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IHI Expedition: Preventing Obstetrical Adverse Events Session 2: Executing Oxytocin Bundles Peter Cherouny, MD Deb Bell-Polson, MSN, RNC-OB These presenters have nothing to disclose Today’s Host 2 Kayla DeVincentis, Project Coordinator, has worked at IHI since 2009, starting as an intern in the Event Planning department. Since then, Kayla has contributed to the STAAR Initiative, the IHI Summer Immersion Program, and the IHI Expeditions. Kayla obtained her Bachelor’s in Health Science from Northeastern University and brings her interest in health and wellness to IHI’s Health and Fitness team.

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Page 1: IHI Expedition Preventing Obstetrical Adverse Events ... Expedition... · IHI Expedition: Preventing Obstetrical Adverse Events Session 2: Executing Oxytocin Bundles Peter Cherouny,

IHI Expedition: Preventing Obstetrical Adverse Events

Session 2: Executing Oxytocin Bundles

Peter Cherouny, MD

Deb Bell-Polson, MSN, RNC-OB

These presenters have nothing to disclose

Today’s Host

2

Kayla DeVincentis, Project Coordinator, has

worked at IHI since 2009, starting as an intern in

the Event Planning department. Since then, Kayla

has contributed to the STAAR Initiative, the IHI

Summer Immersion Program, and the IHI

Expeditions. Kayla obtained her Bachelor’s in

Health Science from Northeastern University and

brings her interest in health and wellness to IHI’s

Health and Fitness team.

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3

WebEx Quick Reference

• Welcome to today’s session!

• Please use Chat to “All

Participants” for questions

• For technology issues only,

please Chat to “Host”

• WebEx Technical Support:

866-569-3239

• Dial-in Info: Communicate /

Join Teleconference (in menu)

Raise your hand

Select Chat recipient

Enter Text

When Chatting…

Please send your message to

All Participants …NOT All Attendees

4

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Schedule of Calls

Session 1 – Introduction to Obstetrical Adverse Events

Wednesday, May 30, 1:00 PM – 2:30 PM ET

Session 2 – Structure and Process for System Redesign

Date: Wednesday, June 13, 1:30 PM – 2:30 PM ET

Session 3 – Executing Oxytocin Bundles

Date: Wednesday, June 27, 1:30 PM – 2:30 PM ET

Session 4 – Designing Reliable Processes

Date: Wednesday, July 11, 1:30 PM – 2:30 PM

Session 5 – Using the Perinatal Trigger Tool to Identify System Harm

Date: Wednesday, July 25, 1:30 PM – 2:30 PM

Session 6 – Results Report-out and Advanced Bundles

Date: Wednesday, August 8, 1:30 PM – 2:30 PM5

Faculty

6

Peter Cherouny, MD, Professor of Obstetrics and

Gynecology, University of Vermont College of Medicine,

has strong clinical interests in obstetric health care

quality improvement and is currently serving as Chair of

the Institute for Healthcare Improvement's Perinatal

Improvement Community. He was also the lead author

of the IHI white paper, "Idealized Design of Perinatal

Care." He has been Chair of Quality Assurance and

Improvement and Credentialing for the Women's Health

Care Service of Fletcher Allen Heathcare for the last 15

years. His recent research and work in obstetric quality

improvement is as Chair of the March of Dimes

collaborative, "Improving Prenatal Care in Vermont,"

and as co-investigator of the MedTeams project.

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Faculty

7

Deb Bell-Polson, MSN, RNC-OB, is a Masters

prepared Perinatal Nurse with 22 years of experience.

Most recently has worked as a Clinical Nurse Manager

leading a multidisciplinary team that has had great

success in the IHI Perinatal Community. We had proven

results in changing culture for quality and safety and

achieving 95% compliance on the Elective Induction and

Augmentation bundles as well as the Vacuum Bundle.

Also serves on a regional Quality and Safety Network

guidelines team that is working to set regional standards

for care in the Northern New England region. Is most

recently a part of a state wide Committee to review

cases of Sudden unexplained infant Deaths and work to

prevent them in the future. When not working I keep

busy with my family of three sons and a wonderful

husband.

Objectives

1. Review the concept of the reliable design

strategies

2. Use the perinatal bundles as examples

of reliable design

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Learning Objectives

At the end of the presentation, the participant:

• Will be able to state what reliable design means in a

clinical setting

• Will be able to describe the oxytocin and vacuum

bundles

• Will be able to implement bundles in their work setting

Questions from Session 2

• Is it recommended to have a written consent for oxytocin

or is documentation in progress notes sufficient?

