Published online November 1, 2006
PEDIATRICS Vol. 118 Supplement November 2006, pp. S153-S158 (doi:10.1542/peds.2006-0913M)
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ARTICLE


Implementation and Case-Study Results of Potentially Better Practices for Collaboration Between Obstetrics and Neonatology to Achieve Improved Perinatal Outcomes

Mara Zabari, RN, MPA-HAa, Gautham Suresh, MDb, Mark Tomlinson, MDa, Justin P. Lavin, Jr, MDc, Kristine Larison, RNa, Louis Halamek, MDd and Janice A. Schriefer, DrPHe

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
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The objective of this study was to make improvements in communication and collaboration between neonatal and obstetric specialties. Five NICUs from the Vermont Oxford Network's Evidence-Based Quality Improvement Collaborative in Neonatal and Perinatal Medicine tested potentially better practices that overlap obstetric and NICU care.

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: VON—Vermont Oxford Network • DHMC—Dartmouth Hitchcock Medical Center • PBP—potentially better practice • IRB—institutional 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 mother–infant 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
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
As part of the Vermont Oxford Network (VON) Neonatal Intensive Care Quality Improvement Collaborative 2002, teams from 5 hospitals joined together to form an exploratory group called Wee Deliver. These hospitals included Akron Children's Hospital and its partners, Akron General Medical Center and Summa Health System; Children's Hospitals and Clinics and its partner, the United Hospital Birth Center (St Paul, MN); Dartmouth Hitchcock Medical Center, Children's Hospital at Dartmouth (DHMC; Lebanon, NH); Providence St Vincent Medical Center; and Rockford Memorial Hospital (Rockford, IL).

Hospital teams consisted of 7 to 19 members with representatives from neonatology and obstetrics/maternal–fetal 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:

  1. Care of the pregnant woman who is at risk for delivering at the margin of viability (ie, 22–26 weeks' gestation) and of infants who are born in this gestational range
  2. Communication between obstetric and neonatology professionals in relation to the antenatal management of high-risk pregnancies
  3. Intrapartum communication and management of high-risk deliveries
  4. Measurement of maternal and neonatal outcomes
  5. Design of organizational structures and processes that facilitate obstetric–neonatal collaboration

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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  		TABLE 1 Measurement of Team Performance and Communication Skills in Delivery Room Crisis Simulation

 
Centers incorporated as many of the visual, auditory, and tactile cues that are found in a real delivery room as possible, using real working medical equipment (an obstetric patient bed and gurney, intravenous infusion supplies, drapes, imitation blood, fetal heart rate monitor, radiant warmer, and neonatal resuscitation equipment) and maternal and neonatal mannequins. Additional staff played the role of the patient's family members.

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
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The following results were used to obtain baseline measures of process performance in a quality improvement collaborative. They are not intended to represent research and do not have statistical testing that often is performed in research projects.

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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  		TABLE 2 Delivery at the Margins of Viability: Parent Satisfaction Survey 2004 (n = 37)

 
The area that showed the most room for improvement was in providing written information about what parents should expect with a delivery before 26 weeks. This measure provided centers more incentive to provide parents hard copies of the guidelines.

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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  		TABLE 3 Mean Days From First Admission to Delivery at 4 Centers in VON Obstetric–Perinatal Group, January to June 2004

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Each participating institution made practice changes to the treatment of patients who present at the margin of viability, perinatal data collection, and the team performance in high-risk deliveries. The actual implementation of the PBPs varied somewhat at each center on the basis of the perceived local needs. All 5 centers created improvements through traditional routes such as e-mails, poster displays, newsletters, meeting discussions, and celebrations related to implementation.

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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  		TABLE 4 PBP Implementation Matrix

 
A number of lessons were learned in the implementation process. In developing guidelines for the treatment of mothers and infants who present at the edge of viability, it is important to understand staff opinions to standardize practice. Each center must develop its own customized guidelines for its institution. The guideline example in Table 5 is simply an example and not a guideline recommended by VON.


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  		TABLE 5 Example of a Guideline for Obstetric and Neonatal Care of Women and Infants Who Present at Extremely Early Gestations

 
Overall, the experience of the group was that simulation-based training is a controlled method to teach skills such as leadership, communication, and decision-making that are required in highly complex environments. One of the most critical aspects of simulation-based training is the debriefing that follows the simulated crisis. Instructors must have a thorough understanding of and appreciation for the tenets of adult learning and the principles of effective, constructive debriefing. Trainees in simulation-based programs need to feel supported by instructors who facilitate constructive discussion of what went well and what did not go well. Trainees need to know that their performance during simulation will be confidential and protected from unauthorized use or display.

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
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
This quality improvement collaborative resulted in the development of PBPs that are directed at improving collaboration between obstetrics and neonatology to achieve improved perinatal outcomes. The PBPs were communicated widely throughout the collaborative by circulation of a resource kit and presentations at network meetings. Internal assessments, review of the literature, and benchmarking from other industries such as aviation contributed new ideas for PBPs. The collaborative process offered the opportunity for small cycle changes and shared experiences across centers. Each center moved at a different pace and in various ways, but the collaborative process allows teams across the United States to share PBPs and learn from each other.


   FOOTNOTES
 
Accepted Jul 18, 2006.

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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 METHODS
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  7. Halamek LP, Kaegi DM, Gaba DM, et al. Time for a new paradigm in pediatric medical education: teaching neonatal resuscitation in a simulated delivery room environment. Pediatrics. 2000;106(4) . Available at: www.pediatrics.org/cgi/content/full/106/4/e45
  8. Gordon JA. Bringing good teaching cases "to life": a simulator-based medical education service. Acad Med. 2004;79 :23 –27[CrossRef][ISI][Medline]
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics



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