1. Premature Labor Assessment Toolkit (PLAT)
Award Recipients:
James Byrne, M.D., Affiliated Clinical Professor in Maternal-Fetal Medicine, Stanford School of Medicine, Chair, Department of Obstetrics and Gynecology, Santa Clara Valley Medical Center
Herman Hedriana, M.D., Associate Clinical Professor, University of California, Davis, Partner, Sacramento Maternal-Fetal Medicine Medical Group
Award Presenter:
John Wachtel, M.D., Chair, ACOG District IX, Adjunct Clinical Professor, Stanford University Medical School
May 3, 2015

2. PLAT Goal
To improve perinatal health outcomes by establishing a standardized clinical pathway for the assessment and disposition of women with suspected signs and symptoms of preterm labor.
The March of Dimes Preterm Labor Assessment Toolkit (PLAT) was the result of this process and the first edition was released in 2005 with letters of support from Society for Maternal Fetal Medicine and District 9 of the American Congress of Obstetricians and Gynecologists or ACOG.
The publication was developed detailing a step-by-step method to support clinical staff in accomplishing this goal hospitals that wanted to adopt the toolkit.
A second edition is forthcoming in 2012 that has been revised to include current evidence-based recommendations and to bridge the gap between ACOG Practice Bulletin 127 and 130 which are focused on Preterm Labor Management and Prevention of Preterm Birth, respectively.

3. History of the Preterm Labor Assessment Toolkit (PLAT)
In 2002, National March of Dimes announced taking on the issue of prematurity. The California chapter convened a Summit of public health and medical experts to discuss the issue. Preterm labor was identified as an intervention opportunity to improve maternal and infant outcomes.
Although the present science could not successfully stop preterm labor once it has begun, there is great value in delaying delivery for 48 hours in order to prepare the fetus for premature life. In the majority of cases, only 10% of patients will deliver preterm with the diagnosis of preterm labor and the majority of women are exposed to unwanted interventions.
Recognizing the gravity of the problem, a cooperative agreement between March of Dimes California Chapter and Sutter Medical Center, Sacramento was established to create a multidisciplinary task force and explore the triage practices in assessing preterm labor and - to determine if standardization of the triage process will improve the quality of determining disposition of women at risk for preterm birth.
In the same year, a task force was established of more than 40 diverse members in the field of maternal-child health who reviewed the current literature and best practices on triage for preterm labor.
The overarching question that was asked of everyone was: “Can we design a toolkit that can be used by every type of maternity hospital?”
After recognizing the wide variation and inconsistencies of protocols, policies and procedures, it was clear that The goal was to create a standardized approach of assessing preterm labor -- recognizing that most facilities do not have a standardized methodology for assessing and making the diagnosis of preterm labor --resulting in starting medical treatment or admission of a patient that may not be indicated.
National experts input was obtained as the toolkit was being developed and was followed with a separate national expert review prior to obtaining endorsements from national organizations.
History of the Preterm Labor Assessment Toolkit (PLAT)
Project initiated at 2002 March of Dimes California Prematurity Summit to address:
Lack of standardized assessment process for preterm labor
Unnecessary maternal admissions and interventions
Need to ensure that women deliver at appropriate level of care for improved outcomes
Cooperative agreement between March of Dimes California Chapter and Sutter Medical Center, Sacramento (SMCS)
Multidisciplinary statewide task force created
Statewide hospital survey examined consistencies and variation in existing preterm labor policies/protocols

4. PLAT Revision: 2011-2012 Enhancements include: Letters of support:
Updated literature and best practices review
New content on preterm labor assessment standardization tools
Simplified algorithm
Data collection and quality improvement tools for hospitals
Clinical appendix
California pilot study evaluation report
Hospital case studies
Letters of support:
American Congress of Obstetricians and Gynecologists, District IX (California), District XII (Florida), District VI (Illinois)
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), California Section and National
First edition of PLAT has been implemented in over 30 hospitals across CA. PLAT has received national attention, most recently at statewide perinatal conferences in Tennessee, Arizona and Missouri.
The authors are comprised of volunteer experts from CA and at the national level with expert assistance from the March of Dimes staff
We learned a great deal through the implementation of the first PLAT. We learned:
How often women do not receive a complete assessment when they are triage for preterm labor
Making changes in hospital practice takes TIME
It is very important to build a strong case to support the need for, and drive, change
We could not over emphasize the importance of baseline data collection and post implementation data feedback to further refine the implementation process
To avoid confusion, it is very important to outline step-by-step implementation guidelines
Last and most importantly, having the right champions in place will move the quality improvement process forward.

5. PLAT Contents Assessment and Disposition Protocol Clinical Algorithm
Order Set
Home Care Instructions
Patient Education
Implementation Checklist
Qualitative Baseline and Follow-Up Surveys
Chart Audit Tool
Clinician Power Point Training Presentation
The preterm assessment toolkit includes the following components and has been expanded and updated in the forthcoming second edition.

6. Why Use a Standardized Assessment for Preterm Labor?
Helps avoid unnecessary interventions while providing reassurance to women who are not in preterm labor.
Ensures pregnancies at highest risk receive beneficial treatments in a timely manner:
Antenatal corticosteroids to women before delivery to help babies’ lungs develop.
Maternal transport (when needed), so that babies are born at the appropriate level of hospital/NICU care.
Assembling a high-risk team of doctors and nurses.
Administering tocolytics to help postpone labor long enough to carry out the interventions listed above.
Using standardized protocols significantly reduces poor outcomes and increases patient safety by reducing unwanted interventions and preventing unplanned perinatal complications.
Standardization will correctly identify the minority of women who would need interventions to prepare for preterm delivery and improve outcomes.
This consist of using short-term tocolysis to prolong gestation long enough to administer antenatal corticosteroids -to reduce the risk of respiratory distress syndrome, magnesium sulfate -reduce the risk for cerebral palsy , and allow maternal transport to a facility with a neonatal intensive care unit or assemble a neonatal team for delivery.

7. March of Dimes California Chapter Evaluation Study: 2008-2012
Evaluation question: Could PLAT implementation improve patient assessment, resulting in appropriate disposition decisions?
Data Source: Medical chart audit at 18 hospitals. Pre-implementation audit and post-implementation audit after 3 months.
Profile of 18 hospitals:
Range from 300 to 4,000 births/year
5 rural, 11 urban, 2 university
Levels of care:
6 Level I (basic)
9 Level II (community)
3 Level III (regional)
As of this presentation, we have collected data from 18 hospitals.
We anticipate to receive data from 3 additional hospitals by year-end and concluding our evaluation with a total of 21 hospitals.
Although our submitted abstract spoke of an initial goal of 25 hospitals, we will not be able to achieve our target due to changes in leadership, staff and priorities at our 4 partnering hospitals.

8. PLAT Evaluation Conclusions
PLAT implementation increased appropriate patient assessment by clinicians
Standardization of practice increased
Disposition decisions based on completed cervical change assessment increased
Full compliance with the new protocol and procedures requires longer than 3 months
PLAT implementation changed clinical practice behavior in labor and delivery triage units.
The standardization of triage evaluation resulted in proper and safe disposition decisions where a majority of patients were discharged home undelivered decreasing the likelihood of unwanted intervention.
Based on our assessment, it will take more than 3 months to ascertain full compliance but the promise of sustained improvement is probable.
The apparent conservation of resources will translate into dollar savings consistent with published data while maintaining utmost perinatal safety.