improvement strategies utilizing bundles and protocols · • the development of reliable clinical...
TRANSCRIPT
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Improvement Strategies Utilizing Bundles and Protocols
Peter Cherouny, MD University of Vermont
Division of Maternal-Fetal Medicine
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Objectives
1. Introduce and define the concept of the bundles
2. Use the perinatal bundles as examples of reliable design
3. Results
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Learning Objectives
At the end of the presentation, the participant: • Will be able to state what a clinical bundle represents • Will be able to describe the induction and augmentation
bundles • Will be able to implement bundles in their work setting Disclosures Dr. Cherouny has no conflict of interest to disclose.
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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.
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Quality Care in Obstetrics Why is this important now
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Quality Care in Obstetrics Why is this important now
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Why focus on perinatal care?
2007 4,317,119 births in US
Birth trauma 6.3-7.3/1000 estimated 50-90% are preventable
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What does that mean for NY?
New York State 1600-1900/yr 800-950 preventable
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What does that mean for US?
27,000-32,000 injured babies total 13,500-16,000 preventable
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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 11
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Reasons for the Reliability Gap In Healthcare
• Communication – 84% of sentinel events reported to JCAHO involving
fetal/infant adverse events cited communication among 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?
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Forbidden Behavior
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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
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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
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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
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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 Summit Hard and Fast Rules
• Acclimatization at altitude
• Work together
• Cannot assist someone on the ascent
• Fixed turn around time
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Assault on Everest Summit Summit Bundle
• Acclimatization at altitude
• Work together
• Cannot assist someone on the ascent
• Fixed turn around time
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Assault on Everest Summit Summit Bundle
• Standard acclimatization techniques
– # days and at what altitude • Work together
• Cannot assist someone on the ascent
• Fixed turn around time
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Assault on Everest Summit Summit 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
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Assault on Everest Summit Summit 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
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Assault on Everest Summit Summit 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 Summit Summit 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 Summit Summit 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
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Assault on Everest Summit Result
• 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 Summit Result
• Eleven Deaths • Survivors
– PTSS – Marital problems – Work problems
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Assault on Everest Summit Summit 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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Mindful Practice
• It is not enough to do your best you must know what to do and then do your best
• W. Edwards Deming
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Quality Care in Obstetrics
• Pitocin Bundles as standardization of care – Developing the Bundles
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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 Obstetrics Birth 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
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Quality Care in Obstetrics Birth Trauma
• Prevention – Practice Dermatology
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Quality Care in Obstetrics Birth 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 Obstetrics Birth 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 Obstetrics Birth 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 Obstetrics Birth Trauma and Pitocin
• Pitocin is involved in over 50% of the situations leading to birth trauma
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Quality Care in Obstetrics Birth 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 Obstetrics Pitocin Use
• Use Pitocin Safely and Effectively
– Know everything about the drug – Have established protocols and use them
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Quality Care in Obstetrics Pitocin 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 Obstetrics Pitocin 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 Obstetrics Elective Labor Induction-Requirements
Assessment of gestational age • Confirmation of Term Gestation • Iatrogenic prematurity is unacceptable and
indefensible
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Quality Care in Obstetrics Elective 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 46
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Quality Care in Obstetrics Elective 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 47
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Quality Care in Obstetrics Elective Labor Induction-Requirements
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Quality Care in Obstetrics Elective Labor Induction-Requirements
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Quality Care in Obstetrics Elective Labor Induction-Requirements
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Quality Care in Obstetrics Elective Labor Induction-Requirements
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Quality Care in Obstetrics Elective Labor Induction-Requirements
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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
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Quality Care in Obstetrics Elective 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 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
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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
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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
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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
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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
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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 Confirmation of Fetal Maturity 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
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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
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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
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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
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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
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Perinatal Care and IHI Perinatal Bundle
• Results – Measure, Measure, Measure
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Seton Hospital Alpha Sites Birth Trauma
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Seton Medical Center Team
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Quality Care in Obstetrics Preventing Trauma with Vacuum Delivery
• Preliminary considerations – Consider alternative management – High chance of success – Exit strategy prepared – Prepared patient
• Informed consent
– Resuscitation team available
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Quality Care in Obstetrics Preventing Trauma with Vacuum Delivery
• Technical considerations – Fetal parameters known and considered
• EFW, Station, Position
– Application time and pop-offs limited – Torque in direct line of birth canal
• No rocking movements
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Quality Care in Obstetrics Preventing Trauma with Vacuum Delivery
• Bundle Components – Individual components supported by science – Required to be performed for every patient, every
time – Bundle compliance measured by fulfilling all parts
of the bundle – Focus on system
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Quality Care in Obstetrics Preventing Trauma with Vacuum Delivery
• Vacuum Bundle – Alternative labor strategies considered – Prepared patient
• Informed consent discussed and documented
– High probability of success • EFW, fetal position and station known
– Maximum application time and number of pop-offs predetermined
– Exit strategy available • Cesarean and resuscitation team available
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