Analysis of the application effect of a rapid response team in emergency cesarean section

Abstract Introduction Emergency cesarean section is one of the most critical methods in the treatment of high-risk emergency obstetric cases. The aim of this study was to explore the clinical effect of constructing a Rapid Response Team (RRT) in emergency cesarean section. Methods This is a pre- and post-implementation study. The patients who underwent emergency cesarean section were retrospectively analyzed and divided into an experimental group and a control group. There were 52 patients (June–December 2020) in the control group who underwent routine emergency cesarean section without an RRT, and 51 patients (January–June 2021) in the experimental group who underwent emergency cesarean section with an RRT. The operation time indexes (DOI, decision-to-operating room interval; O-I, operating room-to-incision interval; DII, decision-to-incision interval; I-D, incision-to-delivery interval; DDI, decision-to-delivery interval), DDI pass rate, neonatal Apgar score and maternal complications in the two groups were compared. Moreover, the management time trends (DOI, DII, and DDI) in the experimental group were analyzed. Results The DDI, DII, DOI, and O-I of the experimental group were shorter than those of the control group, and the differences were significant (p < 0.05). The DDI pass rate in the experimental group was higher than that in the control group, and the difference was significant (p < 0.01). The 1-min Apgar score of the experimental group was higher than that of the control group (p < 0.05). The key intervals of emergency cesarean section in the experimental group leveled off after approximately 3 to 4 months. Conclusion In the face of emergency situations, the implementation of an emergency cesarean section RRT can improve delivery intervals for emergency cesarean and would be conducive to maternal and infant safety.


Introduction
The clinical work of obstetrics involves high-risk patients and often occurs rapidly.Emergency cesarean section is one of the most critical methods in the treatment of high-risk emergency obstetric cases.The National Institute for Health and Clinical Excellence (NICE) [1] and the American College of Obstetricians and Gynecologists (ACOG) [2] both suggest that for emergency cesarean section, the decision-to-delivery interval (DDI) should not exceed 30 min.The efficient implementation of emergency cesarean section is of great significance to maternal and infant health.
A rapid response team (RRT), proposed by ACOG, comprises a group of professional staff members who accurately and quickly respond to emergency situations [3].RRTs may reduce the harm caused by delays in medical treatment.We drew inspiration from this recommendation and constructed an emergency cesarean section RRT to ensure the immediacy of emergency cesarean delivery.A new study showed that their median DDI was 8 min, which is considerably faster than that recently reported in other tertiary care centers [4-5], and they attributed the success to the fact that their center has a dedicated obstetric anesthesia staff and fellow, and two staff obstetricians in-house at all times [6].However, the construction of an emergency cesarean section RRT is not accomplished overnight, and continuous management and quality improvement should be considered after team formation.
In this study, we built an emergency cesarean section RRT, strengthened team quality management through the "PDCA" cycle working model, and applied this method to the clinical practice of emergency cesarean section, to determine if implementation of the RRT would improve delivery intervals for emergency cesarean.

Study design and participants
The Department of Obstetrics of the First Affiliated Hospital of the University of South China established an RRT in January 2021 and managed it according to the PDCA cycle model.In this study, the medical records and related emergency cesarean section data of a control group without the RRT (June-December 2020) and an experimental group with the RRT (January-June 2021) were retrospectively collected.There were 52 patients in the control group who underwent routine emergency cesarean section and 51 patients in the experimental group who underwent emergency cesarean section with the RRT.
The members of the emergency cesarean section RRT included 1 deputy chief obstetrician, 1 attending obstetrician, 1 resident obstetrician, 1 anesthesiologist, 1 neonatologist, 2 obstetric nurses, 1 itinerant nurse, and 1 instrument nurse.Workers who joined the RRT were not permanent.They could be adjusted according to the actual work situation and contingency plans.However, in the initial stage, we tried our best to include qualified medical staff in the RRT and conducted regular training and assessments to expand the RRT member base.We developed a role card for the emergency cesarean section RRT so that roles could be quickly determined and so that the process could be quickly carried out after personnel replacement (Table 1).
This study was conducted in accordance with the Helsinki Declaration and approved by the Ethics Committee of the First Affiliated Hospital of the University of South China.This was a retrospective study, so the committee did not require written informed consent.Participant information is confidential.

Construction of a flow chart for emergency cesarean sections
This flowchart was strictly followed, both in simulation exercises and in clinical practice, and the implementation process was evaluated at the end of the process according to the flowchart.The detailed standard flow chart of emergency cesarean section is presented in Figure 1.

