Comprehensive Program Virtually Eliminates Preventable Birth Trauma

Problem Addressed

• Relatively rare event: In 2001, the rate of birth trauma per 1,000 live births was 7.36.²
• Devastating consequences: Preventable birth trauma is emotionally devastating to families and results in long-term costs to providers and society, including rapidly rising litigation expenses (leading some physicians to stop delivering babies altogether) and an escalation in use of C-section and operative vaginal deliveries as a way to minimize the potential for birth trauma in high-risk situations.³
• Often preventable: Research has identified numerous errors that can lead to high-risk situations and the potential for birth trauma, including failure to recognize fetal distress or nonreassuring fetal status; failure to effect a timely cesarean birth; failure to properly resuscitate a depressed baby; inappropriate use of oxytocin/misoprostol; inappropriate use of vacuum/forceps; poor communication among caregivers; failure of providers to respond when needed; and failure to initiate the chain of command when clinical disagreement exists.^4,5

Description of the Innovative Activity

• Interdisciplinary team at Seton: An interdisciplinary team with representatives from the four hospitals in the Seton Family of Hospitals oversees Seton's effort to eliminate preventable birth trauma. Team membership includes senior administrators, physicians, nurses, risk management personnel, and other key staff members. This team collaborated with teams at two other Ascension sites to initiate the preventable birth trauma initiative.
• Use of standardized protocols: The teams designed and adopted standardized protocols that address topics such as the use of oxytocin in elective induction, the augmentation of labor, and the use of assisted delivery devices (i.e., forceps, vacuum); another protocol prohibits the scheduling of elective inductions before 39 weeks gestational age unless the medical indication for the induction is documented.
• Tools to facilitate adherence to protocols: The teams use standardized order sets and documentation forms with check boxes and “fill-in” blanks to make it as easy as possible for providers to follow the protocols.
• Data collection and monthly feedback: The teams track performance on a set of outcomes, process, and financial indicators. Indicators tracked include (but are not limited to) birth trauma rate, the rate of birth trauma associated with assisted delivery, compliance with oxytocin protocols, incidence of iatrogenic prematurity, and costs associated with birth trauma and iatrogenic prematurity. Data are collected and shared on a monthly basis with staff and obstetricians.
• Monitoring adherence to protocols: A random sample of patient charts is reviewed periodically to monitor adherence to protocols. For example, in conjunction with expert consultants from the Institute for Healthcare Improvement (IHI), compliance with the oxytocin bundle of protocols is assessed by retrospective review of five random charts per week (or 20 per month) for both elective inductions and augmentations.
• Use of SBAR (Situation, Background, Assessment, Recommendation) and other strategies to facilitate communication: The labor and delivery (L&D) clinicians use a common communication tool known as SBAR to guide thorough communication about patients. In addition, the communication processes used during formal and informal department and staff meetings emphasize SBAR use and accommodate joint nurse–physician interpretation of electronic fetal monitoring (EFM) results.
• Hands-on training: Seton used a “live case study” process that allows for direct observation of L&D units by other Seton facilities. Seton also created an infrastructure for simulation of obstetrical emergencies using high-fidelity mannequins, which is an ongoing training method.
  • "Live case study": The "live case study" method, developed by GE, allowed weak-performing divisions and organizations to observe stronger performers. Seton adapted this practice by organizing four different live case study presentations; each of the four hospitals hosted one presentation to L&D clinicians from the three other Seton hospitals. The host hospital representatives gave a presentation about their work processes, and then representatives from the visiting hospitals observed the host L&D unit in action. Participants reconvened and debriefed to discuss what the visitors learned from the process as well as point out observations that could help the host site improve its own processes.
  • Simulation training with mannequins: Crises in the L&D unit are infrequent, meaning that staff do not develop sufficient experience in managing these crises. To address this issue, Seton uses high-fidelity mannequins to simulate known L&D crises (e.g., postpartum hemorrhage, maternal cardiac arrest, and shoulder dystocia) so that the medical and nursing staff can improve their functioning as a team. L&D physicians and nurses develop scenarios and create realistic clinical environments using the mannequins to replicate crisis situations and practice their individual and team responses and then debrief to discuss how to improve their processes. Simulation training using the mannequins is held periodically throughout the year.
• Collaborative learning and sharing of best practices: Seton and the other two sites participate in periodic collaborative learning sessions to identify and share best practices. For example, one early collaborative session led to an agreement by the three sites to adopt a common interpretational format for fetal heart monitoring recommended by the National Institute of Child Health and Human Development guidelines for EFM, which were endorsed by the American College of Obstetrics and Gynecology and the Association of Women’s Health, Obstetric and Neonatal Nurses. Within each site, interdisciplinary teams also meet regularly to identify best practices, which are shared via team meetings and conference calls.

