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Care for the Deteriorating OB Patient during a Rapid Response Event

Care for the Deteriorating OB Patient during a Rapid Response Event. Dionne Walker MSN, RNC-OB Clinical Specialist, Women’s Services Tara Barrick MSN, RNC-OB High Risk OB Clinical Specialist. objectives. Discuss the overview and background in emergency obstetrics

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Care for the Deteriorating OB Patient during a Rapid Response Event

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  1. Care for the Deteriorating OB Patient during a Rapid Response Event Dionne Walker MSN, RNC-OB Clinical Specialist, Women’s Services Tara Barrick MSN, RNC-OB High Risk OB Clinical Specialist

  2. objectives • Discuss the overview and background in emergency obstetrics • Review of Global Maternal Mortality data • Describe the different roles and responsibilities of each team member during a rapid response event • Recognize the importance of communication, collaboration and teamwork during an Rapid Response event • Review of Women’s Services RRT data

  3. Vicki McGuire https://www.usatoday.com/deadly-deliveries/videos/#vicki-mcguire

  4. 42

  5. background The health of the population is rapidly changing, in part related to: Obesity related complications such as hypertension and diabetes The likelihood of developing a comorbidity increases with maternal age Snapshot of today’s OB patient • Advanced Maternal Age • Today’s average age of first time mother is 3.6 years older than in 1970 • Overweight • In 2009, 24.4% of women in childbearing age were considered obese (BMI >30) • More likely to undergo cesarean birth • National rate for C-section delivery is 31.8%

  6. Obesity 30-35% of Texans self-report as “obese”

  7. Globally speaking… Every minute a woman dies from complications related to pregnancy or childbirth Approximately 529,000 women per year

  8. Maternal Death Worldwide } 41% Koch, A. R., Lightner, S., & Geller, S. E. (2018)

  9. Overview

  10. Texas data provided by Dr. Lisa Hollier

  11. Since 2009, obstetric emergencies have 75%associated with delivery complications 114% associated with Postpartum hemorrhage The perinatal team must anticipate and be prepared to respond to obstetric emergencies Committee Opinion #590, 2018

  12. Women’s Services

  13. Recommendations Mechanism for activating a RR based on clinical criteria Multidisciplinary clinical team that responds to, assesses and manages deteriorating patients System for feedback to help mitigate and/or improve future RR events Administrative structure responsible for implementing, training and monitoring all RR events Developed a rapid response (RR) for Perinatal Safety with a focus on physiological deterioration and urgent conditions of maternal and fetal patient population

  14. Recommendations • Planning • Resource Provision • Implementation of an Early Warning System • Implementation of a Rapid Response Team • Training • ***Emergency Drills and Simulation*** • Implementation of the Maternal Fetal Triage Index Preparing for Clinical Emergencies in Obstetrics and Gynecology Committee Opinion #590 Hospital-Based Triage of Obstetric Patients Committee Opinion #667 Committee on Patient Safety & Quality Improvement

  15. Rapid response in the perinatal setting Women’s Services RRT DATA

  16. RRTs by Reason FY18 – FYTD19 43% of RRTs are related to PPH

  17. 46% MBU RRTs by Location FY18 – FYTD19 22% WSU

  18. Postpartum Hemorrhage RRTs by Location FY18 – FYTD19 86% of PPH cases occur after transfer to the MBU

  19. RRTs by Immediate Disposition FY18– FYTD19 31% require surgical intervention

  20. RRTs by Any Post-RRT ICU Admission FY18 – FYTD19 12% result in transfer to ICU status

  21. RRT REBOOT • Review of team members’ role & responsibilities • Patient disposition process • Post RRT patient assessment • Procedural documentation

  22. RRT membership in the pfw • Primary Bedside RN • 1st Emergency Responder LDU RN (ER1) • 2ndEmergency Responder Unit Charge RN (ER2) • Pulmonary Critical Care Physician (PCCM) • Hospitalist/OB Resident (PGY3) • Anesthesiologist/CRNA • Pharmacy • House Supervisor • Respiratory Therapist (RT) • Security

  23. RRT roles & responsibilities Primary RN assumes a lead role during the RRT • Activates RRT to summon help • Remains with the patient prior to team arrival and throughout the RR event • Delegates tasks to other team members as needed • Helper to secure crash cart/PPH cart • Recorder (records details of the RR event in the RRT Navigator) • Runner (to obtain medications and supplies) • Performs ongoing focused assessment/obtains vital signs • Provides SBAR report to responding RRT • Pertinent medical/obstetric history • Other pertinent information (i.e. allergies, medications, lab results) • Indication for activating RR • Interventions performed prior to team arrival

  24. RRT roles & responsibilities Activating Unit’s Charge RN assists the Primary RN/RR Team • Assists with medication preparation or delegates this task • Assists with procedures or delegates this task • Audits EMR to ensure documentation is complete

  25. RRT roles & responsibilities 1st& 2nd RN Responders (ER1/ER2)LDU RN/activating unit’s charge RN who assists the Primary RN/RR Team during the event • ER1 receives SBAR from Primary RN • ER1 reports clinical observations to the team as needed • ER1 & ER2/activating unit’s Charge RN assist with clinical interventions as needed Performs a 1 hour re-assessment if the patient remains on the unit