Construction of a PDCA cycle management model
The PDCA cycle management model included four steps: plan, do, check, and action.Plan: First, summarize the existing core problems according to emergency cesarean section experiences.Then, develop the standard procedure, drill assessment system, and assessment Table 1.Role card for the emergency cesarean section RRT.

Members Duties
Deputy chief obstetrician Initiate the clinical decision of "implementing emergency cesarean section to terminate the pregnancy," contact the operating room, neonatologist, and anesthesiologist, and prepare to wash hands for the surgery.

Attending obstetrician
Inform the family members of the maternal condition, diagnosis and treatment plan and related risks, and inform the family members to sign the written materials prepared by the resident (informed consent/blood transfusion consent/self-payment notification, etc.) Resident obstetrician Establish and print the preoperation conversation template (informed consent/blood transfusion consent/self-payment notice, etc.), provide medical advice, record the time of all aspects of the emergency cesarean section, improve the case record (course record, preoperative discussion and preoperative summary) when necessary, promote completion of the examination report, wash hands, disinfect the patient's skin around the operating area, and take the operating stage after taking the patient to the operating room.

Anesthesiologist
After receiving the emergency cesarean section notice, visit the patient in the delivery room, understand the patient's general situation and condition, develop anesthesia and risk response plans, inform the family members of the anesthesia risk and have them sign the form, and provide the anesthetic.

Neonatologist
After receiving the emergency cesarean section notice, go to the operating room to understand the maternal condition and prenatal examination, and make preparations for the rescue of the newborn.Obstetric Nurse A Observe the patient's condition, immediately notify the doctor and call other nurses to help, follow the resident doctor's advice, and assist in the initial treatment of the patient.Obstetric Nurse B Perform preoperative preparations, assist in transporting the mother and medication to the operating room, place an indwelling catheter and prepare the mother's skin.Itinerant Nurse C Prepare surgical instruments, call the neonatologist, use iodophor to disinfect the skin if necessary, and take care of the newborn.Instrument Nurse D Check the instruments and prepare for the operation.

Evaluation indexes
The job of recording the various time points is basically done by the Resident obstetrician, as his role will continue throughout the emergency cesarean section procedure.And we also prepared a record book to record the key intervals, so that we can query and analyze the data.In our work, the person responsible for the decision to perform the surgery is the deputy chief obstetrician, who communicates to other team members that we need to prepare for a cesarean section at once.In other words, the deputy chief obstetrician's order is the "decision time." The evaluation indexes were as follows: (1) Key intervals(minutes) including the decision-to-operating room interval (DOI), operating room-to-incision interval (O-I), decision-to-incision interval (DII), incision-todelivery interval (I-D), and decision-to-delivery interval (DDI); (2) the DDI pass rate, where the qualification for Class I surgery (applied for conditions that directly threaten the lives of the mother and child) was a DDI of � 30 min, and that for Class II surgery (applied for high-risk conditions that do not immediately threaten the lives of the mother and child) was a DDI of � 75 min; (3) Newborn Apgar scores and mortality, where the Apgar score included scores for respiration, heart rate, muscle tone, skin color, and reflexes, and each score ranged from 0-2 points, with a total of 10 points; (4) Maternal complications, including postpartum hemorrhage, puerperal infection and poor incision healing; and (5) DOI, DII and DDI over management time trends in the experimental group.

Statistical Analysis
The data collected were entered into a Microsoft Excel spreadsheet and statistically analyzed (IBM SPSS version 26; International Business Machine, Armonk, NY, United States of America).The sample size was calculated by using PASS software.
The power for the primary endpoint DDI was calculated based on two-sided t-test with a significance level of 5%.The power regarding the coprimary dichotomous endpoint proportion of subjects with a DDI � 30 min or 75 min(DDI pass rate) was calculated based on a two-sided chi-square test.The sample size of the case group and the control group was proposed to be equal.According to previous reports [7], with a sample size of 39 subjects for each group, the trial will have more than 90% power to detect a difference between the experimental group and the control group in the proportion of subjects with a DDI � 30 min or 75 min, given that the probabilities of achieving this DDI pass rate are 60% for the control group and 90% for the experimental group.In combination with the practical situation of our hospital, the final sample size was 51 patients in the experimental group and 52 in the control group.
Count data are expressed as n (%) and were statistically analyzed with the chi-square test or Fisher's exact probability.Measurement data are expressed as (x ± s) and were statistically analyzed with a t-test or nonparametric tests.p < 0.05 was considered statistically significant.

