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a Department of Perinatology and Neonatal Intensive Care Unit, Providence St Vincent Medical Center, Portland, Oregon
b Neonatal Intensive Care Unit, Medical University of South Carolina, Charleston, South Carolina
c Neonatal Intensive Care Unit and Department of Perinatology, Akron Children's Hospital and Akron General Medical Center and Summa Health System, Akron, Ohio
d Center for Advanced Pediatric Education, Stanford University, Stanford, California
e Vermont Oxford Network, Burlington, Vermont
| ABSTRACT |
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METHODS. One area of practice improvement was the management of the pregnancy at the margin of viability. Another included the use of team training and video simulation to improve team performance during high-risk deliveries using aviation-based communication techniques. Another focus of the collaborative was the creation of a multicenter database to measure combined perinatal and neonatal outcomes.
RESULTS. The principle outcomes are increased patient satisfaction with teamwork between neonatology and obstetric services and improved team response times for emergent deliveries and the increased use of team communication skills during video simulations of high-risk deliveries.
CONCLUSIONS. Implementing these potentially better practices can result in improved communication and collaboration related to perinatal and neonatal care.
Key Words: perinatal collaborative quality improvement crew resource management video simulation team performance
Abbreviations: VONVermont Oxford Network DHMCDartmouth Hitchcock Medical Center PBPpotentially better practice IRBinstitutional review board
Clear communication and effective collaboration between members of the health care team have been identified as key components in any effort that is aimed at health care quality improvement.1 Improving communication and collaboration is a challenge at any level, but the obstacles are magnified when these initiatives cross disciplines such as obstetrics and neonatology.
Medical care of the motherinfant dyad is a continuum that begins in the months before birth, continues through the delivery process, and carries over into the postpartum period. Therefore, the medical specialties of neonatology and obstetrics are uniquely intertwined. Close collaboration between these 2 specialties is essential to promote seamless care across the perinatal continuum and ensure the health of both mother and infant. This article describes how a group of hospitals worked to improve care across this continuum by bringing together medical professionals in obstetrics and neonatology and implementing projects to improve communication across these disciplines.
| METHODS |
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Hospital teams consisted of 7 to 19 members with representatives from neonatology and obstetrics/maternalfetal medicine. Each team was composed of various combinations of physicians, nurse practitioners, midwives, nurses, data collectors, and families. VON faculty facilitated and coordinated the activities throughout the project. Teams met face to face semiannually, by conference call monthly, and continuously via an e-mail discussion list (listserv).
During these discussions, the following potentially better practices (PBPs) were identified:
The teams used literature reviews, expert guidance, brainstorming, internal process analysis, and multivoting methods to derive the PBPs and divide them according to the phases of the delivery process as antenatal, intrapartum, and "other" categories.2 Each center initially performed internal process assessment and described its current practices as they related to each of these PBPs. Each center implemented all 5 PBPs using a customized approach at each institution. Institutional review board (IRB) requirements varied between institutions. IRB approval was obtained when required.
PBP 1: Establish Evidence-Based, Center-Specific Guidelines for the Treatment of Pregnant Mothers and Infants Who Present at the Margin of Viability
This area of focus was identified because in pregnancies that present at the margin of viability, perinatal treatment of pregnant women and infants often is controversial. Decision-making is difficult and frequently varies considerably from provider to provider.3 For example, providers and families often have to make decisions about whether a cesarean section should be performed and whether the infant should be resuscitated and provided intensive care.
Each center implemented the guideline for periviable gestations by building consensus among perinatal and neonatal caregivers. Providers were educated about the survival rates and long-term outcomes for infants using local hospital data, VON data, and information that was obtained from review of the literature.4 They then were surveyed individually to determine their attitudes, perceptions, and opinions regarding clinical management, focusing on resuscitation and neonatal intensive care.5
PBP 2: Create a Documentation System That Reliably Communicates High-Risk Pregnancy Treatment Plans Among All Obstetric and Neonatal Caregivers
Differences in opinions regarding the treatment of patients at the gestational margin of viability and variation in approaches to treatment from caregiver to caregiver and shift to shift were identified as major barriers to the consistency of care for such patients. Each center worked to improve its documentation of treatment plans so that it could be accessed and implemented easily by subsequent providers.6 The documentation included center-specific consult forms, triggers for the providers to outline the specific chosen treatment options, and prompts for regular updates as gestational age advanced.
PBP 3: Implement Processes to Improve Communication, Collaboration, and Performance During High-Risk Deliveries
The increase in obstetric litigation and spiraling malpractice insurance rates make delivery room team performance and error reduction a top priority for any group that is interested in patient safety, including the Joint Commission on Accreditation of Healthcare Organizations.7 The group adopted the principles of crew resource management to the delivery room setting, drawing on the experiences of 2 simulation centers: the Center for Advanced Pediatric Education at Stanford and the Center for Medical Simulation at Harvard, 2 groups with special expertise in simulation-based training in neonatal and obstetric crisis management, respectively.8 Using input from these 2 pioneering centers, the leaders at each of the sites were able to create simulations to enhance delivery room teamwork.9
A pilot study of simulation-based training was conducted between May 2004 and October 2004 (Table 1). Each of the 5 centers performed 1 to 3 simulated delivery room crises each month. A standardized clinical scenario was developed jointly and used at all 5 centers. The simulated crisis consisted of an obstetric patient who presents with a placental abruption necessitating cesarean delivery of the infant. The scenario opens with the initial presentation of the laboring mother with vaginal bleeding and progresses through delivery and resuscitation of the neonate. All members of the delivery room team (obstetricians, obstetric anesthesiologists, labor and delivery nurses, neonatologists, and neonatal nursing) were actively involved in the simulated emergency.10
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The portion of the simulation that involved the delivery of the infant by cesarean section was conducted either in the actual delivery operating room or in a room with a similar layout to the real delivery room. Each simulation was videotaped using various types of video cameras and time-stamped video. Some centers involved their hospital-based audiovisual staff. In some cases, the video cameras were based on tripods to eliminate the need to staff a handheld camera.
