Date of Award
Spring 5-24-2025
Document Type
Doctor of Nursing Practice Final Manuscript
Degree Name
Doctor of Nursing Practice
Department
Nursing
First Advisor
Dr. Lilian Chan, DNP, RN, PCCN-K
Abstract
Background: The United States is seeing an uptick in maternal deaths by 159% since 2019, with maternal mortality higher with cesarean procedures (Hoyert, 2020; Riches et al., 2024[LC1] ). UC San Diego Health NTSV C-Section rates between September 2024 – October 2024 ranged between 22-54%, well above the benchmark of 23.4% in California (Slone, n.d.). Doulas are trained to care for the mother before, during, and after birth by being an advocate, providing physical and emotional support, and being a continuous support person (Dekker, 2017). Doulas have been shown to improve birthing outcomes by providing these support mechanisms, particularly in NTSV (Nulliparous, Term, Singleton, Vertex) caesarean-section rates (Sobczak et al., 2023). Evidence supports the use of early education through patient portals to support resource use such as doulas.
Purpose of Project: The volunteer program at UCSD called Hearts and Hands provides doulas to mothers at no cost. Currently, the program is underutilized due to a minimal to no educational material given at the 32-week outpatient appointment. The purpose of this project is to add an automation in a 32-week provider order set, triggering patient education in the after-visit summary electronically in the EHR for providers to use at the 32-week appointment so that patients can also view the material in the patient portal and then trigger in the patient's inpatient chart upon admission to educate them again about the services. This project aims to increase doula usage at the bedside to reduce adverse birthing outcomes, such as NTSV c-sections.
Methods: Clinical decision support (CDS) build included a smart set was updated to include information about doulas at the 32-week appointment. In this smart set, updated education about the volunteer doula program was provided along with contact information, which triggered information being uploaded to the after-visit summary in both Spanish and English. An order set was also created for the clinician to alert the doula coordinator for birthing persons wanting a doula. For the inpatient side, the flowsheet was updated to include a link to the on-call doula calendar in the EHR. There were also updates to whether a doula was present at active delivery to better capture the data. A tip sheet was created to remind registered nurses at the bedside about the updated changes.
Evaluation of Outcomes/Results: At the end of the go-live 3-month period, doula education in portal by providers increased in both Hillcrest and La Jolla campuses. There was also a slight increase in requested doulas for La Jolla when patients arrived to triage but not in Hillcrest. There was an increase in doulas arriving at the bedside for both Hillcrest and La Jolla post-build launch. NTSV C-section rates with doulas at Hillcrest post-CDS build averaged 12.5%, with the NTSV c-section rates with doulas were 19.5% at La Jolla. With the data collected from September 2024 to February 2025 pre and post implementation comparing all deliveries against deliveries with a doula with NTSV c-section rates, there is statistical significance of (p value= 0.0424) at Hillcrest. However, there was no statistical significance of NTSV c-section rates noted for all deliveries against deliveries with a doula at La Jolla (p =0.0860).
Conclusion:It is essential to incorporate clinical decision support tools such as utilizing smart phrases early in the patient’s health journey until admission to provide up-to-date information for doula services. Consideration should be made to continually update and remind and incorporate evidence-based services, especially now supported by Medi-Cal, and educate both providers and patients accordingly within the electronic health care record (EHR). Considerations should also be made regarding provider electronic workflows and ensuring future build does not also impact operational flow.
Digital USD Citation
Randall, Jonese D., "Electronic Medical Record Clinical Decision Support Across the OB Continuum of Care: Enhancing Doula Education and Usage" (2025). Doctor of Nursing Practice Final Manuscripts. 308.
https://digital.sandiego.edu/dnp/308
Copyright
Copyright held by the author
