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Perinatal Safety: Moving to Zero Harm

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Allen Perinatal Improvement Team - PowerPoint PPT Presentation


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Perinatal Safety: Moving to Zero Harm. Allen Perinatal Team. Dr. Jeffrey Crandall Executive Sponsor Opens doors, improves patient outcomes, and acts as liaison between perinatal team and Allen Board. . Lori Murphy-Stokes RN MA Director Maternal-Child Services Team Leader

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slide1
Perinatal Safety:

Moving to Zero Harm

allen perinatal team
Allen Perinatal Team

Dr. Jeffrey Crandall

Executive Sponsor

Opens doors, improves patient outcomes, and acts as liaison between perinatal team and Allen Board.

slide3
Lori Murphy-Stokes RN MA

Director Maternal-Child Services

Team Leader

Directs team meetings, coordinates resources, keeps team focused on Charter.

slide4
Theresa Pagel RN

OB Nurse Manager

Coordinates improvement activities with staff and providers.

slide5
Dr. Publio Ortiz

Physician Champion

Liaison between team and providers. Assists evidence based practice changes.

slide7
Dr. Michelle Graham

Lori Hanson CNM.

slide8
Karen Storey RN OB QI

Data analysis, report writer.

Sarah Eiklenborg BSN

Marilyn Owusu RN

slide9
Milda Mullesch RN

Director of Case Management

Improvement Advisor

slide10
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.

pitocin induction bundle
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.
pitocin augmentation bundle
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
slide13
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.

pitocin induction and augmentation bundles 2006 2010
Pitocin Induction and Augmentation Bundles 2006-2010

Changed from Composite to All/None Score

culture of safety
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.

perinatal trigger tool elements
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)
slide25
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.

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Perinatal Trigger Tool

2

3

19

7

12

1

11

13

4

5

14

15

18

8

9

17

6

10

16

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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.

slide29

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.

lessons learned
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.
slide31
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.
slide32
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?
slide33

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.
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