (SD = 0.96). Post-survey results of the same metric showed a mean score of 3.9 (SD = 0.7). The change noted between preand post-survey was significant (U = 22, p < 0.05) (Table 2). Qualitative Data Qualitative data was analyzed from post-survey participants. Each individual was provided the opportunity to provide feedback regarding the training, utilization of the protocol and the overall process of the project. Seven of the fifteen respondents to the post-survey provided feedback. Analysis of the seven responses indicated robust feedback in support of and their desire to utilize the new protocol. Of the seven respondents, 57% (n=4) recommended creating specific role cards for staff members instead of one paper containing the entire protocol (Table 3). Discussion Summary This project aimed to adapt and implement an evidence-based precipitous delivery practice change consisting of a protocol and kit in the SHUC. Results demonstrated significant increases in staff members' confidence, ability, and preparedness to handle a precipitous delivery at SHUC when comparing post- to pre-implementation data. All measures demonstrated 15 increased feasibility, usability, and satisfaction. Qualitative data analysis indicated significant support for the protocol and its use in practice. The survey results indicated a notable increase in participants' confidence, ability, and preparedness regarding precipitous delivery assistance, clinic flow processes, and newborn care post-implementation of the protocol. Participants showed significant improvements in their ability to assist with precipitous deliveries, understand clinic flow processes, utilize delivery kits, and deliver care to newborns. The qualitative data analysis further supported the positive reception of the new protocol, with participants expressing a desire to utilize it and providing constructive feedback for improvement, such as creating specific role cards for staff members. Overall, the project enhanced staff readiness and satisfaction in managing precipitous deliveries within the urgent care setting. Notably, 28% of pre-survey participants (n=5) and 27% of post-survey participants (n=4) had prior experience with at least one prior precipitous delivery. Given the rarity of this event, these numbers were greater than one-fourth of the participants. These participants could have been present at the aforementioned incident that occurred in April 2023. Also, some participants had prior experience in the emergency department, where a precipitous delivery is more common than in the urgent care setting. One strength of this project was how well staff members received it. Post-survey analysis demonstrated their willingness to utilize the new kit and protocol. The post-survey questioning of RNs and MA/EMTs (n=15) revealed that 73% of staff felt the additional training benefited their learning. Furthermore, the survey also demonstrated that 80% of staff felt the protocol was clear and easy to follow. Finally, the post-survey showed that 80% of staff members would implement the PDP and kit in the event of a precipitous delivery. 16 Interpretation The association between the adapted PDP and the outcomes showed an improvement in feasibility, usability, and satisfaction for all project participants in the SHUC. Unfortunately, through our research, no additional studies similar to this could be found; therefore, a comparison between other studies was not possible during this study. Hill et al. (2023) found that healthcare providers in community clinics feel unprepared and need more skills and knowledge to handle an unplanned precipitous delivery. Based on the results of this study, staff members at the SHUC have increased confidence, ability, and preparedness. Also, they have the necessary tools to provide improved patient care during an unplanned precipitous delivery (Table 2). The overall impact of the PDP on people and systems is three-fold. First, it can potentially decrease the risk of morbidity and mortality of the newborn. Beaird et al. (2023) found that severe complications can arise from unplanned precipitous deliveries, such as life-threatening hypothermia, perinatal morbidity, and mortality. Second, it can minimize significant emotional and physical stress on the mother. Svedberg et al. (2020) discuss that having an unplanned birth outside of a hospital can be a tumultuous and traumatizing event. Third, it can decrease the mothers’ pain and suffering, which can, at times, lead to a disconnect between the mother and the newborn infant (Molloy et al., 2021). Additionally, the PDP provides a standardized practice change, ensuring that high-quality care will be provided in the event of an unplanned OOH delivery. Limitations The most significant limitation of this project was the lack