Obstetrics poses one of the greatest liability risks in healthcare. There are strategies proven to work in improving patient safety and reducing exposure. Communication and simulation are among the most important issues.
• Physicians, nurses, and other team members should train together.
• Prepare for high-risk events such as obstetrical hemorrhage.
• Simulation drills should be learning opportunities, not tests.
OB/GYN always is a challenge for improving patient safety and avoiding malpractice exposure, but there are strategies that work. As always, communication is a key factor, along with staffing the appropriate clinical professionals when needed.
Communication improves with daily safety briefings or huddles, says Lynda Tyer-Viola, PhD, RNC, FAAN, assistant vice president of OB/GYN and inpatient women’s services at Texas Children’s Pavilion for Women in Houston, which delivers 6,000 babies a year. She also is an assistant clinical professor in the Department of Obstetrics and Gynecology at Baylor College of Medicine in Houston. Teams at the Pavilion for Women huddle four times a day on the inpatient service and once a day as a system, looking at factors like staffing, any facility issues, patient numbers, high-risk patients, and what they call the “watchers list.”
“This is the list where we include patients that might concern someone. The watchers list is those patients whom you believe, not clinically but from a gut feeling or your own personal experience and from knowing the patient’s family, might need more attention from clinicians,” she says. “They might need their care escalated, and we need to be ready.”
The teams also talk about “safety scoops” in the huddles. A safety scoop is any deviation from what the clinicians expected to happen in a particular situation; not a clinical turn, but rather an irregularity in the expected process. An example would be a physician not arriving in a timely manner to care for a patient, requiring a change in plans or calling on another doctor.
Some facilities are finding that hospitalists can improve outcomes for babies and mothers by providing consistent care throughout a hospital stay, but Tyer-Viola says her hospital has found the most success with a nuanced approach. The hospitalist program is aimed at improving safety, she explains, and that does not mean turning over all inpatient care of a patient.
“Each and every one of our mothers has an OB/GYN that is intended to deliver her baby, and our hospitalists are not intended to deliver other doctors’ babies unless there is an emergency and the doctor can’t be there, or if the doctor is busy delivering another baby in another room,” she says. “Our hospitalist program is about quality and safety, not about making the physicians’ lives easier by delivering babies so they don’t have to be there at 2 a.m.”
Focus on Deadly Hemorrhage
The Pavilion for Women also focuses on obstetrical hemorrhage, an uncommon but extremely dangerous condition that can kill the mother during or after delivery. Although clinicians rarely see this threat, they must be ready to respond quickly and effectively when it happens, Tyer-Viola says. Ensuring readiness is a challenge, so the Pavilion for Women uses an evidence-based guideline and a cloud-based education program that must be completed by every provider, resident, midwife, and nurse.
That training is coupled with simulation, using the hospital’s simulation center, an operating room, or on a nursing unit. Training in the different locations is important because the clinicians must see how their response times, and the ability to respond most effectively, can differ depending on whether all necessary team members and equipment are present.
All members of an interdisciplinary team are present for the simulations. A key component of the education is quantifying blood loss. This is more difficult in obstetrics than with many other patients, Tyer-Viola points out, for several reasons. The first reason is that obstetrical patients have more blood.
“They can lose a lot of blood, but not respond in the same way you would expect from another patient. They can lose an amount that would make other patients pass out, but the obstetrical patient keeps talking to you,” she says. “If you wait for their vital signs to drop, they’ve lost more blood than you think and you have a very sick patient at that point. No matter how experienced and expert your clinician is, they can’t accurately estimate how much blood has been lost.”
That means the volume of blood lost must be carefully measured with OB patients and the amount frequently called out during delivery, she says.
The hospital also drills its rapid response team in different locations throughout the hospital, including the use of a massive transfusion protocol (MTP). The MTP is more commonly used in trauma, but the Pavilion for Women uses it to prevent women from losing so much blood that they can die. For an MTP call, the hospital can rapidly deploy six nurses, a respiratory therapist, a pharmacist, a house supervisor, an intensive care physician, and two anesthesiologists.
The Pavilion for Women’s focus on obstetrical hemorrhage and MTP has made it a magnet for women with conditions such as placenta accreta that can lead to life-threatening bleeding.
“Most professionals see this once or twice in their careers. We did 36 last year,” Tyer-Viola says. “Women come here from all over the country if they have this, because they want to be at a place where we do it all the time and have perfected our response.”
Intensive Care Always Available
The hospital also can provide intensive care to both mother and child, which Tyer-Viola says is a significant contributor to patient safety. The Pavilion for Women is a freestanding facility dedicated to women and children and did not have ready access to intensive care, but research has shown that the best place for a high-risk mother to deliver is at a facility that can provide continuing care for the child.
The hospital is able to perform high-risk deliveries without any need to transfer the child or mother. A delivery suite was converted for intensive care, but still provides the birth experience that is important to most parents. An intensive care physician is present at the hospital 24/7.
“In their contract, it says they’re actually not allowed to leave the building,” she says. “They ask if they can go across the street to round at St. Luke’s and they could be right back here in a few minutes. Our answer is no, you have to be present in this building for your entire shift.”
The intensive care doctors are expensive for the hospital because they do not see many patients, typically billing for a total of about 200 patient days a year. But the Pavilion for Women considers their full-time presence important enough to absorb the cost, she says. The same goes for staffing with experienced, intensive care labor and delivery nurses.
