Perinatal Safety:Perinatal Safety:

Moving to Zero Moving to Zero HarmHarm

Allen Perinatal TeamAllen Perinatal Team

Dr. Jeffrey CrandallDr. Jeffrey Crandall

Executive SponsorExecutive Sponsor

Opens doors, improves patient Opens doors, improves patient outcomes, and acts as liaison between outcomes, and acts as liaison between perinatal team and Allen Board. perinatal team and Allen Board.

Lori Murphy-Stokes RN MALori Murphy-Stokes RN MADirector Maternal-Child ServicesDirector Maternal-Child ServicesTeam LeaderTeam Leader

Directs team meetings, coordinates Directs team meetings, coordinates resources, keeps team focused on resources, keeps team focused on Charter.Charter.

Theresa Pagel RNTheresa Pagel RN

OB Nurse ManagerOB Nurse Manager

Coordinates improvement activities Coordinates improvement activities with staff and providers.with staff and providers.

Dr. Publio OrtizDr. Publio Ortiz

Physician ChampionPhysician Champion

Liaison between team and providers. Liaison between team and providers. Assists evidence based practice Assists evidence based practice changes.changes.

Dr. Michelle GrahamDr. Michelle Graham

Lori Hanson CNM.Lori Hanson CNM.

Karen Storey RN OB QIKaren Storey RN OB QI

Data analysis, report writer.Data analysis, report writer.

Sarah Eiklenborg BSNSarah Eiklenborg BSN

Marilyn Owusu RNMarilyn Owusu RN

Milda Mullesch RNMilda Mullesch RN

Director of Case ManagementDirector of Case Management

Improvement AdvisorImprovement Advisor

Our story starts in September Our story starts in September 2006. IHS joined the IHI initiative 2006. IHS joined the IHI initiative for improving patient care for improving patient care through evidence based practice. through evidence based practice.

We began with the White Paper for We began with the White Paper for Pitocin induction and Pitocin induction and augmentation bundles. At that augmentation bundles. At that time we also wanted to know what time we also wanted to know what our baseline for perinatal harm our baseline for perinatal harm was, so we could document was, so we could document improvement. We began using the improvement. We began using the Perinatal trigger tool.Perinatal trigger tool.

Pitocin Induction BundlePitocin Induction Bundle

• Gestational age > 39 weeks.Gestational age > 39 weeks.

• Reassuring Fetal Status.Reassuring Fetal Status.

• Vaginal Exam.Vaginal Exam.

• Hyperstimulation (renamed Hyperstimulation (renamed tachysystole) recognized and treated tachysystole) recognized and treated appropriately or no hyperstimulation appropriately or no hyperstimulation of labor present.of labor present.

Pitocin Augmentation Pitocin Augmentation BundleBundle

• Estimated Fetal Weight DocumentedEstimated Fetal Weight Documented

• Reassuring fetal statusReassuring fetal status

• Vaginal Exam prior to starting pitocinVaginal Exam prior to starting pitocin

• Hyperstimulation (renamed Hyperstimulation (renamed tachysystole) recognized and treated tachysystole) recognized and treated appropriately or no hyperstimulation appropriately or no hyperstimulation of labor presentof labor present

5 charts each week for Induction and 5 5 charts each week for Induction and 5 charts each week for Augmentation charts each week for Augmentation abstracted for the bundle elements.abstracted for the bundle elements.

The results were shared with the IHS The results were shared with the IHS perinatal team.perinatal team.

The IHS perinatal team met monthly The IHS perinatal team met monthly on phone conferences. This is where on phone conferences. This is where ideas, questions, successes, failures, ideas, questions, successes, failures, problems, and barriers were problems, and barriers were discussed. New ideas put foreword discussed. New ideas put foreword for consideration and trial.for consideration and trial.

