Transcript Slide 1

Zero Birth Injury Initiative
Phillip N. Rauk, MD
Associate Professor, Division of Maternal-Fetal Medicine, Department of
Obstetrics, Gynecology, and Women’s Health, University of Minnesota
Medical School
and
Medical Director of the Birthplace at UMMC-Fairview Hospital
Objectives
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Basic safety improvement strategies
Definition of birth trauma
Brief story from Ascension Health
Bundle science and IHI obstetrics bundles
Impact of shoulder dystocia
Where are we at Fairview?
Why are we doing this?
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Overall goal of the initiative is to reduce birth injury
UMMC birth injury rate 2007 – 0.03%
Birth injury is devastating to all involved
“Right thing to do”
Improve patient safety
Improve perinatal outcomes
Reduce medical and nursing errors
Preventable Perinatal Harm and
Obstetrical Liability
• Failure to recognize fetal distress/non-reassuring fetal
status
• Failure to effect a timely cesarean section
• Failure to properly resuscitate a depressed baby
• Inappropriate use of oxytocin/misoprostol
• Inappropriate use of vacuum/forceps
• Failure to manage shoulder dystocia
Characteristics of a Successful Safety
Change Initiative
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High functioning team rather than expert individuals
Shared mental models
Situational awareness
Common language
Policies and order sets support these initiative
Strategy to create Highly Reliable Teams
within a culture of organizational learning
In Situ™
Simulation
Experiential learning
& application, test for gaps
In the “real world”
Just Culture™
Principles of risk,
Accountability,
Behavioral choices,
Drift, and use of
Coaching after errors
High
Reliability
Stan Davis, MD, FACOG & Kristi K Miller RN, MS
TeamSTEPPS™
Define the team,
Curriculum Training
& implementation of
Action Plans
“ME-YOU-US”
Adverse Outcome Index Measure and
Weighting Score
Index Measure
Maternal Death
Intrapartum and Neonatal Death
Uterine Rupture
Maternal Admission to ICU
Score
750
400
100
65
Birth Trauma
60
Return to OR/L&D
Admission to NICU
APGAR <7
Blood Transfusions
3rd and 4th degree perineal laceration
40
35
25
20
5
Birth Trauma as defined for the AOI Measure
•In-born infants only and diagnosis of
•767.0 Subdural and Cerebral Hemorrhage (due to trauma or
to intrapartum anoxia or hypoxia)
•767.11 Epicranial subaponeurotic hemorrhage (massive)
•767.3 Injuries to skeleton (excludes clavicle)
•767.4 Injury to spine and spinal cord
•767.5 Facial nerve Injury
•767.6 Injury to brachial plexus*
•767.7 Other cranial and peripheral nerve injuries
* Not used in AHRQ PSI 17 measure for Birth Trauma Infant
AHRQ Patient Safety Indicator (PSI) 17
- Birth Trauma
• Numerator
– Discharges among cases meeting the inclusion and exclusion rules
for the denominator with ICD-9-CM code for birth trauma in any
diagnosis field
•Exclude infants
•With any diagnosis code of pre-term infant (denoting birth weight
of
less than 2,000 grams)
•With any diagnosis code of osteogenesis imperfecta (756.51)
•With any diagnosis code of injury to brachial plexus (767.6)
Birth Trauma as defined by the AHRQ PSI 17
Birth Trauma Infant
• 767.0 Subdural and Cerebral Hemorrhage (due to trauma
or to intrapartum anoxia or hypoxia)
• 767.11 Epicranial subaponeurotic hemorrhage (massive)
• 767.3 Injuries to skeleton (excludes clavicle)
• 767.4 Injury to spine and spinal cord
• 767.5 Facial Nerve Injury
• 767.7 Other cranial and peripheral nerve injuries
• 767.8 Other specified birth trauma*
*Not used in AOI Birth Trauma Measure
Story at Ascension Health
