Achieving zero preventable adverse events in patients with cesarean scar pregnancy in a tertiary care center: a multidisciplinary team approach

Cesarean scar pregnancy (CSP) is a high-risk condition which can lead to serious morbidities such as hemorrhage, ICU admission, unplanned hysterectomy, and even death. The existing literature describes improvements in diagnostic and treatment modalities; however, there is a lack of consensus on a single pathway to treat these patients. Our institution set out to create a standard care pathway with the goal of zero preventable adverse events. This project was undertaken in a large, urban, academic hospital setting. In 2019, a project was initiated to clearly delineate a pathway for management of CSP at our institution. The following steps were taken: 1. A needs assessment had determined that practices surrounding diagnosis and treatment of CSP were not standardized, and that adverse events had been detected through existing surveillance systems established by the Gynecologic Quality and Safety Committee. 2. The existing literature and best practice were reviewed. 3. A multidisciplinary team was assembled including representatives from Maternal Fetal Medicine, Benign Gynecology, Family Planning, Gynecologic Oncology, Diagnostic and Interventional Radiology. 4. An ideal state process was formulated. 5. Key drivers to achieving ideal state were identified to be early diagnosis, education of all stakeholders, and a straightforward, clearly defined pathway. A summary of this pathway is displayed in Figure 1. Once finalized, this pathway was broadly disseminated to the multidisciplinary group of institutional and community providers in our area. The Gynecologic Quality and Safety Committee has tracked patients diagnosed with CSP who were referred to our center before and after this quality improvement initiative was initiated to assess key safety events. The key safety indicators included EBL >500mL, unplanned hysterectomy, ICU admission, and mortality. Secondary safety indicators included need for blood transfusion, unplanned surgical procedure, re-utilization of healthcare within 30 days of treatment including unplanned admission or re-admission and unplanned Emergency Department (ED) visit. At our institution, 60 cases of CSP were diagnosed between January 2013 and August 2022. Of these 60 cases, 3.3% (2/60) had EBL >500mL. There were 0 cases of unplanned hysterectomy, ICU admission, or death. Regarding secondary safety indicators, 0 cases required a blood transfusion, 1.6% (1/60) underwent unplanned surgery, 8.3% (5/60) with unplanned admission or re-admission within 30 days, and 8.3% (5/60) presented to the ED within 30 days. Since the protocol was finalized in 2020, there have been 0 primary or secondary safety events (Figure 2). The enactment of a standardized, multidisciplinary, team-based approach in the care for a cesarean scar pregnancy has sustainably resulted in zero high-morbidity outcomes.Figure 2Cesarean scar pregnancy cases and associated adverse events over time CSP, cesarean scar pregnancy; FP, Family Planning; GYN, Gynecology; GYN/ONC, Gynecologic Oncology; interventional radiology; MFM, Maternal Fetal MedicineView Large Image Figure ViewerDownload Hi-res image Download (PPT)