Perinatal Safety:
Moving to Zero
Harm
Allen Perinatal Team
Dr. Jeffrey Crandall
Executive Sponsor
Opens doors, improves patient outcomes,
and acts as liaison between perinatal team
and Allen Board.
Lori Murphy-Stokes RN MA
Director Maternal-Child Services
Team Leader
Directs team meetings, coordinates
resources, keeps team focused on
Charter.
Theresa Pagel RN
OB Nurse Manager
Coordinates improvement activities with
staff and providers.
Dr. Publio Ortiz
Physician Champion
Liaison between team and providers. Assists
evidence based practice changes.
Dr. Michelle Graham
Lori Hanson CNM.
Karen Storey RN OB QI
Data analysis, report writer.
Sarah Eiklenborg BSN
Marilyn Owusu RN
Milda Mullesch RN
Director of Case Management
Improvement Advisor
Our story starts in September 2006.
IHS joined the IHI initiative for
improving patient care through
evidence based practice.
We began with the White Paper for
Pitocin induction and augmentation
bundles. At that time we also wanted
to know what our baseline for
perinatal harm was, so we could
document improvement. We began
using the Perinatal trigger tool.
Pitocin Induction Bundle
• Gestational age > 39 weeks.
• Reassuring Fetal Status.
• Vaginal Exam.
• Hyperstimulation (renamed tachysystole)
recognized and treated appropriately or no
hyperstimulation of labor present.
Pitocin Augmentation Bundle
• Estimated Fetal Weight Documented
• Reassuring fetal status
• Vaginal Exam prior to starting pitocin
• Hyperstimulation (renamed tachysystole)
recognized and treated appropriately or no
hyperstimulation of labor present
5 charts each week for Induction and 5
charts each week for Augmentation
abstracted for the bundle elements.
The results were shared with the IHS
perinatal team.
The IHS perinatal team met monthly on
phone conferences. This is where ideas,
questions, successes, failures, problems,
and barriers were discussed. New ideas
put foreword for consideration and trial.
Pitocin Induction and Augmentation
Bundles
2007
100
90
80
De
c-0
6
Jan
-07
Feb
-07
Ma
r-0
7
Ap
r-0
7
Ma
y-0
7
Jun
-07
Jul
-07
Au
g-0
7
Sep
-07
Oc
t-07
No
v-0
7
De
c-0
7
70
Composit Induction Bundle
Composit Augmentation bundle
Pitocin Induction and Augmentation
Bundles
2008
100
95
90
85
Ma
r-08
Apr
-08
Ma
y-0
8
Jun
-08
Jul
-08
Aug
-08
Sep
-08
Oct
-08
Nov
-08
Dec
-08
-08
Feb
Jan
-
08
80
All or None Induction Bundle
All or None Augmentation Bundle
Pitocin Induction and Augmentation
Bundles
2009
100
95
90
Ma
r-09
Apr
-09
Ma
y -0
9
Jun
-09
Jul
-09
Aug
-09
Sep
-09
Oct
-09
Nov
-09
Dec
-09
-09
Feb
Jan
-
09
85
All or None Induction Bundle
All or None Augmentation Bundle
Pitocin Induction and Augmentation
Bundles
2010
100
95
Ma
r-10
Apr
-10
Ma
y-1
0
Jun
-10
Jul
-10
Aug
-10
Sep
-10
Oct
-10
Nov
-10
Dec
-10
-10
Feb
Jan
-
10
90
All or None Pitocin Induction Bundle
All or None Pitocin Augmentation Bundle
Pitocin Induction and Augmentation
Bundles 2006-2010
100
95
90
85
80
75
Dec
-06
Feb
-07
Apr
-07
Jun
-07
Aug
-07
Oct
-07
Dec
-07
Feb
-08
Apr
-08
Jun
-08
Aug
-08
Oct
-08
Dec
-08
Fe b
-09
Apr
-09
Jun
-09
Aug
-09
Oct
-09
Dec
-09
Fe b
-10
70
All/None Induction Bundle
All/None Augmentation Bundle
Changed from Composite to All/None Score
Hourly Documentation of Pitocin Dosage
2009
100
90
80
70
60
Fe
b-0
9
Ma
r-0
9
Ap
r-0
9
Ma
y-0
9
Ju
n-0
9
Ju
l-0
9
Au
g-0
9
Se
p-0
9
Oc
t-0
9
No
v-0
9
De
c-0
9
Ja
n-0
9
50
Percentage of compliance
goal
Hourly Documentation of Pitocin
2010
95
90
85
Hourly documentation of pitocin
0
Dec
-1
0
Nov
-1
0
Oct
-1
0
Sep
-1
-10
Aug
10
Jul-
-10
Jun
Jan
-10
Feb
-10
Ma
r-10
Apr
-10
Ma
y-10
80
goal
Provider Vacuum Documentation
Bundle 2009
Composit percentage of compliance
All/None percentage of compliance
9
Dec
-0
9
Nov
-0
9
Oct
-0
9
Sep
-0
-09
Aug
09
Jul-
-09
Jun
Jan
-09
Feb
-09
Ma
r-09
Apr
-09
Ma
y-09
100
90
80
70
60
50
40
Provider Vacuum Documentation
Bundle 2010
Composit percentage of compliance
All/None percentage of compliance
0
Dec
-1
0
Nov
-1
0
Oct
-1
0
Sep
-1
-10
Aug
10
Jul-
-10
Jun
Jan
-10
Feb
-10
Ma
r-10
Apr
-10
Ma
y-10
100
90
80
70
60
50
40
Culture of Safety
The perinatal teams surveyed staff and
providers regarding the culture of safety
on the OB unit.