─ Will be covered in today’s call

• Is peer review an acceptable form for the EFM and case

study review referred to in number 3 and 4 on the deep

dive?

─ Quality improvement work is very different than Peer Review.

• Does anyone have a standardized definition they find

useful for tachysystole when using an external monitor?

─ NICHD and ACOG definition

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Why focus on perinatal care?

• Good science exists

• Significant variability in process.

─Care is provider driven rather than standardized.

─This autonomous practice focus contributes to the unreliable delivery of care.

What do we want to do?

• Prevent the preventable

• Defend the unpreventable

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What is Idealized Design of Perinatal Care?

• The development of reliable clinical processes to manage labor and delivery (Perinatal Bundles)

• The use of principles that improve safety

(i.e., preventing, detecting, and mitigating errors)

• The establishment of prepared and activated care teams that communicate effectively with each other and with mothers and families

Reasons for the Reliability Gap In

Healthcare

• Communication─ 84% of sentinel events reported to JCAHO involving

fetal/infant adverse events cited communicationamong care providers as the primary factor

JCAHO. Preventing infant death during delivery. Sentinel event alert No. 30. 2004.

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What is Reliability?

• “Reliability is failure free operation over

time.” David Garvin

Harvard Business School

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What is Reliability?

Reliability

Bringing the right care to the right patient

every time by designing and building the

right system

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Study of “Reliability” in American

Health Care

─Medical records for 6712 patients

─ 439 indicators of clinical quality of care

─ 30 acute and chronic conditions, plus prevention

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

Participants had received 54.9% of scientifically indicated

care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%)

McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-2645 (June 26, 2003)

Study of “Reliability” in American

Health Care

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Reasons for the Reliability Gap In Healthcare

• Current Improvement methods in healthcare are highly dependent on vigilance and hard work

• The focus on benchmarked outcomes tends to exaggerate the reliability within healthcare hence giving both clinicians and leadership a false sense of security

• Permissive clinical autonomy creates and allows wide performance margins

• The use of deliberate designs to achieve articulated reliability goals seldom occurs

Improvement Concepts Associated with

10-1 Performance

Primarily can be described as intent, vigilance, and hard work

• Common equipment, standard order sheets, multiple choice protocols, and written policies/procedures

• Personal check lists

• Feedback of information on compliance

• Suggestions of working harder next time

• Awareness and training

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Improvement Concepts Associated

with 10-2 Performance

• Uses human factors and reliability science to design sophisticated failure prevention, failure identification, and mitigation

Improvement Concepts Associated

with 10-2 Performance Uses human factors and reliability science to design sophisticated

failure prevention, failure identification, and mitigation

• Decision aids and reminders built into the system

• Desired action the default (based on scientific evidence)

• Redundant processes utilized

• Scheduling used in design development

• Habits and patterns known and taken advantage of in the design

• Standardization of process based on clear specification and articulation is the norm

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The Reliability Design Strategy

• Prevent initial failure ─ intent and standardization function

• Identify failure (defects) and mitigate─ Redundancy function

• Measure and then communicate learning from defects─ Redesign function

Mindful Practice

• It is not enough to do your bestyou must know what to do

and then do your best

�W. Edwards Deming

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Why Standardize?

• Contributes to building an infrastructure (who does what, when, where, how and with what)

• Support training and competency testing to sustain the process

• Achieve front line articulation of key processes by staff

• Allows the appropriate application of Evidence Based Medicine consistently

• Feedback about errors and application of learning to design is possible

The Clinical Bundle as Standardization

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What is a Clinical Bundle?

• A group of clinical events that should happen every time

a given process occurs

• Individual elements based on solid science

• Emphasis initially on process rather than outcome

• Based on failure modes

• Eventual endpoint is outcome improvement

What is a Clinical Bundle?

• Bundle example with your life on the line

• Into Thin Air by Jon Krakauer

─Assault on Everest, Spring, 1996

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Assault on Everest SummitHard and Fast Rules

• Acclimatization at altitude

• Work together

• Cannot assist someone on the ascent

• Fixed turn around time

• Acclimatization at altitude

• Work together

• Cannot assist someone on the ascent

• Fixed turn around time

Assault on Everest SummitSummit Bundle

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• Standard acclimatization techniques─# days and at what altitude

• Work together

• Cannot assist someone on the ascent

• Fixed turn around time

Assault on Everest SummitSummit Bundle

• Standard acclimatization techniques

─# days and at what altitude

• Practice team work (between and among

teams)