of data from key members of the SHUC team, specifically the providers (MDs, PAs, and NPs). These individuals received their own training from labor and delivery providers instructing them on how to safely deliver a newborn in the event of a precipitous delivery. Even though the protocol contains instructions for 17 providers on safely delivering the newborn, they were not included in the training provided to the RN and MA staff members. Thus, including them in future projects would be a beneficial next step to ensure consistent practice across all providers. Additionally, this project was conducted in a single location, which may not allow for the generalizability of the results to other community urgent care facilities. Also, the location at which this study was conducted is a large and robust urgent care including many staff members. Smaller urgent cares that staff fewer members would not be able to utilize this protocol as it involves multiple people. Finally, this study was subject to potential bias and a ceiling effect. Depending on past healthcare experience, some participants had significantly more experience with a precipitous delivery than others surveyed. Even though the same training was provided to all participants, the confidence and ability of some individuals remained the same as they already had superior training before this study. Conclusions Implementing the PDP at the SHUC clinic allowed for a significant practice change aimed at equipping staff members with the necessary skills and resources to manage unplanned OOH deliveries effectively within the outpatient setting. Alongside implementing the protocol, a specialized precipitous delivery kit was developed and placed in emergency bags to facilitate prompt and efficient responses during such events. Through a specialized evaluation process involving pre- and post-surveys, RNs and MA/EMTs were evaluated concerning the feasibility, usability, and satisfaction levels associated with the protocol, kit, and accompanying training. The results of this study demonstrated notable advancements across all study measures pertaining to feasibility, usability, and satisfaction post-PDP implementation. This implies the project's success in achieving its primary objective of bolstering staff members' confidence, 18 ability, and preparedness in navigating unplanned OOH delivery scenarios. The project's success is further underscored by significant buy-in from the management team and frontline staff at SHUC, signifying a promising foundation for sustained implementation and future scalability within the UUHC system. Future projects could include implementing and utilizing the PDP in all urgent care clinics within the UUHC system. Furthermore, additional research could include adding urgent care providers to the survey participants and a more comprehensive analysis of the protocol's effectiveness during actual unplanned delivery situations. Through ongoing research, outcome evaluations, and beneficial modifications, the PDP can further enhance staff members' readiness and response in addressing emergent obstetric deliveries within the outpatient setting. Acknowledgments I would like to sincerely thank the Sugarhouse Urgent Care staff members whose active participation in this study reflects their unwavering dedication to elevating patient care. Additionally, I am deeply grateful to Sarah Patey for her unwavering support, expertise, and facilitation of this project at the Sugarhouse location. Her invaluable contributions and support have ensured the project's success. I extend a heartfelt thanks to Melissa Baker, whose expertise as my context expert was instrumental in developing this protocol and kit tailored for urgent care. Lastly, I express my profound gratitude to my project chair, Dr. Lisa Taylor-Swanson. 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Johns Hopkins Medicine. http://www.hopkinsmedicine.org/evidence-based-practice/model-tools.html Tables and Figures Table 1 SHUC Staff Demographics Demographic Information Pre-Survey n=18(%) Post-Survey n=15(%) 21 Age (years) 18-24 3(17) 3(20) 25-29 5(28) 4(27) 30-39 5(28) 4(27) 40-49 2(11) 1(6.5) 50-59 2(11) 2(13) 60+ 1(5) 1(6.5) MA/EMT 10(55) 8(53) RN 8(45) 7(47) 1(5) 1(6) 5(28) 4(27) 5(28) 4(27) 3(17) 3(20) 4(22) 3(20) 6-12 months 3(17) 2(13) 13 months-1 year 5(28) 4(27) 3-5 years 6(33) 5(33) 6+ years 4(22) 4(27) 0(0) 0(0) 5(28) 4(27) 13(72) 11(73) Role Health Care Experience (years) 0-1 2-3 4-5 6-10 11+ Time spent in SHUC 0-5 months Involved in Precipitous Delivery Yes No Table 2 SHUC Survey Results Pre-Survey Post-Survey n=18 n=15 22 M SD M SD Mann-Whitney U Test 2.4 ± 1.29 4 ± 0.75 u = 49 (p < 0.05) 2.4 ± 1.29 4 ± 0.84 Yes No Yes No Your ability to assist with a precipitous delivery? (Feasibility) Knowing what