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Maternal and fetal morbidity are ongoing concerns, and hospitals are using an array of evidence-based strategies to improve quality of care, from simple process changes to high-tech virtual reality simulations of obstetric emergencies.
Hospital leaders are under increased pressure to improve patient care in maternal and fetal medicine now in part because of government and public responses to mortality data, says Michael R. Foley, MD, professor and chair of the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine in Phoenix, and chairman of obstetrics and gynecology at Banner - University Medical Center Phoenix. U.S. maternal mortality data from the CDC show room for improvement when compared to other industrialized countries, though there are factors that explain some of the metrics, including the increasing age of pregnant women, Foley says.
“There also is the excellent cardiac care that babies now receive. Whereas in recent years they might not have survived to the reproductive age group, they now have complex cardiac surgeries as neonates and reach the age of having babies themselves,” Foley says. “That brings an increased risk to the pregnancy and increases infant mortality, so a lot of hospitals are recognizing this and looking at what they can do to address infant mortality with more resources and the development of new programs.”
The first step, Foley says, is to determine where the hospital currently stands with quality metrics and mortality, identifying potential targets for improvement. Then hospital leaders must be recruited and given a sense of urgency on the issue, he says.
“Develop a vision of where you want to go and then empower these leaders to implement the right programs in their units,” Foley says. “As they begin to see small wins and improvements, you have to encourage them to make those changes stick and take on additional goals. That’s how you change the culture.”
Maternal and fetal care is one of the most popular quality initiatives among hospitals today, says Diane Doherty, senior vice president of Chubb Healthcare in New York City. Many of the efforts focus on communication and teamwork.
Hospitals are looking to improve the process of communication among clinicians, and also the transfer of information, she says. Two of the most popular strategies are Situation, Background, Assessment, Recommendation (SBAR) and TeamStepps. (More information about SBAR is available online at: http://bit.ly/2iZNwMg, and information on TeamStepps is available at: http://bit.ly/2p0Ysd2.)
“A strategy that has been quite successful is for hospitals to conduct team huddles at least once a day, when the team gets together to review the patient list for half an hour. It’s a short meeting that lets people talk face to face about their patients and any challenges that might arise,” she says.
“Huddles increase situational awareness among the team, and that means not just nurses. The huddle should include team members from obstetrics, anesthesia, neonatology, and anyone else involved in caring for mothers and neonatal patients,” says Doherty.
A hospital’s adverse event reporting system is crucial to improving maternal and fetal care, Doherty notes. Near misses should always be reported and debriefed so that lessons can be learned, she says.
Foley advises aligning the four Ps of OB/GYN safety: People, Place, Programs, and Practice. For people, Foley notes that hospitals are utilizing hospitalists or laborists who can provide consistency in the coverage of emergencies and triage, and the implementation of guidelines and protocols.
This professional is in the OB unit continuously to interact with internal medicine, maternal/fetal medicine, anesthesia, and the ICU, and to look at tracings and possibly intervene with the early deterioration of a patient — key interactions that typically require conveying information to a doctor over the phone, Foley says.
Place is addressed by creating an OB triage, which functions as an ED for OB patients and a 24-hour staffed medical ICU. The OB triage facilitates more oversight and monitoring of mothers and babies, Foley says.
“You have a professional there in the OB triage who can look at that tracing immediately, rather than having a physician in the ED try to figure out what’s going on or waiting until you can reach a doctor at home,” Foley says.
Programs come into play as many hospitals are adopting bundles for OB emergencies and checklists for high-risk issues such as postpartum hemorrhage, hypertension, shoulder dystocia, amniotic fluid embolism, and perimortem cesarean section, Foley notes.
“Making them checklists, as opposed to just guidelines, is a real success measure. We found that with advanced cardiac life support years ago, when we used to have guidelines but now most of those have evolved to checklists and protocols,” Foley says. “A guideline can have too much room for interpretation.”
Hospitals also are creating OB virtual ICUs, which are multidisciplinary teams that care for patients in the most appropriate resourced area of the hospital.
An expectant mother who has hypertension, heart disease, or septic shock may not be cared for in the labor and delivery unit, but rather in a location that is best equipped and staffed for rapidly responding to any deterioration in that patient’s condition, Foley says.
“We’ve now delivered more toward delivering the baby and caring for the mother in those units, rather than trying to create a brick-and-mortar unit that can be all things for all patients,” Foley says. “We can move all the equipment we need for delivering the baby into that cardiac care room and set up a bassinet for monitoring the newborn, for instance, rather than taking the patient away from the location that is best for addressing that critical illness. This has also made a world of difference in fostering camaraderie and communication around critically ill pregnant patients.”
OB rapid response teams also are growing in popularity, Foley says, along with OB Code Blue.
“A rapid response team brings together a number of highly trained professionals for a critical patient situation, but that does not always include people who are trained in maternal and fetal care,” Foley explains. “An OB rapid response team or an OB Code Blue team brings the right people to care for the mother and baby no matter where they are in the hospital.”
Hospitals also use Code Stork to bring the right professionals to a maternal or neonatal emergency. Foley also strongly recommends drills and simulation practice for fellows, residents, nurses, and others.
“Being able to work together and care for the manikin on a computer, right on the floor with the same team that would care for a patient, is invaluable in helping team communication,” Foley says. “It helps you look for breakdowns in teamwork that can be noted before they affect a patient’s care, and addressed properly.”
Foley’s hospital also employs virtual reality experiential training in postpartum hemorrhage and perimortem cesarean section. Clinicians don Oculus virtual reality goggles to view educational videos that place them in the middle of a room watching a well-oiled team care for an obstetrical emergency. “They can watch how the drugs are used, the timing, how different team members interact and communicate, all with a bird’s-eye view as this happens around them,” Foley says.
“Our new millennials love this because it’s a new educational modality for them. They hate the old ‘sage on a stage’ model where somebody teaches them something and they have to go read a chapter,” adds Foley.
The hospital also has a fetal monitoring strip certification program based on the program offered by the Society of Maternal and Fetal Medicine.
The interpretation of maternal and fetal monitoring tracings is a dominant factor in patient safety and can drive the course of care, Foley notes, and disputes over how a tracing should have been interpreted are the foundation of many malpractice lawsuits.
Nurses and physicians take the same certification course so that they all communicate about monitoring strips in the same way, use the same standards and protocols, and hopefully make the same judgment calls.
The University of Arizona College of Medicine has instituted those strategies along with quality programs to measure outcomes on metrics such as postpartum hemorrhage and ICU admissions.
The labor and delivery area uses its own quality program and quality scorecard, and it uses outside scores such as a state mortality review, Foley says. “Having these outside reviews and checks are always good for any hospital, no matter how good your internal measures are,” he says.
The challenges with these quality improvement strategies often involve financing, Foley notes. Hospitals can find it difficult to finance the hiring of hospitalists who will be present at all times, for instance. The University of Arizona College of Medicine justified those costs, in part, by balancing them against the potential costs of two or three severe malpractice cases per year resulting from poor OB care, along with the emotional and life costs of injured patients.
The risk management department funds the strip monitoring certification program because the potential savings from lawsuits outweigh the costs.
“It almost always comes down to a cost/benefit analysis. Everyone wants the best quality, but the reality is that people want the best value, too — the best quality at the lowest cost,” Foley says. “Finding out what that is in an arena like maternal and fetal care can be tricky. We ended up funding some of these projects, like the filming for the virtual reality training, by holding seminars for clinicians from around the country and the money we made on those was used to pay for some of these things that otherwise would be hard to fund through our regular budget process.”