Standardized methods of scoring were developed to assess objectively the technical and behavioral skills of both the individual health care professionals and the entire team during the simulated crisis. One of the most critical markers of performance consisted of the time interval between the decision to perform a cesarean section and the delivery of the infant, defined as performing the incision"decision to delivery" interval.11
PBP 4: Use a Perinatal Database That Allows for Evaluation of the Effects of Perinatal Practices on Maternal, Fetal, and Neonatal Outcomes
Representatives from obstetrics and neonatology services from each of the 5 hospitals collaborated to develop and implement a multiinstitutional comparative database that comprises indicators of the character and the quality of perinatal care. Selected descriptive, process, and outcome variables were based on clinical importance and specificity of definitions.12
Standardized definitions were developed for each variable and incorporated into the data-collection sheets.13 A customized electronic database was created for use by all participating institutions. Data were collected on all maternal admissions to the hospital between 20 and 32 weeks of gestation and on delivered infants. Data quality was checked by independent chart review, and the results were presented periodically to participating institutions.14
PBP 5: Design Organizational Structures and Processes That Promote Collaboration Among Obstetric and Neonatal Services
Each center performed an internal assessment of its needs and developed its own approach to formalizing and improving the opportunities for interaction and communication between obstetrics and neonatology. At DHMC, it was discovered that the paging system was not always effective in timely communication of the need for emergency cesarean section. DHMC focused on mechanisms of summoning required personnel from obstetrics, anesthesiology, and neonatology for emergency cesarean sections to improve the timeliness of responses from such providers. Through staff education, they improved the mechanisms of paging the required providers. DHMC and the other centers used simulation-based training to evaluate and improve organizational structures and processes. DHMC focused specifically on simulations of emergency cesarean sections. Studies have noted that although simulation is a promising technique for improving technical, cognitive, and behavioral skills, it is somewhat limited by the extensive start-up capital cost in creation of the simulation program and staff time required.15 All of the centers in this project have found simulation to be a powerful tool for modeling collaboration between obstetrics and neonatology despite the cost and scheduling difficulty of getting staff to participate in the simulations.
| RESULTS |
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PBP 1: Establish Evidence-Based, Center-Specific Guidelines for the Treatment of Pregnant Mothers and Infants Who Present at the Margin of Viability
The use of the guidelines was implemented at 100% of the centers. All staff were educated on the guidelines, and all centers used the same guideline as a starting point for discussion with the patient. All centers used a standard patient satisfaction survey; the results are shown in Table 2.
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PBP 2: Create a Documentation System That Reliably Communicates High-Risk Pregnancy Treatment Plans Among All Obstetric and Neonatal Caregivers
The use of consultation forms increased on average from 72% to 97% for all centers.
PBP 3: Implement Processes to Improve Communication, Collaboration, and Performance During High-Risk Deliveries
The baseline results of team performance and communication skills are presented in Table 1.
PBP 4: Use a Perinatal Database That Allows for Evaluation of the Effects of Perinatal Practices on Maternal, Fetal, and Neonatal Outcomes
An example of 1 analysis is the assessment of the time from admission to delivery by gestational age groups, as seen in Table 3.
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| DISCUSSION |
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The plan-do-study-act cycles varied across the 5 centers. Some of the centers implemented many cycles, whereas others implemented fewer cycles. One of the barriers to implementing the PBPs was the IRB approval process that was associated with the desire to preserve potential research options. Another was the need to educate staff outside the NICU, many of whom were unfamiliar with organized principles of quality improvement. Table 4 shows a complete listing of PBPs that were implemented at each center.
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There is a need to develop additional training scenarios. The new scenarios that are being developed by the group include shoulder dystocia management, eclampsia seizure management, prolonged postpartum bleeding, and prolonged neonatal resuscitation. The centers now are developing these training materials and plan to train 25% of the neonatal and obstetric staff during the next year. Key training materials include examples of simulated emergencies and debriefings, an instructor's manual, a course agenda, and evaluation forms. Standardized clinical outcome measures are being considered, such as unplanned admission to NICU for infants >2500 g or unplanned maternal admissions to the ICU.
Team communication training and video simulation require new equipment and learning techniques compared with the more traditional classroom teaching methods. The recommendations for others who want to pursue similar improvements in their setting include early involvement of supportive administrative leadership.
| CONCLUSIONS |
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| FOOTNOTES |
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Address correspondence to Mara Zabari, RN, MPA-HA, Providence Everett Medical Center, Family Maternity Center, 900 Pacific Ave, Everett, WA 98206-1067. E-mail: mara.zabari{at}providence.org
The authors have indicated they have no financial relationships relevant to this article to disclose.
| REFERENCES |
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This article has been cited by other articles:
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D Acolet Quality of neonatal care and outcome Arch. Dis. Child. Fetal Neonatal Ed., January 1, 2008; 93(1): F69 - F73. [Abstract] [Full Text] [PDF] |
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