Pitocin Induction and Pitocin Induction and Augmentation BundlesAugmentation Bundles

20072007

70

80

90

100Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Jun-07

Jul-07

Aug-07

Sep-07

Oct-07

Nov-07

Dec-07

Composit Induction Bundle

Composit Augmentation bundle

Pitocin Induction and Augmentation Pitocin Induction and Augmentation BundlesBundles

20082008

80

85

90

95

100Jan-08

Feb-08

Mar-08

Apr-08

May-08

Jun-08

Jul-08

Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

All or None Induction Bundle

All or None Augmentation Bundle

Pitocin Induction and Augmentation Pitocin Induction and Augmentation BundlesBundles

20092009

85

90

95

100Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

All or None Induction Bundle

All or None Augmentation Bundle

Pitocin Induction and Augmentation Pitocin Induction and Augmentation BundlesBundles

20102010

90

95

100Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10

Jul-10

Aug-10

Sep-10

Oct-10

Nov-10

Dec-10

All or None Pitocin Induction Bundle

All or None Pitocin Augmentation Bundle

Pitocin Induction and Augmentation Pitocin Induction and Augmentation Bundles 2006-2010Bundles 2006-2010

70

75

80

85

90

95

100

Dec

-06

Feb

-07

Apr

-07

Jun-

07A

ug-0

7O

ct-0

7D

ec-0

7F

eb-0

8A

pr-0

8Ju

n-08

Aug

-08

Oct

-08

Dec

-08

Feb

-09

Apr

-09

Jun-

09A

ug-0

9O

ct-0

9D

ec-0

9F

eb-1

0

All/None Induction Bundle All/None Augmentation Bundle

Changed from Composite to All/None Score

Hourly Documentation of Pitocin DosageHourly Documentation of Pitocin Dosage20092009

50

60

70

80

90

100

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09

Jul-09

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Percentage of compliance goal

Hourly Hourly DocumentationDocumentation of Pitocin of Pitocin20102010

80

85

90

95Ja

n-10

Feb

-10

Mar

-10

Apr

-10

May

-10

Jun-

10Ju

l-10

Aug

-10

Sep-

10O

ct-1

0N

ov-1

0D

ec-1

0

Hourly documentation of pitocin goal

Provider Vacuum Provider Vacuum Documentation Bundle 2009Documentation Bundle 2009

405060708090

100Ja

n-09

Feb

-09

Mar

-09

Apr

-09

May

-09

Jun-

09Ju

l-09

Aug

-09

Sep-

09O

ct-0

9N

ov-0

9D

ec-0

9

Composit percentage of compliance

All/None percentage of compliance

Provider Vacuum Provider Vacuum Documentation Bundle 2010Documentation Bundle 2010

405060708090

100Ja

n-10

Feb

-10

Mar

-10

Apr

-10

May

-10

Jun-

10Ju

l-10

Aug

-10

Sep-

10O

ct-1

0N

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Composit percentage of compliance

All/None percentage of compliance

Culture of SafetyCulture of Safety

The perinatal teams surveyed staff and The perinatal teams surveyed staff and providers regarding the culture of providers regarding the culture of safety on the OB unit. safety on the OB unit.

Allen’s results were:Allen’s results were:20062006 4.434.4320082008 4.494.4920092009 4.664.66

5 maximum score achievable.5 maximum score achievable.

Perinatal Trigger Tool ElementsPerinatal Trigger Tool Elements1.1. Apgar at < 7 @ 5 minutes of life.Apgar at < 7 @ 5 minutes of life.2.2. Admission to NICU and > 24 hours.Admission to NICU and > 24 hours.3.3. Maternal/Neonatal Transport.Maternal/Neonatal Transport.4.4. Terbutaline administration.Terbutaline administration.5.5. Naloxone administration.Naloxone administration.6.6. Infant Serum Glucose < 50. Infant Serum Glucose < 50. 7.7. 33rdrd or 4 or 4thth degree laceration. degree laceration. 8.8. Prolonged decelerations Prolonged decelerations 9.9. Blood Transfusion.Blood Transfusion.10.10. Platelet count < 50,000.Platelet count < 50,000.11.11. Abrupt Medication stop. (eg. Suntocinon)Abrupt Medication stop. (eg. Suntocinon)

12.12. Hypotension/Lethargy (OD on Mag SO4)Hypotension/Lethargy (OD on Mag SO4)13.13. Transfer to a higher level of care, including ICU in house.Transfer to a higher level of care, including ICU in house.

