Jennifer L. Brockmeyer , RN-BSN, MS.Mount Carmel-St. Ann’s

September 13, 2013-Friday

Bridging the Gap

• Effective Communication• Sentinel Event• Event Debriefing/Root

Cause Analysis• Skills Erosion• QI Initiative• Direct Communication• Implementation• Conclusion

Presentation Overview

L & D Nurses identified:

-Lack of Understanding by some EMS units about complications and potentially life threatening events-Lack of timely/adequate communication among EMS/ED/L&D-Assumptions by staff that EMS and ED staff “should know” all the proper information to gather, steps to take, etc….

We Have a Problem

Top Priority-Effective Communication

Joint Commission-2005Communication Failures

Leading cause of preventable patient

injuries & death

Effective Communication is most vulnerable during patient hand off

-SAFE HAND OFFVital to the outcome of the mother and fetus

-potential ineffective & fragmented communication

-established a NATIONAL GOAL to create a safer hand off process

-Communication between EMS and L & D

Agency for Healthcare Research & Quality 2012

HAND OFF-Multiple Indicators• EMS care provided• Pre hospital

communication• Hand off EMS-ED• Evaluation in ED• Hand off ED-L& D• Process leads to

third hand information

STUDY DONE BY CENTERS FOR DISEASE CONTROL, IN UNITED STATES BETWEEN 1991-1997

Leading cause of Maternal Death included:hemorrhage

hypertensive disorder

pulmonary embolism

infection

pre-existing conditions

SENTINEL EVENT ALERT-2010

2009Maternal & Fetal Mortality

RESULT-inadequate assessment-incomplete transmission of information-communication between EMS & receiving medical personnel

Sentinel Event

-identify basic and contributing factors

-underlying performance variations associated with adverse events

( Hsu, 2007)

Identify key points for improvement:-professional discussion

-performance standards

-what happened

-why it happened

-how to sustain strengths

-improve on weaknesses

Event Debriefing Root Cause Analysis

Root Cause Analysis-4 step process

Prepare

IdentifyFactors

CreateIdeas Implement

Process

12

3 4

 

MEETINGS• Director of Emergency Medical Services• Emergency Medical Services Coordinator from the ED• Labor and Delivery Personnel• Emergency Medical Personnel• Emergency Department Personnel

Event Debriefing

Skill Erosion•EMS has infrequent calls for emergencies involving a pregnancy•Low percentage of calls•Subject to knowledge and skill erosion•Lack of physical assessment skills•Inability to recognize acuity level•Inability to communicate pertinent information•RCA CONCLUDED•EMS needs for training in obstetrical emergencies•EMS needs knowledge to determine acuity•Vital patient information

-INITIAL PHASE

-Letter sent to all EMS stations

-Create obstetrical quick reference resource-Create communication tools-Change communication protocols

Quality Improvement Initiative:Address pre hospital assessment & direct communicationPrevent delay in patient treatment & medical intervention

-Positive response from EMS-Re-affirmed skills erosion -Re-affirmed inability to attain acuity level-COLLABORATIVE EFFORTS*Identified issues were addressed*

INITIAL PHASE RESPONSE

-Most common obstetrical emergencies to include: HEMORRHAGE

ABRUPTIO PLACENTAE

PLACENTA PREVIA

PRE-ECLAMPSIA

VAGINAL DELIVERY

-L & D Nurses & EMS personnel developed resource document

QUICK TIPS FOR OBSTETRIC PATIENTS

-SECOND PHASE

-Provide EMS personnel a form

-Capture critical information

-Specific to the pregnant patient

-Developed in likeness of a familiar format

Quality Improvement Initiative:INCOMING OBSTETRIC PATIENT CARE REPORT

SBAR ApproachSituation

BackGround

Assessmentrecommendation

12

3 4

-Using SBARUnderwent final review & refinementFINAL PHASE-Literature review-Details regarding terminology-Printed on pink paper for rapid identification

Incoming Obstetric Patient Report ( IOPR)

-Delay identified related to hospital policy-Traditional communication pathwayNEW POLICIES ESTABLISHED-pregnant patient 16+ weeks gestation-direct to L & D-communication from EMS is directly to L & D

Patient Treatment Delay

Implementation

IOPR & QUICK TIPS PILOT

Meetings to review processRefinement via practice scenariosCare specific to pregnant patient

30 % improvement reported from EMS

Direct transfer via EMS to L & D39 week gestation patient

EMS implemented IOPR & Quick TipsPlacenta previa was identified by EMSL & D prepared for immediate cesarean sectionRESULT OF HEALTHY MOTHER AND CHILD!

TRUE TEST INITIATIVE

Top Priority-Effective Communication

Poor Communication found to be ROOT CAUSE in over80% of preventable deaths

& injuriesCommunication

Imperative!!

In perinatal care, a normal condition has potential to become critical very quickly

• It is VITAL for all medical personnel to be aware

• A woman, whatever her complaints, may be pregnant or may have recently

been pregnant.• OVERALL GOAL• Stability of the mother &

the fetus

CONCLUSION

1. Vital part of healthcare

2. Requires a sender, a message & a receiver

3. Process is complete with understanding of the message

4. Effective communication relies on capability and interpretation of information

5. Communication must be evaluated on a continuing basis

WHEN COMMUNICATION IS DISRUPTED, PATIENTS CAN BE PLACED AT RISK!!

Communication

Agency for Healthcare Research and Quality (2012). Crew resource management and its applications in medicine. January 19, 2012.

Benrubi, G. I. (2010). Handbook of Obstetric and Gynecologic Emergencies. (4th ed.). Wolters Kluwer/ Lippincott Williams & Wilkins, Philadelphia.

Clancy, C. M. (2008). AHRQ commentary. the importance of simulation: Preventing hand-off mistakes. AORN Journal, 88(4), 625-627. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010058400&login.asp&site=ehost-live

Collins, D. E. (2008). Multidisciplinary teamwork approach in labor and delivery and electronic fetal monitoring education: A medical-legal perspective. The Journal of Perinatal & Neonatal Nursing, 22(2), 125-132.

References

Defective handoffs reduced by 52%. (2011). ED Management, 3-4. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010938527&login.asp&site=ehost-live

Kelly, A. E. (2005). Relationships in emergency care: Communication and impact. Topics in Emergency Medicine, 27(3), 192-197. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009029556&login.asp&site=ehost-live

Lingafelter, M., Brockmeyer, J., Foley, P (2012). Bridging the Gap: Building a Collaborative Relationship between Labor and Delivery and Emergency Medical System Response Units. JOGGN, 2011, S93.

McEwen, M. and Wills, E. (2011). Theoretical basis for nursing (3rd ed.) Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins.

References

Sexton, J. B., Holzmueller, C. G., Pronovost, P. J., Thomas, E. J., McFerran, S., Nunes, J., . . . Fox, H. E. (2006). Variation in caregiver perceptions of teamwork climate in labor and delivery units. Journal of Perinatology, 26(8), 463-470.

The Joint Commission (2012). National Patient Safety Goals Effective January 1, 2012.

The Joint Commission: “Preventing maternal death.”Sentinel Event Alert, Issue 44, January 26, 2010. Retrieved from http://www.jointcommission.org/SentinelEvents/Sentinel EventAlert/sea_44.htm (Accessed September 20, 2011)

Williams, P. M. (2001). Techniques for root cause analysis. Baylor University Medical Center Proceedings, 14(2), 154-157

References

. References