• Cannot assist someone on the ascent

• Fixed turn around time

Assault on Everest SummitSummit Bundle

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Assault on Everest SummitSummit Bundle

• Standard acclimatization techniques

─# days and at what altitude

• Practice team work (between and among

teams)

• No “short-roping” on the ascent

─No assisting with climbing on the ascent

• Fixed turn around time

Assault on Everest SummitSummit Bundle

• Standard acclimatization techniques─# days and at what altitude

• Practice team work (between and among teams)

• No “short-roping” on the ascent─No assisting with climbing on the ascent

• Turn around time fixed and honored ─(1 PM for most groups)

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Assault on Everest SummitSummit Bundle Compliance

• All teams acclimatized but there was no standard

• Teams refused to cooperate on timing through Hilary’s Step (one person rope)

• Some climbers were assisted on the ascent as it was felt they had to summit on this climb

• Turn around time was set but not honored

─ Last summit was about 5 PM

Assault on Everest SummitResult

• Experienced leader; summits at 3PM

• Less experienced leader; assisted two

climbers up

• Inexperienced leader; split group up with

one climber summiting at 5 PM

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Assault on Everest SummitResult

• Eleven Deaths

• Survivors

─PTSS

─Marital problems

─Work problems

Assault on Everest SummitSummit Bundle

• Standard acclimatization techniques─# days and at what altitude

• Practice team work (between and among teams)

• No “short-roping” on the ascent─No assisting with climbing on the ascent

• Turn around time fixed and honored ─(1 PM for most groups)

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Quality Care in Obstetrics

• Pitocin Bundles as standardization of

care─Developing the Bundles

Quality Care in Obstetrics Birth Trauma

• Causation─Large fetuses

─Operative vaginal deliveries (esp midpelvic & combined)

─Vaginal breech delivery

─ Inappropriate use of pitocin

─Abnormal/excessive traction

─ Inadequate assessment of fetal status

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Quality Care in ObstetricsBirth Trauma

• Prevention─Don’t deliver large fetuses

─Don’t do Operative vaginal deliveries

─Don’t do Vaginal breech delivery

─Don’t use pitocin

─Don’t pull too hard

─ Interpret fetal status perfectly

Quality Care in ObstetricsBirth Trauma and Pitocin

• Causation─Large fetuses

─Operative vaginal deliveries (esp midpelvic & combined)

─Vaginal breech delivery

─ Inappropriate use of pitocin (tachysystole)

─Abnormal/excessive traction

─ Inadequate assessment of fetal status

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Quality Care in ObstetricsBirth Trauma and Pitocin

• Causation─Large fetuses

─Operative vaginal deliveries (esp midpelvic & combined)

─Vaginal breech delivery

─ Inappropriate use of pitocin (tachysystole)

─Abnormal/excessive traction

─ Inadequate assessment of fetal status

Quality Care in ObstetricsBirth Trauma and Pitocin

• Causation─Large fetuses

─Operative vaginal deliveries (esp midpelvic & combined)

─Vaginal breech delivery

─ Inappropriate use of pitocin (tachysystole)

─Abnormal/excessive traction

─ Inadequate assessment of fetal status

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Quality Care in ObstetricsBirth Trauma and Pitocin

• Pitocin is involved in over 50% of the

situations leading to birth trauma

Quality Care in ObstetricsBirth Trauma and Pitocin

• Prevention of Pitocin Related Trauma─ Identify large babies

─Don’t do midpelvic deliveries when macrosomia is suspected

─Limit vaginal breech delivery

─ Identify and respond to tachysystole

─Avoid abnormal/excessive traction

─ Interpret fetal monitor by consensus guidelines

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Quality Care in ObstetricsPitocin Use

• Use Pitocin Safely and Effectively

─Know everything about the drug

─Have established protocols and use them

Quality Care in ObstetricsPitocin Use

Requirements for elective labor induction

�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

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Quality Care in ObstetricsPitocin Use

Requirements for elective labor induction

�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in ObstetricsElective Labor Induction-Requirements

Assessment of gestational age�Confirmation of Term Gestation

�Iatrogenic prematurity is unacceptable and indefensible

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Quality Care in ObstetricsElective Labor Induction-Requirements

Confirmation of Term Gestation

• Fetal heart tones have been documented for 20 weeks

by nonelectronic fetoscope or for 30 weeks by Doppler.

• It has been 36 weeks since a positive serum or urine

human chorionic gonadotropin pregnancy test was

performed by a reliable laboratory.

• An ultrasound measurement at less than 20 weeks

supports gestational age of 39 weeks or greater.