• Three hospital sites were selected for
implementation of:
– Standardized order sets specific to augmentation
and induction of labor
– Complete adherence to a IHI induction,
augmentation and operative delivery bundles
– Best practices sharing across all disciplines
– Effective communication strategies using SBAR
and culture change
Story at Ascension Health
• From February 2004 to June 2006
– Bundle compliance achieved the goal of 95%
compliance
– Elective inductions before 39 weeks fell to zero
– Operative delivery rate fell from 7.4% to 4.8%
– Birth trauma rate fell from 0.2% to 0.03%
– Primary cesarean rate remained unchanged at
22.5%
0
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
Oct-06
Sep-06
Aug-06
Jul-06
Jun-06
May-06
Apr-06
Mar-06
Feb-06
Jan-06
System Birth Trauma Rate per 1,000 Live Births
Ascension Health Birth Trauma
3.5
3
2.5
2
1.5
1
0.5
Quality Care in Obstetrics
Addressing Harm Using Bundles
• The Bundle Science
– Individual components supported by evidence
based medicine/professional guidelines
– Required to be performed for every patient,
every time
– Bundle compliance measured by fulfilling all
parts of the bundle
– Focus on system
Bundle Science
• A bundle is a group of evidence-based
interventions related to a disease or care
process that, when executed together, result
in better outcomes than when implemented
individually.
• All components of the bundle must be met to
achieve the desired better outcome
The Oxytocin Bundles
Elective Induction Bundle
 Gestational Age > 39
weeks
 Reassuring Fetal Status
 Pelvic Exam prior to the
start of Oxytocin
 Recognition and
management of
Hyperstimulation
Augmentation Bundle
 Documentation of
Estimated Fetal Weight
 Reassuring Fetal Status
 Pelvic Exam prior to the
start of Oxytocin
 Recognition and
management of
Hyperstimulation
No Elective Inductions at < 39 weeks
No Elective Late-Preterm Infants
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RDS
TTN
Pulmonary infection
Unspecified respiratory
failure
Recurrent apnea
Temperature instability
Jaundice that delays
discharge
Bilirubin induced brain injury
• Hypoglycemia
• Rehospitalization for
any cause
• Rehospitalization for
neonatal dehydration
• Death
• Feeding difficulties
• Long term behavioral
problems
(Pediatrics, September 2006. 118:1207)
Vacuum Bundle
 Alternative labor strategies considered
 Prepared patient
 Informed consent discussed and documented
 High probability of success
 EFW, fetal position and station known
 Maximum application time and number of pop-offs
predetermined
 Exit strategy available
 Cesarean and resuscitation team available
Vacuum Delivery
• Incidence of operative vaginal delivery is
10 – 15%
• Compared with SVD (SVD vs Vacuum)
– Rate of Death is 1/5000 vs 1/3333
– Rate of IVH is 1/1900 vs 1/860
– Rate of all injury is 1/216 vs 1/122
• Includes nerve injury, seizure, CNS depression, mechanical
ventilation
• Vacuum and Forceps rate of death is 1/1666 and rate
of IVH is 1/280.
ACOG 2000
Pop-Offs
• “Pop-offs” are defined as a sudden complete
detachment of the vacuum from the head with a
rapid loss of pressure from the green zone to
zero pressure.
• The number of “pop-offs” correlates with birth
trauma, ranging from abrasions to subgaleal
hemorrhage
• Generally > 3 increases the risk for birth injury
Maximum Pulls
• A pull is defined as use of traction during each
contraction not the number of pulls within each
contraction.
• There is no clear definition of the maximum pulls that
should be attempted before the procedure is
abandoned.
• Most experts feel up to 3-4 pulls is appropriate if
progression in descent is noted with each subsequent
pull.