Allen’s results were:
2006
4.43
2008
4.49
2009
4.66
5 maximum score achievable.
Perinatal Trigger Tool Elements
1. Apgar at < 7 @ 5 minutes of life.
2. Admission to NICU and > 24 hours.
3. Maternal/Neonatal Transport.
4. Terbutaline administration.
5. Naloxone administration.
6. Infant Serum Glucose < 50.
7. 3rd or 4th degree laceration.
8. Prolonged decelerations
9. Blood Transfusion.
10. Platelet count < 50,000.
11. Abrupt Medication stop. (eg. Suntocinon)
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Hypotension/Lethargy (OD on Mag SO4)
Transfer to a higher level of care, including ICU in house.
Unplanned return to surgery.
Estimated blood loss > 1500ml.
Specialty consult.
Administration of Oxytocic agents post-delivery.
Instrumental delivery.
Administration of general anesthetic for delivery.
Cord gases < 7.1.
Gestational Diabetes.
Other.
20 random charts reviewed per month. Triggers don’t necessarily
mean an event happened. Must look for level of harm.
Perinatal Trigger Tool
2
3
7
1
12
11
4
5
14
8
6
19
13
15
9
17
10
16
18
Perinatal Trigger tool consists of the following
Interventions:
Perinatal Trigger tool consists of the following triggers:
1 - Perinatal team begins abstraction of data, meetings, goals
and agenda's discussed.
2 - Perinatal work presented to OB and Peds Committee's and
in OB unit meetings. Bundle elements discussed.
3 - Hyperstimulation of labor using pitocin discussed in OB
unit meetings.
4 - Version 1 of induction of labor tool developed and
implemented with providers.
5 - Ephedrine audit done and shared with Anesthesia
Committee.
6 - Hyperstimulation algorithm implemented, shared in OB
Committee and unit meetings.
7. - Ephedrine audit done and shared with Anesthesia.
8 - Ephedrine audit done and shared with Anesthesia.
9 - Iowa Perinatal Team visit.
10- Version 2 of induction of labor form and C/Sections
implemented. Providers education done.
11- Pitocin bundle fallouts and perinatal team progress shared
with providers at OB Committee meeting.
12- Perinatal team progress shared at OB Committee meeting.
13- Ephedrine audit results shared with Anesthesia.
14 -Vacuum bundle elements discussed with OB Committee need
to come to agreement of Allen Providers standard
documentation for operative deliveries.
15- Iowa Perinatal Team visit.
16- Ephedrine audit requested by anesthesia and results shared.
17- Documentation elements of vacuum bundle agreed upon by
providers. Start abstraction of 100% vacuum assisted
deliveries for compliance.
18- Pitocin bundle fallouts, Vacuum bundle fallouts, and
perinatal team progress shared with providers at all OB
Committee meetings. Individual providers contacted and
informed of specific fallouts.
19 – Pitocin bundle fallouts, Vacuum bundle fallouts, and
perinatal team progress shared with providers at all OB
Committee meetings. Individual providers contacted and
informed of specific fallouts.
Lessons Learned:
• It is essential to have Executive
•
•
involvement. Without this your team will
struggle to make progress.
You need the right mix of team members.
If team members can’t or won’t work
together no progress is made.
• Physician champion needs to be someone
committed to the process and willing to go to
peers to ask the tough questions, to demand
the tough answers.
• You need Cheerleaders on the staff.
Representation from the front line staff is
essential for momentum building and getting
the staff excited about changes and buying in
to Scientifically proven safety measures.