• Amniocentesis and documentation of fetal maturity

ACOG Practice Bulletin #97, August 2008

Quality Care in ObstetricsElective Labor Induction-Requirements

Confirmation of Term Gestation

• An ultrasound measurement at less than 20 weeks

supports gestational age of 39 weeks or greater.

─ Ultrasonography may be considered to confirm

menstrual dates if there is a gestational age

agreement within 1 week by crown–rump

measurements obtained in the first trimester

─ An ultrasound obtained in the second trimester at up

to 20 weeks by multiple biometeric parameters

confirms the gestational age of at least 39 weeks

within 10 days. ACOG Practice Bulletin #97, August 2008

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Quality Care in ObstetricsElective Labor Induction-Requirements

Requirements for elective labor induction�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in ObstetricsElective Labor Induction-Requirements

Monitoring fetal heart rate for reassurance�Reassuring Fetal Status – use a common

language (NICHD)

�Personnel familiar with the effects of uterine

stimulants on the fetus

�Physician capable of performing a cesarean

delivery should be readily available and responds

when asked

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Quality Care in ObstetricsElective Labor Induction-Requirements

Requirements for elective labor induction�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Elective Labor Induction-Requirements

What is Tachysystole� > 5 contractions in 10 minutes

� Contractions persistently lasting greater than 2

minutes

� < 60 seconds baseline tone between contractions

� Tachysystole associated with fetal compromise not

necessary

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Quality Care in Obstetrics

Elective Labor Induction-Requirements

What is Tachysystole

�> 5 contractions in 10 minutes� Contractions persistently lasting greater than 2

minutes

� < 60 seconds baseline tone between contractions

� Tachysystole associated with fetal compromise not

necessary

Quality Care in Obstetrics

Elective Labor Induction-Requirements

Monitoring uterine contractions for

tachysystole

�Personnel familiar with the effects of uterine stimulants

�Monitoring fetal heart rate and uterine contractions is recommended as for any high-risk patient in active labor

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Quality Care in Obstetrics

Elective Labor Induction-Requirements

Requirements for elective labor induction

�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Elective Labor Induction-Requirements

Pelvic assessment

�Cervical evaluation

� Bishop’s Score

�Fetal presentation and size

�Clinical Pelvimetry

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Quality Care in Obstetrics

Elective Labor Induction-Requirements

Requirements for elective labor induction

�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Elective Labor Induction-Requirements

Elective Labor Induction Bundle

�Assessment of gestational age

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

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Quality Care in Obstetrics

Elective Labor Induction-Requirements

Elective Labor Induction Bundle

�Gestational age > 39 weeks

�Monitoring fetal heart rate for reassurance

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Elective Labor Induction-Requirements

Elective Labor Induction Bundle

�Gestational age > 39 weeks

�Category I EFM

�Monitoring uterine contractions for tachysystole

�Pelvic assessment

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Quality Care in Obstetrics

Elective Labor Induction-Requirements

Elective Labor Induction Bundle

�Gestational age > 39 weeks

�Category I EFM

�Absence of tachysystole with increases in pitocin/Response to tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Elective Labor Induction-Requirements

Elective Labor Induction Bundle

�Gestational age > 39 weeks

�Category I EFM

�Absence of tachysystole with increases in pitocin/Response to tachysystole

�Pelvic assessment

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Quality Care in Obstetrics

Augmentation-Requirements

Augmentation Bundle

�Gestational age > 39 weeks

�Category I EFM

�Absence of tachysystole with increases in pitocin/Response to tachysystole

�Pelvic assessment

Quality Care in Obstetrics

Augmentation-Requirements

Augmentation Bundle

�Estimated fetal weight

�Category I EFM

�Absence of tachysystole with increases in pitocin/Response to tachysystole

�Pelvic assessment

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Quality Care in Obstetrics

Augmentation-Requirements

Augmentation Bundle

�Estimated fetal weight

�Category I and some Category II EFM

�Absence of tachysystole with increases in pitocin/Response to tachysystole

�Pelvic Assessment

Reliable Design in Obstetrics

Implementing a Clinical Bundle

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Composite Measures

• Measure each component of the bundles

individually to determine where to focus

your improvement efforts.

• When you reach 95% or greater, only

collect the all or nothing measurement.