to do when a precipitous delivery is paged in the clinic? (Feasibility) u = 47.5 (p < 0.05) n/a Do you know the location of 3 15 15 0 (17%) (83%) (100%) (0%) 2.1 ± 1.13 3.7 ± 0.96 Helping deliver and care for a newborn? (Satisfaction) 2.4 ± 1.09 4 ± 0.75 Caring for a mother who just 3 ± 1.24 4 ± 0.75 2.1 ± 0.96 3.9 ± 0.7 u = 22 (p < 0.05) Yes No Neutral 11 0 4 the precipitous delivery kit? Utilizing the precipitous delivery kit? (Usability) gave birth? (Feasibility) The overall process of a u = 41.5 (p < 0.05) u = 36.5 (p < 0.05) u = 71.5 (p < 0.05) precipitous delivery? (Satisfaction) Were the training and mock delivery beneficial to your learning? (Feasibility)** n/a n/a 23 Is the precipitous delivery n/a (73%) (0%) (27%) Yes No Neutral 12 0 3 (80%) (0%) (20%) Yes No Neutral 12 0 3 (80%) (0%) (20%) n/a protocol clear and easy to follow? (Usability)** Will you use the protocol in n/a the event of a precipitous n/a delivery in the clinic? (Satisfaction)** Note. Results denote a Likert scale survey's mean and standard deviation, ranging from 1 to 5. **Questions asked only in post-survey 24 Table 3 Feedback from Post-Survey Survey Respondent 1 2 5 8 Response “Well done, I liked the training. It was very helping and informative.” “It was great. Thank you! Excited to use in the future.” “Excellent protocol, will help the clinic, I would like individualized cards for the nurses and MAs.” “Really enjoyed this training and protocol. I hope to never need it but if I do, it will be very beneficial.” 11 “Loved it! You should split the different roles onto cards for ease of use.” 13 “Great job. Make separate cards for the roles.” 15 “Excellent! Individual cards for the different roles in the protocol would be helpful.” 25 Appendix A Urgent Care Pre-Survey 1) What is your age? 18-24 25-29 30-39 40-49 50-59 60+ 2) What is your role in urgent care? MA/EMT RN 3) How many years of experience do you have in healthcare? 0 - 1 year 2 - 3 years 4 - 5 years 6 - 10 years 11+ years 4) How long have you worked in urgent care? 0 - 5 months 6 - 12 months 13 months - 2 years 3 - 5 years 6+ years 5) Have you ever been involved in a precipitous delivery? Yes No 26 6) How comfortable do you feel in your ability to assist with a precipitous delivery? (Feasibility) Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Uncomfortable 7) Comfortable How comfortable do you feel in knowing what to do when a precipitous delivery is paged in Somewhat Comfortable the clinic? (Feasibility) Neutral Somewhat Uncomfortable Uncomfortable 8) Do you know the location of the precipitous delivery kit? 9) How confident are you in utilizing the precipitous delivery kit? (Usability) Yes No Confident Somewhat Confident Neutral Somewhat Unconfident Unconfident 27 10) How confident are you in helping deliver and Confident care for a newborn? (Satisfaction) Somewhat Confident Neutral Somewhat Unconfident Unconfident 11) How confident are you in caring for a mother Confident who just gave birth? (Feasibility) Somewhat Confident Neutral Somewhat Unconfident Unconfident 12) How comfortable are you with the overall process of a precipitous delivery? (Satisfaction) Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Uncomfortable 28 Appendix B Urgent Care Post-Survey 1) What is your age? 18-24 25-29 30-39 40-49 50-59 60+ 2) What is your role in urgent care? MA/EMT RN 3) How many years of experience do you have in healthcare? 0 - 1 year 2 - 3 years 4 - 5 years 6 - 10 years 11+ years 29 4) How long have you worked in urgent care? 0 - 5 months 6 - 12 months 13 months - 2 years 3 - 5 years 6+ years 5) Have you ever been involved in a precipitous delivery? 6) Yes No Comfortable How comfortable do you feel in your ability to assist Somewhat Comfortable with a precipitous delivery? (Feasibility) Neutral Somewhat Uncomfortable Uncomfortable 7) How comfortable do you feel in knowing what to do when a precipitous delivery is paged in the clinic? (Feasibility) Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Uncomfortable 8) Do you know the location of the precipitous delivery Yes kit? No 30 9) How confident are you in utilizing the precipitous delivery kit? (Usability) Confident Somewhat Confident Neutral Somewhat Unconfident Unconfident 10) How confident are you in helping deliver and care for a newborn? (Satisfaction) Confident Somewhat Confident Neutral Somewhat Unconfident Unconfident 11) How confident are you in caring for a mother who just gave birth? (Feasibility) Confident Somewhat Confident Neutral Somewhat Unconfident Unconfident 12) How comfortable are you with the overall proce ss of a precipitous delivery? (Satisfaction) Comfortable Somewhat Comfortable Neutral Somewhat Uncomfortable Uncomfortable 31 13) Do you feel the training and mock delivery were beneficial to your