  26. RRT roles & responsibilities Pulmonary Critical Care Physician (PCCM) and/or Hospitalist/OB Resident (PGY3) • Performs comprehensive assessment • Determines treatment/plan of care • Enters orders as needed • Determines whether patient remains on unit versus transfer to HLOC

  27. RRT roles & responsibilities Pharmacist • Provides emergency medications as needed

  28. RRT roles & responsibilities House Supervisor • Room traffic control • Coordinates transfer to HLOC/room management

  29. RRT roles & responsibilities • Respiratory Therapist (RT) • Performs respiratory assessment/treatments as needed • Provides ventilation/oxygenation as needed • Obtains blood gases if ordered

  30. RRT roles & responsibilities Anesthesiologist/CRNA • Obtain IV access • Manages airway as needed • Assume lead role if RR escalates to OH/MTP or necessity to transfer patient to the operating room

  31. RRT roles & responsibilities Security • Traffic control (hallways/elevators) • Elevator securement • Visitor management

  32. RRT roles & responsibilities findings #1 The primary RN should remain with the patient throughout the RR event • Provides SBAR report to responders • Delegates tasks to other team members (i.e. recorder, runner, etc.) • Assist with medication prep/procedures/transfers #2 The RR Team members should offer coaching & mentoring to the primary RN and the activating unit’s nursing team #3 The RN responder roles/responsibilities should be shared between the LDU RNs and the activating RNs charge RN #4 Charge RN on activating unit ensures that RRT documentation is complete

  33. Drills/Simulation • Conducted periodic drills on the two units with highest incidence of rapid response events • Focused on PPH drills and the hypertensive/eclamptic patient.

  34. Results: a Reduction in OB hemorrhage RRTs Updated the Immediate Postpartum Postpartum Care P&P documents Implemented MEWS Implemented in-situ SIMS Aligned with AWHONN’s 3rd Stage labor Oxytocin infusion

  35. Other initiatives • Obstetric Hemorrhage Algorithm • Adult Massive Transfusion Protocol • Maternal Fetal Triage Index (MFTI) • Maternal Early Warning System (MEWS) • The Alliance for Innovation of Maternal Health (Texas AIM)

  36. Obstetric Hemorrhage Algorithm (*related to uterine atony)

  37. Adult Massive Transfusion Protocol (MTP)

  38. AWHONN Maternal fEtal Triage Index (MFTI)

  39. Maternal early Warning system (Mews)

  40. TEXAS AIM data

  41. Patient safety bundle: Obstetric Hemorrhage • Readiness • Recognition & Prevention • Response • Reporting/Learning

  42. Our goal as a perinatal team: Healthy Mom, Healthy Newborn, Happy Family! #oneamazingteam

  43. References (n.d.). Clinical Update: Improving response to signs of patient deterioration. Retrieved fromhttps://www.nursingtimes.net/roles/practice-nurses/clinical-update-improving-response-to-signs-of-patient-deterioration/296278.article#. (2016). Committee Opinion No. 667. Obstetrics & Gynecology, 128(1). doi: 10.1097/aog.0000000000001524. (2014). Committee Opinion No. 590. Obstetrics & Gynecology, 123(3), 722–725. doi: 10.1097/01.aog.0000444442.04111.c6. (2011). Guidelines for Professional Registered Nurse Staffing for Perinatal Units Executive Summary. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40(1), 131–134. doi: 10.1111/j.1552-6909.2010.01214.x. AWHONN. Guidelines for Oxytocin Administration after Birth: AWHONN Practice Brief Number 2. (2015). Nursing for Womens Health,19(1), 99-101. doi:10.1111/1751-486x.12199. Aebeersold, M., & Tschannen, D. (2013). Simulation in nursing practice: The impact on patient care. The Online Journal of Issues in Nursing, 18(2), manuscript 6. doi:10.3912/OJIN.Vol18NoO2Man06. Brown, H. L., Simpson, L. L., & Eckler, K. (2019, May 22). Overview of maternal mortality and morbidity. Retrieved from https://www.uptodate.com/contents/overview-of-maternal-mortality-and-morbidity. Women’s Services

  44. References, continued Green, M., Rider, C., Ratcliff, D., & Woodring, B. C. (2015). Developing a Systematic Approach to Obstetric Emergencies. Journal of Obstetric, Gynecologic & Neonatal Nursing, 44(5), 677–682. doi: 10.1111/1552-6909.12729. Koch, A. R., Lightner, S., & Geller, S. E. (2018). Identifying Maternal Deaths in Texas Using an Enhanced Method, 2012. Obstetrics & Gynecology, 132(2), 520–521. doi: 10.1097/aog.0000000000002771. Massey, D., Chalboyer, W., & Anderson, V. (2016). What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open,1-18. doi:10.1002/nop2.53. (n.d.). Maternal and Child Health Epidemiology Program | Reproductive Health | CDC. Retrieved from https://www.cdc.gov/reproductivehealth/mchepi/index.htm. Petersen EE, Davis NL, Goodman D, et al. Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;68:423–429. DOI: http://dx.doi.org/10.15585/mmwr.mm6818e1external icon. Vincent, J., Einav, S., Pearse, R., Jaber, S., Kranke, P., Overdyk, F. J., . . . Hoeft, A. (2018). Improving detection of patient deterioration in the general hospital ward environment. European Journal of Anaesthesiology,1. doi:10.1097/eja.0000000000000798. Women’s Services

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