Perinatal Safety: Moving to Zero Harm

1. Perinatal Safety: Moving to Zero Harm

2. Allen Perinatal Team Dr. Jeffrey Crandall Executive Sponsor Opens doors, improves patient outcomes, and acts as liaison between perinatal team and Allen Board.

3. Lori Murphy-Stokes RN MA Director Maternal-Child Services Team Leader Directs team meetings, coordinates resources, keeps team focused on Charter.

4. Theresa Pagel RN OB Nurse Manager Coordinates improvement activities with staff and providers.

5. Dr. Publio Ortiz Physician Champion Liaison between team and providers. Assists evidence based practice changes.

7. Dr. Michelle Graham Lori Hanson CNM.

8. Karen Storey RN OB QI Data analysis, report writer. Sarah Eiklenborg BSN Marilyn Owusu RN

9. Milda Mullesch RN Director of Case Management Improvement Advisor

10. Our story starts in September 2006. IHS joined the IHI initiative for improving patient care through evidence based practice. We began with the White Paper for Pitocin induction and augmentation bundles. At that time we also wanted to know what our baseline for perinatal harm was, so we could document improvement. We began using the Perinatal trigger tool.

11. Pitocin Induction Bundle • Gestational age > 39 weeks. • Reassuring Fetal Status. • Vaginal Exam. • Hyperstimulation (renamed tachysystole) recognized and treated appropriately or no hyperstimulation of labor present.

12. Pitocin Augmentation Bundle • Estimated Fetal Weight Documented • Reassuring fetal status • Vaginal Exam prior to starting pitocin • Hyperstimulation (renamed tachysystole) recognized and treated appropriately or no hyperstimulation of labor present

13. 5 charts each week for Induction and 5 charts each week for Augmentation abstracted for the bundle elements. The results were shared with the IHS perinatal team. The IHS perinatal team met monthly on phone conferences. This is where ideas, questions, successes, failures, problems, and barriers were discussed. New ideas put foreword for consideration and trial.

14. Pitocin Induction and Augmentation Bundles2007

15. Pitocin Induction and Augmentation Bundles2008

16. Pitocin Induction and Augmentation Bundles2009

17. Pitocin Induction and Augmentation Bundles2010

18. Pitocin Induction and Augmentation Bundles 2006-2010 Changed from Composite to All/None Score

19. Hourly Documentation of Pitocin Dosage2009

20. Hourly Documentation of Pitocin2010

21. Provider Vacuum Documentation Bundle 2009

22. Provider Vacuum Documentation Bundle 2010

23. Culture of Safety The perinatal teams surveyed staff and providers regarding the culture of safety on the OB unit. Allen’s results were: 2006 4.43 2008 4.49 2009 4.66 5 maximum score achievable.

24. Perinatal Trigger Tool Elements • Apgar at < 7 @ 5 minutes of life. • Admission to NICU and > 24 hours. • Maternal/Neonatal Transport. • Terbutaline administration. • Naloxone administration. • Infant Serum Glucose < 50. • 3rd or 4th degree laceration. • Prolonged decelerations • Blood Transfusion. • Platelet count < 50,000. • Abrupt Medication stop. (eg. Suntocinon)

25. Hypotension/Lethargy (OD on Mag SO4) • Transfer to a higher level of care, including ICU in house. • Unplanned return to surgery. • Estimated blood loss > 1500ml. • Specialty consult. • Administration of Oxytocic agents post-delivery. • Instrumental delivery. • Administration of general anesthetic for delivery. • Cord gases < 7.1. • Gestational Diabetes. • Other. 20 random charts reviewed per month. Triggers don’t necessarily mean an event happened. Must look for level of harm.

26. Perinatal Trigger Tool 2 3 19 7 12 1 11 13 4 5 14 15 18 8 9 17 6 10 16

27. Perinatal Trigger tool consists of the following Interventions: Perinatal Trigger tool consists of the following triggers:

28. 7. -Ephedrine audit done and shared with Anesthesia. 8 - Ephedrine audit done and shared with Anesthesia. 9 - Iowa Perinatal Team visit. 10- Version 2 of induction of labor form and C/Sections implemented. Providers education done. 11- Pitocin bundle fallouts and perinatal team progress shared with providers at OB Committee meeting. 12- Perinatal team progress shared at OB Committee meeting. 13- Ephedrine audit results shared with Anesthesia.

29. 14 -Vacuum bundle elements discussed with OB Committee need to come to agreement of Allen Providers standard documentation for operative deliveries. 15- Iowa Perinatal Team visit. 16- Ephedrine audit requested by anesthesia and results shared. 17- Documentation elements of vacuum bundle agreed upon by providers. Start abstraction of 100% vacuum assisted deliveries for compliance. 18- Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts. 19 – Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts.

30. Lessons Learned: • It is essential to have Executive involvement. Without this your team will struggle to make progress. • You need the right mix of team members. If team members can’t or won’t work together no progress is made.

31. Physician champion needs to be someone committed to the process and willing to go to peers to ask the tough questions, to demand the tough answers. • You need Cheerleaders on the staff. Representation from the front line staff is essential for momentum building and getting the staff excited about changes and buying in to Scientifically proven safety measures.

32. Celebrate the successes no matter how big or small. This keeps the momentum going and staff excited about continuing to bring ideas of improvement. • Think about the changes you are trying to make. Do they affect other disciplines? Should you add someone from that discipline to your team as a consultant?

33. Publish your data! Let everyone know how they are doing. • Give THANKS to the staff, providers, ancillary staff and the patients. Teamwork from all creates the atmosphere we want to work in. We all want the best outcome for every patient every time.