learning? (Feasibility) Yes No Neutral 14) Is the precipitous delivery protocol clear and ea sy Yes No to follow? (Usability) Neutral 15) Will you use the protocol in the event of a precipitous delivery in the clinic? (Satisfaction) Yes No Neutral 16) Do you have any suggestions for improvement (trainings, protocol, flow process)? Appendix C Precipitous Delivery Protocol Definitions: Precipitous Delivery Team • Provider, RN, MA/EMT x3 (when possible) Roles: • • • • • Provider: Manage precipitous delivery (Leader) RN: Assist provider / care of baby after delivery MA (1): Assist provider MA (2): Runner MA (3): Recorder 32 Description: OB RRT is called in clinic: Rapid response team (RRT) responds A. Preparation 1. RN and MA (3) - Grabs RRT backpack(s) (kit located inside backpack) 2. MA (1) - Get vitals cart and portable oximeter (from clinic) 3. MA (2) - PPE for team (gloves, gowns, face shields, etc.) B. Arrive to RRT site 1. RRT Provider assesses the patient 2. MA #1 - Obtain patient vital signs 3. **If OB midwife or provider is available, they will arrive at scene and help/take over for provider. However, not a requirement** C. Delivery 1. Determine if delivery is imminent (Crowning?) 2. If no, proceed with normal RRT response 3. If yes, deliver the baby if the doctor/midwife is not present: i. MA (2) call for transport OR 911 based on acuity ii. RN and MA (1) open precipitous delivery kit and assist in delivery iii. Assist patient into position for imminent delivery a. Control the fetal head with slight downward counterpressure b. Control maternal perineum with your other hand c. As the head emerges allow for spontaneous restitution d. Check for the umbilical cord around the neck (nuchal cord) e. If nuchal cord is present: i. Reduce over the head OR ii. Reduce over the body (deliver through cord) OR iii. Double clamp and cut f. Resume maternal pushing efforts g. Downward pressure to deliver the anterior shoulder under the symphysis h. Upward pressure to deliver the posterior shoulder i. Baby delivered j. Determine vigor (Is baby term? Good tone? Crying or breathing?) k. Watch for signs of placental separation such as: i. Gush of blood (can give IM meds?) ii. Uterine contraction (fundus balling up) iii. Cord lengthening 4. Deliver the placenta 5. Perform fundal massage as needed to firm up the fundus and slow vaginal bleeding. Also, can perform breastfeeding to help. D. Recovery 33 1. Initiate postpartum care: a. Provider OR RN to provide newborn care i. Place infant on mom’s belly and determine if baby is vigorous i. If vigorous (Is baby term? Good tone? Crying or Normal Vitals for Newborn breathing?), continue with below HR 110 - 160 ii. If NOT vigorous, cut cord and proceed with RR 30 - 60 Newborn resuscitation (NRP) Temp 36.5 - 37.5 ii. Provide warmth (skin-to-skin, blankets, hat, etc.) O2 sats iii. Dry infant (discard wet blankets) 1 minute 60-65% iv. Stimulate (by rubbing back or extremities) 2 minutes 65-70% v. Position the head and neck (to ensure airway is open) 3 minutes 70-75% vi. Clear secretions, if needed (blue bulb suction) 4 minutes 75-80% vii. Delay cord clamping by 1-minute if baby is vigorous 5 minutes 80-85% 10 minutes 85-95% AND ≥ 34 weeks i. Clamp cord in 2 places and cut cord ii. 1st clamp about 6” from baby iii. 2nd clamp about 2” distal from first (8”) iv. Cut between clamps viii. Listen to heart rate, note tone, respiratory effort, appearance (color), and response to stimulation b. MA (1) care for mother i. Cover mom and baby with warm blankets ii. Allow for breastfeeding, if mother is desires and baby is vigorous iii. Monitor vital signs c. Wait for EMS arrival and transport to birthing facility E. Documentation – MA (3) 1. Record vitals of mother every 5 minutes during birth 2. Document time of when head is out 3. Document time of birth (when baby is out) 4. Document baby HR, temperature, respiratory effort, tone, oxygen saturation, every 3-5 minutes. 5. Record any medication administration 6. Record a clinical event and RL6 References: 1- AWHONN (2019) Standards for Professional Nursing Practice in the Care of Women and Newborns (8th ed.) 2- Simpson, K.R. & Creehan, P.A. (2014) Perinatal Nursing (4th ed.), Lippincott, Philadelphia. 34 3- Textbook of Neonatal Resuscitation, 8th Edition (2021), American Academy of Pediatrics, Lesson 3 Initial Steps of Newborn Care, pgs 33-63 Appendix D Precipitous Delivery Kit 35 Kit Contents (1) Plastic Lined Underpad (1) Receiving Blanket (1) Bulb Syringe, Sterile (1) Pair Latex Free Gloves, Sterile (2) Umbilical Clamps, Sterile (2) O.B. Towelettes (1) Disposable Scalpel, Sterile (1) Plastic Bag & Ties for Placenta (1) O.B. Pad, Sterile (4) Disposable Towels (2) Nylon Tie Offs (3) 4x4 Gauze Sponges, Sterile 2’s (1) Red Biohazard Bag (2) Alcohol Prep Pads Appendix E 36