References/Related Articles

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Results

• Significant reduction in birth trauma: The incidence of birth trauma fell by 85 percent after implementation of the program, from 2 per 1,000 births in fiscal years 2003 and 2004 to 0.3 per 1,000 births in fiscal years 2005 and 2006.
• Steady C-section rate: Although hard data are unavailable, Seton's primary (elective) C-section rate has remained relatively steady at a time when rates are rising for the nation as a whole. However, because Seton has reduced the use of assistive devices for high-risk deliveries, the organization has experienced a small (although not statistically significant) increase in its secondary (emergency) C-section rate.
• Reduction in operative vaginal deliveries: Between fiscal year 2001 and fiscal year 2006, operative vaginal deliveries decreased from a frequency of 7.4 to 4.7 percent.
• More appropriate use of assistive operative devices: Standardizing the use of operative devices has led to more evidence-based use, and very low rates of misuse, to a rate of fewer than 5 per 100 (e.g., avoiding vacuum device use after three "pop offs" have occurred; avoiding combined use of forceps and vacuum; and avoiding vacuum use prior to 36 weeks gestation).
• Lower costs: Annual neonatal intensive care unit (NICU) charges were reduced from $4 million before program implementation to $183,000 after implementation.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Adoption of common principles: Teams at the three Ascension sites adopted principles common to a “high-reliability organization” (an organization that successfully avoids accidents despite high potential risk, due in health care to factors such as case complexity or serving a high-risk patient population).
• Adoption of standard definition of birth trauma: In keeping with widely accepted standards, the Ascension sites decided to use the Agency for Healthcare Research and Quality (AHRQ) definition of birth trauma, which is defined in AHRQ’s Birth Trauma–Injury to Neonate Patient Safety Indicator (also known as PSI 17).²
• Review of the evidence-based literature: The Ascension teams reviewed and reported on evidence-based literature on common reasons, risk factors, and prevention strategies related to birth trauma.
• Development of standardized protocols: Highly standardized order sets linked to all major areas of obstetrical care were either updated or developed and then tested and incorporated into the workflow of the L&D units. For example, in collaboration with the IHI, two new sets (or “bundles”) of perinatal protocols were developed, one for the use of oxytocin in elective induction and one for the augmentation of labor.
• Development of tools to facilitate protocol adherence: To facilitate adherence to adopted protocols and bundles, standardized order sets and documentation forms with "forcing functions" such as check boxes and “fill-in” blanks were created.
• Adaptation of SBAR and development of other communication strategies: The teams customized SBAR for perinatal care and obtained agreement from all providers to use the tool to improve provider-to-provider communication. In addition, the communication processes used during formal and informal department and staff meetings were restructured to emphasize SBAR use and to accommodate joint physician–nurse interpretation of EFM results.
• Data collection and feedback: The teams identified a set of indicators that related to desired outcomes. The teams sent notices to physicians that they would be benchmarking units and medical staff members against each other via monthly data reports.
• Live case study process: The IHI introduced the Seton team to the live case study process. The Seton team researched the process and developed four live case study presentations (with each to be hosted at a different site), along with a standard list of questions that each participant group could ask about the host site's processes of care.
• Simulation planning: Seton purchased five high-fidelity mannequins to use in simulation exercises. Seton also hired a dedicated staff member to run the mannequin during simulations, facilitate the creation of training scenarios, and facilitate the debriefing following each simulation.

Resources Used and Skills Needed

• Staffing: A project manager oversees the program at Seton Family of Hospitals. Front-line staff promote the effort and help collect the data.
• Costs: While no hard estimates are available, general program costs include the project manager salary and the time of existing staff. Each mannequin ranges in price from approximately $30,000 to $250,000. Live case study costs include those related to audiovisual supplies and training personnel.

Funding Sources

Seton Family of Hospitals, Austin, Texas; Ascension Health, St. Louis, Missouri

Tools and Other Resources

Getting Started with This Innovation

• Enlist the support of senior leadership: An organization cannot achieve success with a performance improvement imperative of any significant magnitude without having senior leadership involved and helping to promote it.
• Enlist the support of front-line staff: Real change does not happen at the leadership level, but rather at the front line of care. Interdisciplinary teams are critical and can empower front-line staff to help develop, promote, and execute process improvement.
• Standardize practices to reduce variation: Significant variation in practice creates an environment in which errors are more likely to occur. All processes should be standardized based on clinical evidence, and clinical staff should be educated about how the standardized process can improve clinical outcomes.
• Train for crises: The L&D unit is one in which crises occur infrequently. Staff should anticipate and train for crisis situations in a realistically simulated environment to build clinical skills and team-based processes of care.

Sustaining This Innovation

• Maintain state-of-the-art practices: Periodically review the evidence-based literature for relevant ideas for improving care that can be incorporated into practice.
• Maintain a focus on safety: As noted, Seton adopted the principles of "high reliability" organizations, including empowering team members with the right to say "no" when necessary.
• Continue collecting and disseminating data: Data revealing positive trends in outcomes will prompt continued participation and protocol adherence, particularly among physicians who may initially be resistant to change.

Additional Considerations and Lessons

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