14.14. Unplanned return to surgery.Unplanned return to surgery.15.15. Estimated blood loss > 1500ml. Estimated blood loss > 1500ml. 16.16. Specialty consult.Specialty consult.17.17. Administration of Oxytocic agents post-delivery.Administration of Oxytocic agents post-delivery.18.18. Instrumental delivery.Instrumental delivery.19.19. Administration of general anesthetic for delivery.Administration of general anesthetic for delivery.20.20. Cord gases < 7.1.Cord gases < 7.1.

21.21. Gestational Diabetes.Gestational Diabetes.22.22. Other.Other.

20 random charts reviewed per month. Triggers don’t necessarily 20 random charts reviewed per month. Triggers don’t necessarily mean an event happened. Must look for level of harm.mean an event happened. Must look for level of harm.

1

54

2

3

7

6

98

10

11 13

14

16

18

12

1517

19

Perinatal Trigger ToolPerinatal Trigger Tool

Perinatal Trigger tool consists of the following triggers:Perinatal Trigger tool consists of the following triggers:1 - Perinatal team begins abstraction of data, meetings, goals

and agenda's discussed.

2 - Perinatal work presented to OB and Peds Committee's and in OB unit meetings. Bundle elements discussed.

3 - Hyperstimulation of labor using pitocin discussed in OB unit meetings.

4 - Version 1 of induction of labor tool developed and implemented with providers.

5 - Ephedrine audit done and shared with Anesthesia Committee.

6 - Hyperstimulation algorithm implemented, shared in OB Committee and unit meetings.

Perinatal Trigger tool consists of the following Perinatal Trigger tool consists of the following Interventions:Interventions:

7. - Ephedrine audit done and shared with Anesthesia.

8 - Ephedrine audit done and shared with Anesthesia.

9 - Iowa Perinatal Team visit.

10- Version 2 of induction of labor form and C/Sections implemented. Providers education done.

11- Pitocin bundle fallouts and perinatal team progress shared with providers at OB Committee meeting.

12- Perinatal team progress shared at OB Committee meeting.

13- Ephedrine audit results shared with Anesthesia.

14 -Vacuum bundle elements discussed with OB Committee need to come to agreement of Allen Providers standard documentation for operative deliveries.

15- Iowa Perinatal Team visit.16- Ephedrine audit requested by anesthesia and results shared.17- Documentation elements of vacuum bundle agreed upon by

providers. Start abstraction of 100% vacuum assisted deliveries for compliance.

18- Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts.

19 – Pitocin bundle fallouts, Vacuum bundle fallouts, and perinatal team progress shared with providers at all OB Committee meetings. Individual providers contacted and informed of specific fallouts.

Lessons Learned:Lessons Learned:• It is essential to have Executive It is essential to have Executive

involvement. Without this your team will involvement. Without this your team will struggle to make progress.struggle to make progress.

• You need the right mix of team members.You need the right mix of team members.

• If team members can’t or won’t work If team members can’t or won’t work together no progress is made.together no progress is made.

• Physician champion needs to be someone Physician champion needs to be someone committed to the process and willing to go to committed to the process and willing to go to peers to ask the tough questions, to demand peers to ask the tough questions, to demand the tough answers.the tough answers.

• You need Cheerleaders on the staff. You need Cheerleaders on the staff. Representation from the front line staff is Representation from the front line staff is essential for momentum building and getting essential for momentum building and getting the staff excited about changes and buying in the staff excited about changes and buying in to Scientifically proven safety measures.to Scientifically proven safety measures.