Obstetric Anal Sphincter Injuries: Implementation of a Standardized Care Bundle

Objectives: This quality improvement (QI) initiative aimed to implement a standardized obstetric anal sphincter injury (OASIS) care bundle on a high-volume, tertiary-care, academic labor and delivery unit in order to improve adherence to evidence-based management strategies

Methods: We used the Plan-Do-Study-Act quality improvement methodology to create a standardized care bundle for management of OASIS. A retrospective chart review identified patients who sustained OASIS from 9/2018 to 9/2023 to form a preintervention dataset. A literature search identified best available evidence. Local practice patterns deviating from this evidence were identified. Departmental support was ensured by presenting findings and objectives to an institutional QI committee. An interdisciplinary collaboration of stakeholders in obstetrics, urogynecology, colorectal surgery, functional gastroenterology, and nursing was formed. Experts in each discipline provided recommendations. Five best practices for the management of OASIS emerged and our standardized care bundle interventions were designed to address each (Table 1).

Results: Preintervention, there were 292 documented OASIS; 269 (92.1%) third, and 23 (7.8%) fourth degree lacerations. 142 (48.6%) lacked documentation of a post-repair rectovaginal exam. 198 (67%) utilized chromic suture for repair of the anal sphincter(s). 130 patients (44.5%) did not receive antibiotics at the time of repair. 54 patients (18.5%) were not prescribed a bowel regimen. Since launching the care bundle, there have been 13 OASIS cases. The bundle was utilized completely in 4 patients and partially in 9. Timely, direct provider feedback is being utilized to improve compliance with the care bundle and identify barriers to change.

Conclusions: Implementation of a standardized, evidence-based care bundle is feasible and may mitigate gaps in care for patients who sustain OASIS. Further post-intervention data is required to identify trends in compliance over time and to tie care bundle implementation with patient outcomes.