Managing Risk in Perinatal Care

Linda A. Hunter, CNM, EdDRobin Shields, RNC-OB

Disclosures- We have received financial support from

Laerdal to present this topic- We have no contractual relationship with

Laerdal

ObjectivesDiscuss 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 problemsLack of communicationIneffective interdisciplanary cooperation

IOM, 2000

IOM Key RecommendationsEstablish national focus to enhance

knowledge about patient safetyLeadership, research, tools, protocols

Identifying and learning from errors through mandatory reporting effortsEncourage voluntary non-punitive reporting

Raising standards and expectationsCreating safety systems within health care

organizations

Perinatal Safety IssuesNational 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 teamsImproves collaboration and communicationIncreases understanding of differing rolesEnhances professional confidenceAvoids “professional silos”Improves attitudes and morale Improves quality of care

Reduces errors

Teamwork TrainingAviation Industry: Crew Resource

ManagementReplace hierarchal relationships with mutual

decision-making Organize individuals to think/act as a team

Structured Communication “SBAR”SituationBackgroundAssessmentRecommendationsReduces errors

Using Simulation for Team Training

Active interdisciplinary learning environmentIntegrates cognitive, affective, psychomotor

skillsAssesses team management of high risk

scenariosIncreases shared learning, interaction, and

collaboration

Reduces Errors

Importance of DebriefingSafeguard learning experienceConfidentiality agreementsNot part of performance evaluationRules of conduct

Constructive feedbackEvaluate team performanceFollow standards of care

EMTALAEmergency Medical Treatment and Labor

ActAny 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 chaoticSuboptimal locationMinimal patient infoLack of equipmentInexperienced birth

attendantsTraumatizing experience

Factors

Choice

Access

Time

Perinatal RisksMaternal

Shoulder dystocia

Postpartum hemorrhage

Serious lacerationsCervical/vaginalPerineum

3rd/4th degree

FetalFetal distressMeconium

aspirationLow Apgar scoresNeonatal injuryHypothermiaInfection

Maternal and family dissatisfaction

Making a Decision to TransferTo another facility

EMTALA rules applyTo another unit (ie Labor & Delivery)

Bed & provider availability

Judgment of the examining provider

Where is the safest location?

Establishing a ProtocolALL Emergency Departments

Training, simulation & practice drillsALL staff (MDs, APRNs, RNs, Unit secretaries etc)

Having equipment readyInfant warmerPrecipitous birth packs

Specialized documentationBirth summary

Implementing a Work in Progress

Crisis SituationThemes

Lack of Communication Between team Between family

Lack of Team LeadershipLack 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 & DebriefingInadequate 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 careSuspension of Disbelief

Improving ComplianceHigh Risk/Low Frequency event

Reading policy clearly not enoughCreating a visual example -> Educational

VideoTeam Preparation

Multidisciplinary (RNs, CNMs, MDs, support staff)

Intradepartmental (Triage, LDR, NICU)Scenario Creation

Established guidelines in policy

Learning ObjectivesFoster communication between the

teamEnhance communication with the

familyEstablish leadership in a crisis situationStandardize delivery of equipmentProvide efficiency in the delivery of

care

Implementation PlanDVD 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

teamEnhance communication with the

familyEstablish leadership in a crisis situationStandardize delivery of equipmentProvide efficiency in the delivery of

care

Thank You!

Questions?

ReferencesAngelini 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/medicalresources_tiop.html on September 23, 2011

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