Results
The median gestational weeks in the experimental group was 38(37-39) weeks, with a median age of 28(26-32) years.The median gestational weeks in the control group was 38(37-39) weeks, with a median age of 28(26-31) years.There was no significant difference in gestational weeks, age, BMI, the number of births, or the number of pregnancies between the two groups (p > 0.05) (Table 2.).
The DDI, DII, DOI, and O-I of the experimental group were shorter than those of the control group, and the differences were significant (p < 0.05).Although the I-D was also shorter, the difference was not significant (p ¼ 0.103) (Table 3.).The median DDI, DII, and DOI values were significantly different between the two groups (p � 0.001) (Figure 2.).In the experimental group, 49 cases passed the DDI, with a pass rate of 96.10%.While the control group passed in 32 cases, the pass rate was only 61.50%.The DDI pass rate in the experimental group was higher than that in the control group, and the difference was highly significant (p < 0.001).
The 1-min Apgar score of the experimental group was higher than that of the control group (p ¼ 0.036), but there was no significant difference between the experimental and control group scores at 5 min (p ¼ 0.977).There was no significant difference in mortality between the two groups (p ¼ 0.320) (Table 4.).The incidence of maternal complications in the experimental group was lower than that in the control group, but there was no significant difference between the two groups (p > 0.05) (Table 5.).
In both category-1 and category-2 emergency cesarean sections, the key intervals of emergency cesarean section leveled off after approximately 3 to 4 months in the experimental group (Figure 3.).