Augmentation Composite

Chart

1

Chart

2

Chart

3

Chart

4

Chart

5

Total

EFW yes yes no no yes 3

Reassuring

FHR

yes yes yes yes yes 5

Pelvic Exam yes no no yes yes 3

Tachysystole no no no yes no 1

12/20=

60%

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All or None Measurement

• All-or-none measurement fosters a system

perspective, not parts of the system

• Offers a more sensitive scale for

assessing improvements

Augmentation Bundle

All or None

Chart

1

Chart

2

Chart

3

Chart

4

Chart

5

EFW yes yes no no yes

Reassuring

FHR (not

Category III)

yes yes yes yes yes

Pelvic Exam yes no no yes yes

Tachysystole no no no yes no

TOTAL 0 0 0 0 00%

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<70%

80%

90%

Hospital A

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Your Experience

• Think of a process or service you think is reliable

• How do you know it is reliable?

• What makes it reliable?

Your Experience

• What is the first step or most critical step

in the process?

• Are there steps in the process where…

─ if you asked each person who does that step how they do it, would there be differences?

─ there are no tools for the step or there are several different tools?

─ if the step fails, how people respond is different?

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Discuss your process

Are there steps where….

─people must rely on memory to complete any portion of the step (no reference, tool, etc.)?

─a distraction or interruption during the step would likely lead to failure of the step?

─are there >10 things a person must do at this step?

─a new or untrained person is much more likely to encounter error or failure with the step?

Lessons from Human Factors

• Reliance on memory

• Distractions / interruptions

• Fatigue

• Sleep deprivation

• Shift work

• Lack of training and experience

• Overload

• Psychosocial factors

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Do you know if you do what you say you do…??

For one patient, for one shift,

with one nurse, with one

doctor?

83

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Always ask:

What is the real problem we are

trying to solve?

85

Does your data look like this?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ju

ne

06

Ju

ly 0

6

Au

g 0

6

Se

pt

06

Oc

t 0

6

No

v 0

6

De

c 0

6

Ja

n 0

7

Feb

07

Mar

07

Ap

r 0

7

May

07

Ju

ne

07

Ju

ly 0

7

Au

g 0

7

Oc

t 0

7

No

v 0

7

De

c 0

7

Ja

n 0

8

Feb

08

Ap

r 0

8

May

08

Ju

ne

08

Ju

ly 0

8

Au

g 0

8

Se

pt

08

No

v 0

8

De

c 0

8

Ja

n 0

9

Feb

09

Ap

ril

09

May

09

Ju

ne

09

Ju

ly 0

9

Au

g 0

9

Se

pt

09

Oc

t 0

9

No

v 0

9

Induction Bundle - Gest Age≥39wks

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Or like this?

87

In August, 4 infants were electively

delivered prior to 39 weeks gestation

and were transferred to NICU/SCN.

What are your conversations like?

Test for Reliability

Ask 5 different clinicians the following:

What is the definition of

tachsystole?

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IHI’s Oxytocin Bundles-

References

1. ACOG Practice Bulletin Number 10, 1999 “Induction of Labor”:

2. ACOG Practice Bulletin Number 49, 2003 “Dystocia and Augmentation of Labor”

3. ACOG Practice Bulletin Number 70, 2005 “Intrapartum Fetal Heart Rate Monitoring.

4. ACOG Practice Bulletin Number 97, September 2008, “Fetal Lung Maturity”

Oxytocin Bundle References

5. The 2008 National Institute of Child

Health and Human Development

Workshop Report on Electronic Fetal

Monitoring, VOL. 112, NO. 3,

SEPTEMBER 2008. OBSTETRICS &

GYNECOLOGY.

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Tools for Bundle Success

• One stop documentation- all bundle

elements rolled into a sticker/stamp

• Decision aids/reminders built into the

system.

• Everyone on the same page and

understanding of expectations.

Make it easy!

Tools for Bundle SuccessExamples

• Hard stop in booking elective cases- no

elective inductions (or elective

cesareans) prior to 39 weeks GA.

1. Stopped at the booking point

2. Prenatal record required on unit prior to booking of any procedure.

3. Supported by the Physician Champion and backed up by the OB/GYN Department.

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Perinatal Care and IHI Perinatal Bundle

• Results

─Measure, Measure, Measure

Page 48: IHI Expedition Preventing Obstetrical Adverse Events ... Expedition... · IHI Expedition: Preventing Obstetrical Adverse Events Session 2: Executing Oxytocin Bundles Peter Cherouny,

Expedition Communications

• If you would like additional people to

receive session notifications please send

their email addresses to

[email protected].

• We have set up a listserv for the

Expedition to enable you to share your

progress. To use the listserv, address an

email to [email protected].

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Next Session

Session 4 – Designing Reliable

Processes

Date: Wednesday, July 11, 1:30 PM – 2:30 PM

Remember: Continuously add your data to your Storyboard!

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