Reducing Birth-Related Trauma and Liability Exposure

Lehigh Valley Hospital and Health Network
Allentown, Pennsylvania, USA
The Lehigh Valley Hospital and Health Network team is a participant in IHI’s Learning and Innovation Community on Improving Perinatal Care. 
Anthony Ardire, MD, Senior Vice President for Quality and Care Management
John Collins, MD, Anesthesia
Lorraine Dickey, MD, Neonatology
Amy DePuy, Resident Physician
Karen Gerlach, Quality Liaison
Julia Gogle, Nurse Educator
Karen Groves, Clinical Coordinator
L. Wayne Hess, MD (Chair, June 2005-June 2008)
Thomas Hutchinson, MD, Physician Leader (Chair, beginning June 2008)
Erika Linden, Director, Labor and Delivery
Francine Miranda, Director, OB/GYN Quality and PI
Marion Nihen, Quality Liaison
Gregory Radio, MD, Obstetrician
Robin Ruch, Obstetrical Analyst
Michael Sheinberg, MD, Obstetrician
The many determined nursing, attending obstetrician and resident staff, without whom none of this would be possible.
Original aim:
  • Reduce birth-related trauma by 2 percent within 1 year of project initiation (June 2006)
  • Reduce adverse events by 5 percent within 1 year of project initiation (June 2006)
  • Achieve 100 percent defensive documentation
  • Improve bundle compliance by 50 percent
We added a short-term aim statement (May 2008):
  • Reduce variability along the continuum of care within 3 months
  • Enhance patient safety through the assistance of patients and families within 6 months
  • Birth trauma rate per 1,000 live births
  • Elective Induction Bundle compliance (reduction of elective inductions prior to 39 weeks’ gestation)
  • Augmentation Bundle compliance
  • Adverse Outcome Index (AOI): AOI is a departmental metric also used by a number of US hospitals to demonstrate the results when patient safety initiatives such as crew resource management, are implemented. A measure of potential harm is created by identifying any of the following: maternal death, maternal admission to the ICU, birth trauma, return to the OR, transfusion, third and fourth degree lacerations, newborn death  at < 2,500 grams, admission to the NICU for patients > 2,500 grams, > 24 hours; or > or equal to 37 weeks, Apgar < 7; transfusion. The statistic is a weighted adverse outcome score per case, divided by total deliveries per month.
The team, utilizing a package of changes, was able to improve birth trauma rates, as well as to streamline and increase documentation to reflect an accurate picture of care, thus reducing liability exposure to the organization. Most of the following items were tested and implemented utilizing the Model for Improvement.
  • Created 24-hour OB/Maternal Fetal Medicine (MFM) Hospitalist coverage system.                     
  • Established crew resource management (CRM) training and methods as a means to improve communication along the continuum. Multidisciplinary members included: Neonatal ICU, MFM, OB, Nursing, Anesthesia, Resident and Attending Obstetricians. Rounding occurs at 7am  and 7pm. Spread plan being discussed in Surgical and Medical Divisions.
  • Tested the use of a small bed board, a 15-inch monitor screen at the nursing station displaying active laboring patient’s fetal monitor tracings, and found it to be an effective tool. To further enhance active participation by the entire Crew Team, we moved to a 46-inch flat screen bed board for Crew rounds. We are purchasing an additional 40-inch flat screen bed board to perform Fetal Monitor Strip review for all staff members.
  • Initiated the two challenge rule for all team members. Spread plan for other departments in discussion.
  • Established evidence-based policy and procedure committee. Spread plan: Hospital developed new process to address evidence-based medicine.
  • Developed OB Rapid Response Team.
  • Developed Core C-Section (Surgical) Team.
  • Developed a customized electronic Labor & Delivery Summary, thus capturing regulatory requirements, reducing variability, and improving patient care documentation.   Through the Academic Chronic Care Collaborative (AAMC), instituted changes in care for those afflicted with chronic illnesses (e.g., diabetes and asthma). For example, for diabetic patients, we standardized testing of diabetics, HbA1c, foot evaluations, baseline eye exams, nutritional assessments, development of self-management goals, and standardized laboratory and fetal testing. The result, better outcomes for the high-risk obstetrical patients.
  • Tested and implemented Elective Induction Bundle and Augmentation Bundles. Provided staff education on the importance of following the established criteria: documentation of estimated fetal weights; hyperstimulation, defined as ≥ 6 contractions/10 minutes; fetal reassurance; pelvic exam to include dilitation, effacement, and station in a document for the nursing staff to fill out with each augmentation. A similar form was utilized for elective inductions to include estimated gestational age; hyperstimulation, defined as ≥ 6 contractions/10 minutes; documented fetal reassurance; and pelvic exam to include dilitation, effacement, and station in a document for the nursing staff to fill out with each induction. Forms were utilized as hard stops to eliminate noncompliance.
  • Empowered the correct people, such as the front desk person or the administrative partner who performed the scheduling activities, to stop processes that were not consistent with our mission.                                                                
  • Standardized triage beds, equipment, and physician order sets.             
  • Conducted simulation training sessions.
  • Began communiqué newsletter for improved communication throughout entire department to reflect ongoing changes.
  • Continued the Code Crimson Team. Created previously, this team responds to anticipated and unanticipated emergent obstetrical hemorrhage. It is a multidisciplinary team, compromising Anesthesia, Neonatology, Respiratory Therapy, Maternal Fetal Medicine, Blood Bank, and Nursing. Together with the staff, the team functions to achieve desirable patient outcomes when called to a “Crimson Code.”
Summary of Results / Lessons Learned / Next Steps
Summary of Results:
  • Lehigh Valley Hospital has seen a decrease in birth-related trauma by 2 percent over the past 2 years. The current rate is around 1.88 percent, which includes mainly minor skin injury (for example, minor abrasions and minor bruising). The AHRQ rate remains at or near 0.30 percent. AHRQ birth trauma levels differ from our hospital’s calculated rates because AHRQ data excludes some newborns.
Key Lessons:
  • Challenges to address:
    • It is difficult for Information Services to provide clinical nurse support and resources to keep up with demands of improvement.
    • Record deliveries (>350/month) occurred in the past year, causing even more pressure on staff, with concerns about space, volume and inability to complete documentation and studies.
  • Develop physician and nurse champions. Support of the Chairman and other key clinical leaders led to the success of the program.
  • Create the team environment and ensure responsiveness to any issue that surface.
  • Hold appropriate individuals accountable for their actions, specifically related to not following departmental policy on the Elective Induction and Augmentation Bundles.
  • Empower all staff to perform their job as assigned and to be a patient advocate. Place the hard stops at the front desk and have staff utilize the chain of command if disagreement with any attending physician arises.
  • Begin to identify the areas for improvement that will provide a quick win and increase buy-in from your staff.
  • Presence and perseverance are key to sustaining the gain.
  • Complete small tests of change and spread the momentum to as many members as possible.
  • Communicate, communicate, and communicate!
  • Educate and re-educate on key issues. Build a website location for all important forms and policies in one location for easy access by all.
  • Demonstrate by example and show the department their results. Provide positive reinforcement for a job well done!

Contact Information
Francine Miranda, BSN, RN, FASHRM
OB/GYN Quality and PI
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