National safety effort targets perinatal injuries

Improved doctor-nurse communication and strict adherence to guideline-based care "bundles" can eliminate preventable birth trauma, project leaders say.

By — Posted June 16, 2008

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A group of 16 hospitals last month announced a collaboration on a 21-month patient safety initiative to eliminate preventable birth injuries in their facilities, building on the success of an effort spearheaded by the Institute for Healthcare Improvement.

Three in 1,000 deliveries involve serious perinatal injuries that can result in cerebral palsy, birth asphyxia or permanent neurological disability, said officials involved in the initiative. Many of these can be prevented if physicians follow evidence-based guidelines and do a better job recognizing when infants are in distress, initiating timely cesarean births, properly resuscitating depressed babies and appropriately using labor-inducing drugs and vacuum or forceps, they added.

Participating hospitals are members of Premier Inc., a purchasing alliance of 2,000 nonprofit hospitals that is coordinating the new pilot project. They intend to implement three evidence-based care "bundles" -- groups of related interventions shown to most reduce harm when performed in concert -- on the use of oxytocin to induce or augment labor and the use of vacuum extractors in operative vaginal deliveries.

The bundles are based on clinical practice guidelines from the American College of Obstetricians and Gynecologists and the Assn. of Women's Health, Obstetric and Neonatal Nurses.

The hospitals also will work to improve the teamwork between obstetricians and nurses by communicating through use of the well-known situation-background-assessment-recommendation, or SBAR, technique. Doctors and nurses will be trained jointly on how to consistently interpret electronic fetal monitoring and use mannequins to simulate worst-case scenario perinatal crises and practice teamwork skills.

Premier will collect outcomes and cost data and compare them to other member hospitals not participating in the project to gauge success. The organization hopes that more hospitals adopt the changes once results of the pilot come in.

"What we're trying to do is make care delivered in the birth process more effective," said Susan DeVore, Premier's chief operating officer. "This is about hospitals, doctors and nurses working together to eliminate preventable birth injuries. Our goal is to get as close to zero as possible, with zero being the only acceptable number."

Earlier work shows that the goal is achievable. In 2004, the Institute for Healthcare Improvement began work with St. Louis-based Ascension Health on a system-wide effort to reduce perinatal injuries. Three hospitals in the system that implemented the care bundles and worked to improve communication scored "birth trauma rates that were at or near zero," said a January 2007 study in the Joint Commission Journal on Patient Safety and Quality.

The Kettering Medical Center in Miamisburg, Ohio, also took part in the IHI-led initiative and cut elective inductions before 39 weeks gestation by 30%. Compliance with perinatal care bundles jumped from 40% in 2005 to more than 90% in 2006, and neonatal intensive care unit admissions were cut in half.

Frank Perez, president and CEO of the Kettering Health Network, said physicians who want to induce labor electively have to give the hospital a medical reason, such as pre-eclampsia, why it is necessary before scheduling delivery.

This hard line from the hospital "helped obstetricians respond more effectively to pressure from families for induced labors prior to 39 weeks," Perez said. "It is now easier for them to delay elective induction for nonmedical reasons."

Steve McAvoy, MD, is an ob-gyn championing the Premier perinatal safety initiative at Aurora West Allis Medical Center in suburban Milwaukee. Since February, he has been making presentations about it to medical groups whose physicians deliver babies at the hospital.

Dr. McAvoy gets "a little bit of heartache and pushback from the other providers" but said that once the underlying evidence and efficacy of the bundles is presented, most doctors are ready to accept the project.

"The good thing is that this is not a two-month initiative but a two-year initiative, and in the end, we're going to have some wonderful data about preventing birth trauma at the medical center," he said. "Any initial naysayers will definitely be on board."

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Steps to safer deliveries

The use of drugs such as oxytocin to induce labor is sometimes associated with birth injuries. Hospitals participating in a new perinatal safety initiative aim to implement steps that, when performed together, have been shown to nearly eliminate such outcomes. When using oxytocin to induce labor, physicians participating in the safety effort will:

  • Assess gestational age, ensuring that it exceeds 39 weeks.
  • Monitor fetal heart rate for reassurance according to specific definitions developed by the National Institute for Child Health and Human Development.
  • Assess pelvis to determine dilation, effacement, station, fetal presentation, and cervical position and consistency.
  • Monitor and manage hyperstimulation and respond according to a predetermined consensus plan.

Source: Premier Perinatal Safety Initiative

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