Door to Drug in Obstetrics

Background: The concept of "door-to-drug" or "door-to-balloon" times as standard of care for care of acute STEMI are well known. We propose using the same concept to review opportunites for improvement in "door-to-drug" for obstetrical patients. A woman with a high risk of delivering prematurely should receive betamethasone (or appropriate alternative) at least 48 hours prior to delivery if she is between 24-34 weeks gestation in order to improve neonatal outcomes. Both the delivery and duration of drug administration of antenatal corticosteroids have been shown to positively improve neonatal outcomes. Currently at our facility, only 61% of women appropriately receive antenatal steroids prior to delivery. Women who are candidates for this therapy may have a delay in presentation, decision for treatment, and initiation of care based on a variety of variables. There can be critical time subinterval variations which affect timely care for these patients where there is potential for improvement. This warrants further investigation in order to improve door-to-drug time regardless of day or time of arrival. We sought to examine both maternal and system issues that may be associated with delayed delivery of antenatal corticosteroids.

Purpose: To examine both maternal and system issues that may be associated with delayed delivery (Door-to-Drug) of antenatal corticosteroids.

Methods: This was a retrospective cohort study of obstetric patients at a tertiary care level suburban teaching hospital with 6500 deliveries/year. Women were included who were evaluated in our OB Triage unit and ultimately delivered less than 34 0/7 weeks gestation in 2011. Our primary outcome was time of presentation to drug delivery (Door to Drug Interval [DDI]).The charts were reviewed for time of arrival, time of evaluation, time of admission, and time of medication administration. Other patient demographics/clinical characteristics were explored for confounding variables. Analysis was performed using Univariable analysis and cox proportional hazard. A second review and analysis was done of women in 2013 after relocation of the steroids to the OB Triage Dept.

Results: A total of 87 women were identified in 2011 and 70 were identified in 2013. Mean door-to-drug times were calculated and logistic regression was used to determine factors associated with longer times. The mean door-to-drug time for 2011 was 195.49 minutes and 180.73 minutes in 2013. There was no significant improvement in achieved time to delivery. Maternal demographics including ethnicity, gravidity, parity, admission diagnosis and gestational age did not alter DDI. Similarly, system factors such as time of day and day of week did not effect DDI. Moving the steroids to the OB Triage area did not significantly reduce the DDI.

Conclusions: There is no standard door-to-drug time for administration of antepartum steroids. We offer the above data as a starting point to stimulate discussion of an appropriate time frame in which steroids should be administered. Though door-to-drug delivery interval is an important outcome, it does not appear to be affected by demographics or system factors. Future research should seek a larger sample and explore further variables. In both time periods 31% of women did not receive steroids in time to receive optimum benefit for the fetus. Consideration of an early warning system similar to heart- or stroke alert could improve compliance with drug delivery to eligible mothers and to shorten the DDI.