• Failure to abandon the procedure when progress has
not occurred is associated with an increase in birth
trauma
Application Time
• There is limited data on application time
• Longer application times are associated with an
increased risk for failure and for neonatal morbidities
• Most experts believe that consistent with other
guidelines in the use of vacuum (i.e maximum pulls and
progress) that 10 – 20 minutes is appropriate and that
failure of any descent after 10 minutes predicts a high
rate of failure
Other Considerations
• Poor technique also effects maternal and
neonatal morbidity and mortality
– Improper application both with respect to placement
on the head and station/position
– Lack of training and credentials to perform the
procedure
– Use of a rocking motion or rotation
– Inattention to number of “pop-offs” and pulls
Shoulder Dystocia Facts And
Strategies
• Most often unpredictable; 0.2 – 3.0% of deliveries
• Most brachial plexus injuries will resolve within a year but
you can’t be sure in advance which one’s will.
• Standard of care is to perform correctly when it is
encountered. (In Situ Simulations)
• When there are risk factors, it is probably prudent to inform
the parents and discuss options. It is also reasonable and
acceptable to make a recommendation based on your
knowledge and experience.
• Get credit for meeting the standard with appropriate
documentation
• Shift to the “management of bad results” mode of care
when injury occurs.
What Does ACOG Say?
November, 2002. The following recommendations are based on limited or
inconsistent scientific evidence:
• Shoulder Dystocia cannot be predicted or prevented because accurate
methods for identifying which fetuses will experience this complication do
not exist.
• Elective induction of labor or elective cesarean delivery for all women
suspected of carrying a fetus with macrosomia is not appropriate.
What Does ACOG Say?
November, 2002. The following recommendations are based primarily on
consensus and expert opinion:
• In patients with a history of shoulder dystocia, EFW, gestational age,
maternal glucose intolerance, and the severity of the prior neonatal injury
should be evaluated and the risks and benefits of cesarean delivery
discussed with the patient.
• Planned cesarean delivery to prevent shoulder dystocia may be considered
for suspected fetal macrosomia with estimated fetal weights exceeding
5,000 grams in women without diabetes and 4,500 grams in women with
diabetes.
• There is no evidence that any one maneuver is superior to another in
releasing an impacted shoulder or reducing the chance of injury. However,
performance of the McRoberts maneuver is a reasonable initial approach.
Are We There Yet?
• Induction and Augmentation Bundles
– Everyone knows about it but still not at 100%
– Problems with EFW
• Operative Vaginal Delivery Bundle
– >70% compliance but not integrated into system
practice yet.
• We do have a 70% reduction in birth trauma
and 30% reduction in AOI at UMMC-Riverside
Acknowledgements
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Becky Gams, R.N., M.S., A.P.N.L., University of Minnesota Medical Center, Fairview
Phillip Rauk, M.D., University of Minnesota Medical Center, Fairview
Samantha Sommerness, R.N., M.S.N., C.N.M., A.P.N.L., Fairview Southdale Hospital
Ann Page, R.N., M.S.N., C.N.M. , University of Minnesota Medical Center, Fairview
Charlie Hirt, M.D., Fairview Southdale Hospital
Kristi Miller, R.N., M.S., Fairview Hospitals, Patient Safety
Stan Davis, M.D., Fairview Hospitals, Patient Safety
Carol Clark, R.N., M.S.N., C.N.P., Fairview Ridges Hospital
Suzin Cho, M.D., Fairview Ridges Hospital
Cass Dennison, R.N., B.S.H.A., Fairview Lakes Medical Center
Ralph Magnusson, M.D., Fairview Lakes Medical Center
Jan Gilmore, R.N.C, M.S,H.A., Fairview Red Wing Medical Center
William Saul, M.D., Fairview Red Wing Medical Center
Char Dekraker, R.N., I.B.C.L.C., Fairview Northland Medical Center
Kathy Abrahamson, M.D., Fairview Northland Medical Center
Tom George, M.D., University of Minnesota Medical Center, Fairview
Ted Thompson M.D., University of Minnesota Medical Center, Fairview
Michelle O’Brien, M.D., University of Minnesota Medical Center, Fairview