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Does Quality “Bundling” Improve Obstetrical Outcomes?

Date: 05.03.2011
Contact: Jennifer Farquhar Phone: (330) 375-4930

Contact: Jennifer Farquhar, Phone: (330) 375-4930, Email:

WASHINGTON, DC, April, 30, 2011 – Healthcare quality “bundling” is a metric of effective and safe care, comprised of three to five essential, evidence-based practices that together improve outcomes of procedures with inherent risk. Among mother-infant pairs achieving the elective induction bundle, favorability of the cervix is associated with significantly better outcomes and cost, according to researchers at Summa Health System in Akron, Ohio.

Authors believe the study is one of the first to look at cost related to favorability of the cervix and outcomes, which has implications as providers across the country create an environment of accountable care under healthcare reform. The study is being presented on May 3 at The American College of Obstetricians and Gynecologists 59th Annual Clinical Meeting in Washington, DC, by Tiffany Kenny, RN, MSN, CEFM.

“We believe that the elective induction bundle should evolve to better measure quality and cost,” Kenny said. “As it stands now, if a woman’s Bishop Score measuring readiness to deliver is less than 6, and she is being induced, the standards say to council her on the risks of induction and to document it. Based on the outcomes in the study, we believe that favorability of the cervix should receive more emphasis and play a greater role in elective induction decisions.”

The Bishop Score is a pre-labor measurement that helps predict whether induction will be necessary. It is based on several measures of cervical readiness and fetal position. The elective induction bundle is a quality metric comprised of four essential, evidence-based practices that when implemented together are assumed to significantly improve outcomes. Other obstetric bundle examples include the augmentation bundle and vacuum bundle. Each step in the bundle must be completed or the bundle cannot be considered achieved.

Summa researchers looked at bundle criteria, clinical outcomes and cost data. Ninety-six percent (n=173) of the study group achieved bundle criteria, and those with a Bishop Score greater than six (52%, n=90) had fewer cesarean deliveries (4% vs. 19%, p=0.003), fewer neonates to special or intensive care (1% vs. 10%, p=0.015), shorter lengths of labor independent of delivery type, fewer cesarean deliveries for dystocia (75% vs. 94%, p=0.002) or fetal heart rate (25% vs. 50%, p=0.015) and were one-sixths the average net income lost to the hospital ($423 vs. $2,600) compared to bundle achievers with a Bishop Score of six or less.

“When you examine mother-infant dyads that meet all the criteria in a bundle, favorability of the cervix by way of a Bishop Score greater than six is associated with significantly better outcomes and costs,” Kenny said. “The elective induction bundle should evolve, requiring a favorable cervix instead of a documented Bishop Score to proceed with induction.”

Abstract authors include Tiffany H. Kenny, RN, MSN, CEFM, Jacqueline M. Nicodermo, Bradford W. Fenton, MD, PhD, and Vivian von Gruenigen, MD. There are no potential conflicts of interest for any author. The research was supported by the Summa Foundation.

About Summa Health System
Summa Health System is one of the largest integrated healthcare delivery systems in Ohio. Encompassing a network of hospitals, community health centers, a health plan, a physician-hospital organization, a multi-specialty physician organization, research and multiple foundations, Summa is nationally renowned for excellence in patient care and for exceptional approaches to healthcare delivery. Summa's clinical services are consistently recognized by the American Nurses Credentialing Center (Magnet® status), U.S. News and World Report, Thomson Reuters and The Leapfrog Group. Summa also is a founding partner of the Austen BioInnovation Institute in Akron. For more information, visit or find us on Facebook and Twitter at