Discussion
In 2000, Lucas et al. classified cesarean delivery into classes I, II, III and IV [8].Among these, category-1 and category-2 cesarean sections are considered emergency cesarean sections.Category-1 cesarean section is applied mainly for conditions that directly threaten the lives of the mother and child, such as fetal bradycardia, fetal distress, umbilical cord prolapse, placental abruption, and severe maternal blood loss.Category-2  cesarean section is applied for high-risk conditions that do not immediately threaten the lives of the mother and child, such as an abnormal fetal heart rate, fetal distress, vaginal delivery failure, serious pregnancy hypertension (preeclampsia, eclampsia), intrauterine infection, periods of stagnation, and abnormal presentation.In these cases, emergency cesarean section is performed to rapidly terminate the pregnancy, saving the lives of the pregnant woman and fetus, and is a key measure to protect the safety of the mother and child [9].
The key components of emergency cesarean section are urgency, improved speed, and shortened time intervals.Dedicated personnel are an effective way to increase speed.Therefore, the construction of an emergency cesarean section RRT and the provision of training to strengthen the proficiency of the RRT in the process of emergency cesarean section are effective measures to implement emergency cesarean section.The RRT was established in December 2004 and consists of experienced nurses and a small number of experienced physicians.The main responsibilities of the team are to identify changes in a patient's condition as soon as possible and contact the corresponding doctors for effective treatment [10].
In this study, we constructed an RRT specifically for patients requiring emergency cesarean section.An RRT does not replace the responsibilities of other doctors or nurses in patient management.The purpose of the RRT is to shorten the time from the change in condition to the end of the operation by quickly identifying changes in maternal and infant conditions and determining the emergency cesarean section treatment plan.All the preparation work before the operation is carried out efficiently, and the patient is quickly transferred to the operating room.An RRT needs at least nine people, each performing his or her duties.Each member of the team has a clear division of labor and responsibilities and needs to keep their duties in mind.Timely self-improvement of the RRT is    key to building a high-level RRT [11].Regular and simulation training for RRT members is the main measures to improve outcomes [12].
The second step of this study was to train the RRT for emergency cesarean sections by using the "PDCA" cycle model.The PDCA cycle is a quality management model that includes four stages: Plan, Do, Check and Action [13].It is a closed-loop management method for sustainable quality improvement [14][15].In this study, we use regular training instead of the "Do" phase and simulation training instead of the "Check" phase to construct the PDCA cycle.After training the "PDCA" cycle model, we found that this method could significantly shorten the preparation time for emergency cesarean sections and accelerate the delivery of the fetus.Before the RRT was set up, a large amount of time was wasted communicating with the operating room and anesthesiology department, and the waiting time was long.Through this drill involving operating room nurses and the anesthesiology department, academic communication between departments can be strengthened, and the connection between departments can be closer.Therefore, the time to the operating room and the time to start the operation can be greatly reduced.This is similar to international research results [16].
The DDI, DII, DOI and O-I of the experimental group were shorter than those of the control group (p < 0.05), as shown in Table 3 and the medians of DDI, DII, and DOI were significantly different between the two groups (p � 0.001), as shown in Figure 2.This means that the implementation of the RRT would improve delivery intervals for emergency cesarean sections.There was little difference in the I-D scores between the two groups.We considered the process from skin dissection to fetal delivery, mainly based on the skill and cooperation of the obstetrical surgery team.Training for the RRT focused on coordination between care providers, communication between obstetricians and operating room staff, and anesthesiologists, and the acceleration of the transport process.
In developed countries, the proportion of emergency cesarean sections with a DDI � 30 min is approximately 65% [17][18][19], but that in developing countries is only 20% [20][21][22][23].In this study, we increased the DDI pass rate from 61.50% to 96.10% after the RRT was constructed.Interestingly, it may come as a surprise that especially low 1-min Apgar scores led to significant results, while 5-min Apgar scores were less pronounced.This is slightly different from Xu's findings [24] but the same as Liu's findings [25].However, this can be explained by the fact that a 1-min Apgar score is indicative of the intrauterine condition of the fetus, while a 5-min Apgar score is more indicative of the efficacy of resuscitation after birth.Clinically, neonatologists are often called to the operating room before emergency cesarean section begins to better prepare for the resuscitation of neonates with asphyxia.Another study has shown that the earlier a high-risk fetus delivered, the less time it will spend in the uterine environment, and the better the feto-maternal outcomes will be after birth [26][27].This is exactly what our results showed.
Although there did not seem to be a significant difference in maternal outcomes, we believe that shortening the duration of the operation must be beneficial to women, not only because the damage caused by prenatal bleeding is proportional to the duration of the bleeding but also because the termination of pregnancy can relieve some maternal symptoms, such as eclampsia and preeclampsia.Perhaps if we expand the sample size, we can observe a difference.
As shown in Figure 3 we can see that the key intervals in the early stage of training were shortened more significantly, and the speed of the team gradually stabilized in the middle and late stages, indicating that the team's skill proficiency had basically stabilized after 3-4 months.Due to time constraints, the RRT members of the experimental group were fixed.However, in actual clinical work, team members must be continuously updated.The addition of new members is bound to require more time to become proficient.Through the step-by-step process of the dynamic cycle, we gradually improved medical quality and, ultimately, achieved the ideal goal.It takes at least 3-4 months for new members to become proficient in the entire process of performing emergency cesarean sections.
The present study had several limitations.This study was a retrospective, single-center study with a small sample size.The roles and responsibilities of the RRT should be adjusted according to the actual medical resources of each hospital.We are unable to control for secular trends or unmeasured confounders in this study design.We can hardly avoid the limitations of data collection around decision time.This needs to be further observed in multicenter studies.Perhaps we can build RRTs for other emergencies to see if they have the same effect under PDCA cycle management.
In summary, we innovatively constructed an RRT specifically for emergency cesarean section and provided training with the PDCA cycle management model.The construction of an obstetric RRT can reduce the operation time, increase the speed of treatment, improve rescue efficiency, and reduce the neonatal asphyxia rate.Therefore, in the face of emergency situations, the implementation of an emergency cesarean section RRT can improve delivery intervals for emergency cesarean and would be conducive to maternal and infant safety.Further studies in more centers and with larger samples are needed to confirm the results.
rating table for emergency cesarean sections.Do: RRT members must be proficient in the standard procedures for emergency cesarean delivery.Trainings and drills are organized every two weeks.The training content should be presented in strict accordance with the standard procedures.Check: Medical department leaders participate in the supervision of team members, analyze the problems causing delayed operation time, and negotiate to solve the problems.The time trial method is used to evaluate RRT members.Action: In clinical work, the RRT should implement an emergency cesarean section procedure according to the standard procedure.At the end of each emergency cesarean section, members work together to summarize their experiences and correct deficiencies.Problems and improvement targets are incorporated into the next PDCA cycle model to continuously and systematically monitor emergency cesarean delivery.
� indicates a significant difference among groups with p < 0.05.

Figure 3 .
Figure 3. DOI, DII and DDI over management time trends in the experimental group.A: the DOI of category-1 emergency cesarean section; B: the DII of category-1 emergency cesarean section; C: the DDI of category-1 emergency cesarean section; D: the DOI of category-2 emergency cesarean section; E: the DII of category-2 emergency cesarean section; F: the DDI of category-2 emergency cesarean section.DOI: decision-to-operating room interval; DII: decision-to-incision interval; DDI: decision-to-delivery interval.

Table 2 .
Comparison of the general data between the two groups.

Table 3 .
Comparison of the key intervals between the two groups.

Table 4 .
Comparison of newborn Apgar scores and mortality between the two groups.

Table 5 .
Comparison of maternal complications between the two groups.