“Having well-trained ICU labor and delivery nurses is very important. When one leaves, we have to replace them right away. We can’t say we’re not delivering that many babies this month, so we can wait,” she says. “It is a special cadre of nurses that have to be trained in intensive care and also in all our systems. Just like with the intensive care physicians, we need these specially trained people in the hospital right now, all the time.”
Communication among team members is a leading factor in obstetrical claims, says Pamela Willis, RN, JD, a regional patient safety risk manager at The Doctors Company, a Napa, CA-based professional liability insurer. She has 14 years of experience as a labor and delivery nurse, including serving as a travel nurse in five states.
The Doctors Company studied closed obstetrical claims and found that a top allegation was a delay in treatment of fetal distress, she notes, which is related to how clinicians in the hospital communicated with those outside. (The closed claim study is available online at: http://bit.ly/2ACd0mW.)
“I do not believe the delay of treatment for fetal distress is caused by someone not wanting to come to the hospital. I believe it boils down to a communication issue,” Willis says. “That is about a nurse at the bedside being able to communicate effectively with a physician on the outside.”
Willis advises hospitals to provide fetal monitor training for nurses and physicians together. That rarely happens, she says. Nurses are required to refresh their training periodically but do so only with other nurses, and physicians are similarly on their own.
“You have two sets of professionals learning something in their own silos,” she says. “But you’re expecting them to communicate the most important and urgent information in the language they learned, which is not necessarily the language the other party learned. Everyone kind of knows what a category 1 strip means versus a category 2 strip, but there’s still some gray area there.”
Hashing out the small questions and understanding what each means with certain statements and questions can immensely improve communication, Willis says. This does not require any wholesale change in policy or procedures, but just getting people face to face so the nurse can explain, “Oh, I wouldn’t call you for this level of concern. But if I call you for this, I’m very concerned about your patient.”
Willis advises mutual reviews of fetal monitoring strips by physicians and nurses. When a doctor arrives for a delivery, the team can take five minutes afterward to review those strips and any other strips they had seen recently that were of interest.
“It’s sort of an impromptu effort to communicate a little better. The nurses say they found this particular part interesting and the doctor might tell them something about that one and point out something else they could learn from,” Willis says. “It goes a long way toward everyone being on the same page about what those strips mean and what kind of interventions they might signal, but it also is just one more way they improve their ability to talk to one another and get a clear message across.”
Another top allegation in obstetrical claims is the improper performance of vaginal delivery, Willis notes. In the closed claims study, almost half of these claims involved shoulder dystocia — another high severity, low frequency event. The best way to address it to use more simulation drills, Willis says.
But clinicians often dislike simulation drills because they see drills as a test, she says. They see the drill not as an opportunity to learn or improve, but as something that could expose their weaknesses and harm them in the workplace.
“I’d like to see simulation drills move more toward what they’re meant to be, an education tool. Not a test, but a way to choreograph that emergency,” Willis says. “We need to be careful not to say at the end, ‘How did everyone do? Did everyone pass the test?’ We need to say, ‘How did our team do? What could we do better? How could we position our supplies and medications better? What do we need access to?’”
The simulation must be repeated often, Willis notes, to ingrain the processes and highlight any shortcomings. It also is important for nurses and physicians to run the simulations together rather than each doing their own, she says.
“The best part of simulation comes when you can get the providers on the unit and finding the time to do the simulation with the nurses. The benefits are just incredible,” she says. “It gives the providers a great benefit, rather than the doctor just being there to make it more realistic for the nurses. They learn how to communicate what they need and how to best work with these nurses who want to do their best for the patient, the same as the physician does.”
The biggest challenge for these efforts is finding the time for simulations or other education efforts, Willis says. That is mostly because people think of them as big, formal events that require a lot of planning and coordination. They don’t have to be, she says.
“You have to look for the opportunities to work these into your day-to-day operations, to make the best use of those few minutes you can find here and there. It doesn’t have to be a big deal where you get out your million-dollar simulation baby,” she says. “Throw a pillow in a bag, call it a baby, and take a few minutes to run through a shoulder dystocia drill and see what you might learn from it. Run through what you can do in those few minutes and do it often, so it all becomes second nature.”
Documentation of shoulder dystocia should be a part of that simulation, Wills says. A shoulder dystocia documentation template can help nurses properly document the maneuvers performed by the doctor in real time, she says. Just as one person in a code blue always is the recorder, there should be a designated dystocia recorder.
“The form should be readily available in all labor and delivery rooms so that one person in the team can easily document in real time all the details of what maneuvers were performed, when exactly they were done, who was in the room, and what happened,” she says. “This is not always documented well and the facts are difficult to reconstruct later when there is a malpractice case. This also requires good communication, with the doctor aware that someone is documenting and calling out the maneuvers clearly as they happen, so it should be part of the drill.”
- Lynda Tyer-Viola, PhD, RNC, FAAN, Assistant Vice President, OB/GYN and Inpatient Women’s Services, Texas Children’s Pavilion for Women, Houston. Email: firstname.lastname@example.org.
- Pamela Willis, RN, JD, Regional Patient Safety Risk Manager, The Doctors Company, Napa, CA. Email: email@example.com.