Patient Safety Officer Executive Development Program



Background:Reliable care, understanding the process of care, and decreasing variation while being mindful of weak signals in the system allows the Perinatal teams to now learn about opportunities in the 1st and 2nd stage of labor.Prerequisite: understanding of HRO concepts and proven record of execution (IHI oxytocin bundles >95%compliance). This work builds on successful execution of the oxytocin bundles, incorporates the work needed for effective vacuum bundle execution, and supports enhanced understanding of the process of labor experienced by patients in your organization.Supporting References:Nursing Care and Management of the Second Stage of Labor, Second Edition. Association of Women’s Health, Obstetric and Neonatal Nurses. 2008.Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.Bakker, P.C.Kurver, P.H. Kuik, ZD.J. et al. Elevated uterine activity increases the risk of fetal acidosis at birth. American Journal of Obstetrics and Gynecology.196, 313e311-e316.ACOG Practice Bulletin. Dystocia and Augmentation of Labor. Number 49. December 2003.ACOG Practice Bulletin. Fetal Lung Maturity. Number 97. September 2007.ACOG Practice Bulletin. Induction of Labor. Number 107, August 2009.ACOG Practice Bulletin. Intrapartum Fetal Heart Rate Monitoring. Number 106, July 2009.ACOG Practice Bulletin. Operative Vaginal Delivery, Number 17. June. 2000.ACOG Practice Bulletin. Postpartum Hemorrhage. Number 76. October 2006.ACOG Practice Bulletin. Shoulder Dystocia. Number 40. November 2002.Johnson J, Figueroa R, Garry D, et al. Immediate Maternal and Neonatal Effects of Forceps and Vacuum-Assisted Deliveries. Obstetrics and Gynecology. 2004; 103:513-8.Please see Perinatal Bibliography for a complete list.StructureYesNoN/A1. Interdisciplinary Fetal Monitoring Education2. Documentation tools consistent with NICD terminology 3.Weekly fetal monitoring strip and case reviews (or#4)4. Monthly fetal monitoring strip and case reviews5. Standard mixture and policy for oxytocin administration6. One standard administration order setOxytocinDeep Dive7. If provider opts out of standard order set, system in place to identify and address when standardized dosage is not followed.8. Team definition for tachysystole9. Clinical algorithm for identification and management of tachysystole10. Clinical algorithm for management of indeterminate/abnormal FHR patterns (NICHD 2009)11. RN empowered to call cesarean team (not to diagnose the need for cesarean, but to activate the team)12. RN empowered to call neonatal team13. Consistent handoff tool {SBAR, etc} specify14. Informed Consent for oxytocin administration15. Individual Provider data published about induction/augmentation rates?Labor Deep Dive Tool16. Gestational age criteria standardized17. Team definition for labor 18. Team definition for normal and abnormal first stage of labor.19. Admission criteria standardized20. Established criteria for augmentation.21. Established team huddle at critical decision points in the patient journey. Example- (1)admission, (2)when patient is complete to review risk factors to proceed forward, (3)other examples- after 2 hours with minimal or no progress, discuss plan of care to include- forceps, vacuum, CB, continuation of pushing, etc.)22. Second Stage Algorithm in place23. Established policy and criteria for operative vaginal delivery ( forceps and vacuums)24. Established team definition of normal and abnormal second stage of labor 25. Any dual mode delivery reviewed (vacuum-forceps; forceps-cesarean; etc)26. Established neonatal hand off criteriaWorksheetStudy Population:(TJC PC-02 Denominator) Nulliparous patients delivered of a live term singleton newborn in vertex presentationOR: (NQF Definition) Live births at or beyond 37.0 weeks gestation that are having their first delivery and are singleton (no twins or beyond) and vertex presentation (no breech or transverse positions). Excluded- patients with abnormal presentation, preterm, fetal death, multiple gestation diagnosis codes, or breech procedure codes. Random sample of 20 patients who meet the definition. Teams will then further define the segment of the population they will work on, example would be 1st or 2nd stage focus as a patient segment.Team Worksheet (include all structural questions that request definitions)Definition of Labor: _________________________________________________________________________________________________________________________________________________________________________________________________________Team definition for normal and abnormal first stage of labor._________________________________________________________________________________________________________________________________________________________________________________________________________Definition of protracted labor or arrest of descent ______________________________________________________________________________________________________________________________________Notes: All patient records: (TJC PC-02 Denominator) Nulliparous patients delivered of a live term singleton newborn in vertex presentationBMI on admission _____Gestational Age:____________Weight gain in pregnancy___________EFW:______________________Diabetic Yes □ No□Reason for admission:YESNOBishops score / cervix on admitPrevious cervical ripeningSpontaneous laborSROMMedical induction reasonElective InductionAROMOtherFirst Stage Recognition SystemTime labor Diagnosed___________ Cervical status_______________Time of arrest of labor_____________Time of oxytocin augmentation___________ Cervical status_______________ If patient receives oxytocin in 1st Stage, review oxytocin deep dive process questions.1st Stage Oxytocin Specific Review ProcessYesNoExplanations to support the process questionsCareful Monitoring- 1. Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity while oxytocin administered.(Per Perinatal Guidelines)High risk- every 15 minutes during the active phase of the first stage of labor. Every 5 minutes during the second stage of labor2. Oxytocin initiated as intended – no delay in administration due to provider or nursing response. Was there a delay in initiation or during administration due to provider unavailability, nursing staffing, provider staffing issues?Timely Identification-3. □Tachysystole identified and managed according to protocol /algorithm□Tachysystole identified and managed according to team definition and standing ordersIf tachysystole was not present, please make sure you note this in this column but do not collect information on yes/no unless it is present.□ No tachysystole present4. □ Indeterminate/abnormal FHR identified Note in this column if reassuring/normal status always present.Appropriate Interventions-5. Oxytocin dose decreased or discontinued during labor due to tachysystole?__________#times6. Oxytocin dose decreased or discontinued during labor due to FHR?__________#times7. Oxytocin resumed after a decrease or stop?Decrease or stop related to the presence of tachysystole or non-reassuring FHR. Other?8. Terbutaline administered?9. Interventions needed?Interventions may be change in position, IV fluid bolus, and emergency cesarean.10. Once labor was progressing, was oxytocin discontinued?Was oxytocin stopped when labor pattern was effective?Activation of Team Response11. Documentation of physician notification of change in dosage of oxytocin.12. If requested, timely response by OB care provider for bedside evaluation.13. Escalation plan in place if needed and documented.If tachysystole or indeterminate/abnormal FHR noted, was provider supportive of decision to discontinue medication?Delivered by cesarean yes no (if no proceed to 2nd Stage)If yes, indication _______________________________________ Proceed to outcomes box.SECOND STAGE RECOGNITION SYSTEMTime complete: _____________Station at start of 2nd stage: ____________Time pushing started: ___________ProcessYesNoNAExplanations to support the process questions Careful Monitoring- 1. -Appropriate level (high risk) based electronic fetal monitoring (or IA) for fetal heart rate and uterine activity if oxytocin administered. (Per Perinatal Guidelines).-With or without oxytocin, FHR and uterine activity is recorded, interpretable and consistent with risk level.2. Supportive Care-If AWHONN 2nd stage algorithm in place, evidence it was followed in the record.-Evidence patient received alternative strategies for comfort care.3.Powers: Uterine contractility adequateConsider: adequate when entering second stage to turn off the Pit or to go up on the Pit to get the patient delivered.4.Pitocin initiated / reinitiated in 2nd stageConsider: starting augmentation in second stage or restarted once off for a prolonged deceleration Timely Identification5.FHR interpretation:Category II or IIIIf identified, team documents plan for reassessment ____minutes and exit strategyConsider: -N/A if FHR remains in Category I. -If Category III, evidence that delivery occurred by internal standards (30 minutes or less)6. EFM tracing remains adequate for fetal assessment during second stageAppropriate Interventions7. Oxytocin dose decreased or discontinued during 2nd stage due to tachysystole__________#times8.Oxytocin dose decreased or discontinued during 2nd stage due to FHR?9.If protracted, arrested or abnormal descent identified then team / algorithm interventions were performed?10. Interventions needed for change in FHR? Document those applied (intrauterine resuscitation measures)11.Pushing Interventions-If FHR decelerations, was pushing with every 2nd or 3rd contraction initiated?Consider: team has implemented this as a multidisciplinary strategyActivation of Team Response12.Documentation of physician notification of change in status13.If requested, timely response by OB care provider for bedside evaluation.14.Escalation plan in place if needed and documented.15. Recognition of abnormal 2nd stage and plan documented- may include nursing interventions such as positioning/pushing techniques, proceed to delivery, expectant management, augmentation.ConclusionLength of Second Stage:Time of Delivery:Mode of Delivery:Single or dual mode of delivery SVD Cesarean SectionStation: Reason: VacuumStation: Reason: ForcepsStation: Reason:NOTES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Outcomes (T=from Perinatal Trigger Tool)YesNoN/ACommentsNeonatal Outcomes 1. (T1) Apgar <7 at 5 min 2. (T2) Admission to NICU or higher level of care3. (T18) Instrumented delivery, vacuum or forceps (document indication) 4. 2 or more late preterm infant (LPI Indicators)- Respiratory distress (tachypnea, retractions, nasal flaring, grunting, apnea, cyanosis, low O2 sat)Thermoregulation issues (temp instability)HypoglycemiaSignificant feeding issues (greater than 10% weight loss)Hyperbilirubinemia (requiring phototherapy, prolonged hospital stay5. (T16) Neonatal Injury (e.g. fractured clavicle) cephalohematoma, facial drooping, documented palsy, hyperbilirubinemia6. (T20) Cord gas < 7.207. (T22) Other Shoulder dystocia (document morbidity)Maternal Outcomes1. (T7) 3rd or 4th degree laceration.2. (T9) Blood Transfusion3. (T18) Instrumented delivery, vacuum or forceps (document indication)4. (T15) Excessive blood loss, postpartum hemorrhage5. (T22) Other Shoulder dystocia (document morbidity)6. Cesarean section (indication)NOTES: ................
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