Prenatal initiative yields safety improvements
Prenatal initiative yields safety improvements
Birth traumas reduced, gains in documentation
A prenatal care quality initiative at the North Shore-LIJ Health System in Great Neck, NY, has achieved significant improvement in the 11 adverse outcome measures followed via modification of the Adverse Outcome Index (MAOI), according to a study published in the Journal for Healthcare Quality.1 Within the first year, the researchers reported, the MAOI decreased from 2% to 0.8%.1
In addition, the authors noted significant improvement in the management and documentation of abnormal fetal heart tracings and the documentation of obstetric hemorrhage. They also cited significant improvements in staff perceptions of safety and in patient perceptions of whether staff worked together.
"The Rationale for the initiative came from several directions," says Adiel Fleischer, MD, Chairman of Ob/Gyn at North Shore University Hospital and Long Island Jewish (LIJ) Medical Center, and leader of the initiative. "For one, there was a general realization that we can do things better if we change how we practice, based on statements from IOM and other reports from various specialties, and the impetus from adverse outcomes we had here and reviewed." An analysis of these events, he adds, "Clearly identified areas that could be modified and improved."
The effort, he continues, included obstetrician specialists in maternal fetal medicine, nurses, physician assistants, anesthesiologists, and neonatologists.
"We reviewed a large number of cases in general, and discussed management and clinical care for various types of patients with different complications on a weekly basis," Fleischer says. "Based on that, we identified which practices resulted in the lowest number of complications. We also looked in the literature at what various recommendations were for the management of specific pregnancy complications."
In terms of the complications, he notes, the team looked at where most of the potential problems came from and how to approach them in terms of prevention. "In addition, since we can't always prevent them, we also looked at what could be done to minimize untoward outcomes once the complication was identified," he adds.
Communication is critical
Communication was identified as a key element in potential adverse events, notes Fleischer. "For example, there might be incomplete communication of information provided; it became clear that by having better communication between members of the healthcare team you could greatly improve patient safety and decrease the rate of complications," Fleischer says. "We defined several protocols and methods that are used in order to improve communications — one we use, for example, is the SBAR. We basically had all the people taking care of the patients participate in the Team STEPPS methodology for team training [reported on in 2010 by AHRQ, it emphasizes communication techniques including SBAR] to help ensure the person you were communicating with understood the degree of acuity, and so on."
Another area of concern, also related to communication, was the lack of "escalation" if there was a disagreement in the management of a specific patient or the interpretation of a specific test or finding, such as fetal heart rate tracings. "We noticed that very often if you had a disagreement in general, under the old approach the person with the highest rank — usually the attending — was never questioned," Fleischer says. "We've taken a much more progressive approach; under Team STEPPS, the person who has a concern can voice that concern disregarding that difference in rank. If there was a disagreement, anyone on the floor could escalate the issue to the physician in charge."
Other steps taken
In addition to improvements in communication, concrete changes were made in processes. For example, a standardized approach was introduced for the interpretation of electronic fetal monitoring based on NIH guidelines. "The advantage is that now, when I use a term such as late decelerations, everybody on the team knows what I mean and knows what the implication is," Fleischer says. "In the past, terms might have been used like 'slightly reassuring,' 'OK,' or 'Not so OK.' I'm not sure I would know what you meant if you told me that, but if we all interpret readings and then reach conclusions in the same way you'll know what I mean."
In addition, says Fleischer, certain clinical protocols were adopted. "One of our major concerns is avoidance of iatrogenic prematurity, which is a major public health concern," he notes. This, he explains, involves delivering babies before 39 weeks without a strong medical reason.
"We introduced several protocols, and educated doctors and the entire health care team, and we have specific requirements before a patient can be brought in for induction or a cesarean section," says Fleischer. "We brought the number of elective deliveries before 39 weeks down to zero."
Other evidence-based protocols were introduced, including the following:
- the use of Pitocin augmentation of labor;
- the use of antibiotics and thromboembolics;
- prophylaxis for cesarean;
- the use of magnesium for seizure prophylaxis;
- hemorrhage protocol;
- protocol for induction of labor;
- management of intrapartum fetal heart rate abnormalities;
- obstetrical rapid response team.
Fleischer is very clear on why the initiative was successful. "The main factor was that we changed the way we work and got everyone together in a team approach to improve communication," he says. "We have multidiscipline rounds several times a day, where we discuss the entire number of patients admitted to the clinical floors. If we have a patient admitted with a complication, or if an admitted patient has had a change in status we have a huddle — a meeting of all the individuals and specialties that take care of the patient. Together we decide on the best mode of management; we also underscore the ability to escalate any time a team member sees anything they believe to be unsafe. All of this could be encompassed in the Team STEPPS approach to patient care."
Reference
- Fleischer et al. Comprehensive Perinatal Safety Initiative to Reduce Adverse Obstetric Events. Journal for Healthcare Quality 2011; DOI: 10.1111/j.1945-1474.2011.00134.
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