Managing Risk in Perinatal Care

Linda A. Hunter, CNM, EdD Robin Shields, RNC-OB

Disclosures

We have received financial support from Laerdal to present this topic We have no contractual relationship with Laerdal

Objectives

     Discuss the medical/legal environment in the perinatal area.

Identify issues specific to perinatal care.

Describe the role of simulation in providing safe, reliable care.

Discuss collaboration with multidisciplanary leadership.

Describe how to plan and implement in-situ simulation

“To Err is Human”

 Factors contributing to errors:  It’s NOT an “individual provider issue”  Convergence of multiple contributing factors    Complexity of many health problems Lack of communication Ineffective interdisciplanary cooperation IOM, 2000

IOM Key Recommendations

    Establish national focus to enhance knowledge about patient safety  Leadership, research, tools, protocols Identifying and learning from errors through mandatory reporting efforts  Encourage voluntary non-punitive reporting Raising standards and expectations Creating safety systems within health care organizations

Perinatal Safety Issues

   National Quality Forum: 

National Voluntary Consensus Standards for Perinatal Care

Joint Commission: 

Perinatal Core Measures Set

March of Dimes: 

Toward improving the outcome of pregnancy III.

Interprofessional & Interdisciplinary Education

       Core competencies include working in teams Improves collaboration and communication Increases understanding of differing roles Enhances professional confidence Avoids “professional silos” Improves attitudes and morale Improves quality of care 

Reduces errors

Teamwork Training

  Aviation Industry: Crew Resource Management   Replace hierarchal relationships with mutual decision-making Organize individuals to think/act as a team Structured Communication “SBAR”     Situation Background Assessment Recommendations

Reduces errors

Using Simulation for Team Training

    Active interdisciplinary learning environment Integrates cognitive, affective, psychomotor skills Assesses team management of high risk scenarios Increases shared learning, interaction, and collaboration

Reduces Errors

Importance of Debriefing

    Safeguard learning experience Confidentiality agreements Not part of performance evaluation Rules of conduct  Constructive feedback   Evaluate team performance Follow standards of care

EMTALA

 Emergency Medical Treatment and Labor Act  Any patient who presents to the ED must have an appropriate medical screening examination to determine if an “emergency medical condition” exists  Pregnant women in active labor  Must be examined   Can they be sent home?

Can they be safely transferred?

Emergency Deliveries

      Often chaotic Suboptimal location Minimal patient info Lack of equipment Inexperienced birth attendants Traumatizing experience

Factors

 Choice  Access  Time

Perinatal Risks

 Maternal    Shoulder dystocia Postpartum hemorrhage Serious lacerations  Cervical/vaginal  Perineum  3 rd /4 th degree  Fetal       Fetal distress Meconium aspiration Low Apgar scores Neonatal injury Hypothermia Infection

Maternal and family dissatisfaction

Making a Decision to Transfer

  To another facility  EMTALA rules apply To another unit (ie Labor & Delivery)    Bed & provider availability Judgment of the examining provider Where is the safest location?

Establishing a Protocol

   

ALL Emergency Departments

Training, simulation & practice drills  ALL staff (MDs, APRNs, RNs, Unit secretaries etc) Having equipment ready   Infant warmer Precipitous birth packs Specialized documentation  Birth summary

Implementing a Work in Progress

Crisis Situation

 Themes     Lack of Communication   Between team Between family Lack of Team Leadership Lack of Efficiency   Role delineation Access to necessary equipment Lack of Patient Satisfaction

Division of Labor Coordination of External and Internal Resources Procurement of Necessary Equipment

• • •

“Code Stork” Test Run

Goals: Assess knowledge and compliance with the policy “Surprise” simulation Realistic scenario • Failed home birth with meconium

Observations & Debriefing

    Inadequate communication     Key questions not asked No SBAR No clear team leader No delegation of roles No coordination  Overhead “Code Stork” not called Limited knowledge on standard of care Suspension of Disbelief

Improving Compliance

    High Risk/Low Frequency event  Reading policy clearly not enough Creating a visual example -> Educational Video Team Preparation   Multidisciplinary (RNs, CNMs, MDs, support staff) Intradepartmental (Triage, LDR, NICU) Scenario Creation  Established guidelines in policy

Learning Objectives

     Foster communication between the team Enhance communication with the family Establish leadership in a crisis situation Standardize delivery of equipment Provide efficiency in the delivery of care

Implementation Plan

 DVD was shown to all triage staff  Managerial Staff monitored educational opportunity  Allowed for Q+A from Staff  Prompted discussion  Over next few weeks, surprise drills were conducted on each shift

• • •

Follow-Up Results

Policy awareness was raised • Staff knew the correct “steps” Some action steps were still inconsistent • Self identified

Staff were much more vested in the debriefing process and open to learning/improving

Import DVD here

Achieving Our Objectives?

     Foster communication between the team Enhance communication with the family Establish leadership in a crisis situation Standardize delivery of equipment Provide efficiency in the delivery of care

Questions?

Thank You!

   

References

Angelini DA. Interdisciplanary and interprofessional education. J Perinat Neonat Nurs. 2011;25:175-9.

Arafeh JM, Hansen SS, Nichols A. Debriefing in simulation-based learning: facilitating a reflective discussion. J Perinat Neonat Nurs. 2010;24:302-9.

Institute of Medicine: To err is human: building a safer health system. National Academy of Sciences,2000; accessed from http://www.nap.edu/catelog/9728.html

on September 23,2011. The Joint Commission. Perinatal core measures set. Oakbrook Terrace, Il. The Joint Commission; 2009.

    National Quality Forum. National Voluntary Consensus

Standards for Perinatal Care 2008: A Consensus

Report. Washington, DC: National Quality Forum: 2008 Simpson, KR. Perinatal safety and quality. J Perinat Neonat Nurs, 2011; 25:103-7.

FAQ on EMTALA. What are the provisions for pregnant women in active labor? April 25, 2011. accessed from www.EMTALA.com/faq.html

on September 23, 2011.

March of Dimes. Toward improving the outcome of pregnancy III. White Plains, NY: March of Dimes Foundation 2010. accessed from http://www.marchofdimes.com/professionals/medicalr esources_tiop.html

on September 23, 2011

 Robinson L. Preparing for precipitous vaginal deliveries in the emergency department. J Emer Nurs, 2009; 35:256-8.