Bridging the Gap

1. Bridging the Gap Jennifer L. Brockmeyer , RN-BSN, MS. Mount Carmel-St. Ann’s September 13, 2013-Friday

2. Presentation Overview • Effective Communication • Sentinel Event • Event Debriefing/Root Cause Analysis • Skills Erosion • QI Initiative • Direct Communication • Implementation • Conclusion

3. We Have a Problem • L & D Nurses identified: • -Lack of Understanding by some EMS units about complications and potentially life threatening events • -Lack of timely/adequate communication among EMS/ED/L&D • -Assumptions by staff that EMS and ED staff “should know” all the proper information to gather, steps to take, etc….

4. Top Priority-Effective Communication Joint Commission-2005 Communication Failures Leading cause of preventable patient injuries & death Effective Communication is most vulnerable during patient hand off

5. Agency for Healthcare Research & Quality 2012 • -potential ineffective & fragmented communication • -established a • NATIONAL GOAL to create a safer hand off process • -Communication between EMS and L & D • -SAFE HAND OFF • Vital to the outcome of the mother and fetus

6. HAND OFF-Multiple Indicators • EMS care provided • Pre hospital communication • Hand off EMS-ED • Evaluation in ED • Hand off ED-L& D • Process leads to third hand information

7. SENTINEL EVENT ALERT-2010 • STUDY DONE BY CENTERS FOR DISEASE CONTROL, IN UNITED STATES BETWEEN 1991-1997 • Leading cause of Maternal Death included: • hemorrhage • hypertensive disorder • pulmonary embolism • infection • pre-existing conditions

8. Sentinel Event 2009 Maternal & Fetal Mortality • RESULT • -inadequate assessment • -incomplete transmission of information • -communication between EMS & receiving medical personnel

9. Event Debriefing Root Cause Analysis • Identify key points for improvement: • -professional discussion • -performance standards • -what happened • -why it happened • -how to sustain strengths • -improve on weaknesses • -identify basic and contributing factors • -underlying performance variations associated with adverse events • ( Hsu, 2007)

10. Root Cause Analysis-4 step process 1 Prepare 2 Identify Factors 3 Create Ideas Implement Process 4

11. Event Debriefing • MEETINGS • Director of Emergency Medical Services • Emergency Medical Services Coordinator from • the ED • Labor and Delivery Personnel • Emergency Medical Personnel • Emergency Department Personnel

12. Skill Erosion • EMS has infrequent calls for emergencies involving a pregnancy • Low percentage of calls • Subject to knowledge and skill erosion • Lack of physical assessment skills • Inability to recognize acuity level • Inability to communicate pertinent information • RCA CONCLUDED • EMS needs for training in obstetrical emergencies • EMS needs knowledge to determine acuity • Vital patient information

13. Quality Improvement Initiative:Address pre hospital assessment & direct communicationPrevent delay in patient treatment & medical intervention • -INITIAL PHASE • -Letter sent to all EMS stations • -Create obstetrical quick reference resource • -Create communication tools • -Change communication protocols

14. INITIAL PHASE RESPONSE • -Positive response from EMS • -Re-affirmed skills erosion • -Re-affirmed inability to attain acuity level • -COLLABORATIVE EFFORTS • *Identified issues were addressed*

15. QUICK TIPS FOR OBSTETRIC PATIENTS • -Most common obstetrical emergencies to include: HEMORRHAGE • ABRUPTIO PLACENTAE • PLACENTA PREVIA • PRE-ECLAMPSIA • VAGINAL DELIVERY • -L & D Nurses & EMS personnel developed resource document

16. Quality Improvement Initiative:INCOMING OBSTETRIC PATIENT CARE REPORT • -SECOND PHASE • -Provide EMS personnel a form • -Capture critical information • -Specific to the pregnant patient • -Developed in likeness of a familiar format

17. SBAR Approach 1 Situation 2 Back Ground 3 Assessment recommendation 4

18. Incoming Obstetric Patient Report ( IOPR) • -Using SBAR • Underwent final review & refinement • FINAL PHASE • -Literature review • -Details regarding terminology • -Printed on pink paper for rapid identification

19. Patient Treatment Delay • -Delay identified related to hospital policy • -Traditional communication pathway • NEW POLICIES ESTABLISHED • -pregnant patient 16+ weeks gestation-direct to L & D • -communication from EMS is directly to L & D

20. Implementation IOPR & QUICK TIPS PILOT Meetings to review process Refinement via practice scenarios Care specific to pregnant patient 30 % improvement reported from EMS

21. TRUE TEST INITIATIVE Direct transfer via EMS to L & D 39 week gestation patient • EMS implemented IOPR & Quick Tips Placenta previa was identified by EMS L & D prepared for immediate cesarean section RESULT OF HEALTHY MOTHER AND CHILD!

22. Top Priority-Effective Communication Poor Communication found to be ROOT CAUSE in over 80% of preventable deaths & injuries Communication Imperative!! In perinatal care, a normal condition has potential to become critical very quickly

23. CONCLUSION • It is VITAL for all medical personnel to be aware • A woman, whatever her complaints, may be pregnant or may have recently • been pregnant. • OVERALL GOAL • Stability of the mother & • the fetus

24. Communication • Vital part of healthcare • Requires a sender, a message & a receiver • Process is complete with understanding of the message • Effective communication relies on capability and interpretation of information • Communication must be evaluated on a continuing basis • WHEN COMMUNICATION IS DISRUPTED, PATIENTS CAN BE PLACED AT RISK!!

25. References • Agency for Healthcare Research and Quality (2012). Crew resource management and its applications in medicine. January 19, 2012. • Benrubi, G. I. (2010). Handbook of Obstetric and Gynecologic Emergencies. (4th ed.). WoltersKluwer/ Lippincott Williams & Wilkins, Philadelphia. • Clancy, C. M. (2008). AHRQ commentary. the importance of simulation: Preventing hand-off mistakes. AORN Journal, 88(4), 625-627. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010058400&login.asp&site=ehost-live • Collins, D. E. (2008). Multidisciplinary teamwork approach in labor and delivery and electronic fetal monitoring education: A medical-legal perspective. The Journal of Perinatal & Neonatal Nursing, 22(2), 125-132.

26. References • Defective handoffs reduced by 52%. (2011). ED Management, 3-4. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010938527&login.asp&site=ehost-live • Kelly, A. E. (2005). Relationships in emergency care: Communication and impact. Topics in Emergency Medicine, 27(3), 192-197. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009029556&login.asp&site=ehost-live • Lingafelter, M., Brockmeyer, J., Foley, P (2012). Bridging the Gap: Building a Collaborative Relationship between Labor and Delivery and Emergency Medical System Response Units. JOGGN, 2011, S93. • McEwen, M. and Wills, E. (2011). Theoretical basis for nursing (3rd ed.) Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins.

27. References • Sexton, J. B., Holzmueller, C. G., Pronovost, P. J., Thomas, E. J., McFerran, S., Nunes, J., . . . Fox, H. E. (2006). Variation in caregiver perceptions of teamwork climate in labor and delivery units. Journal of Perinatology, 26(8), 463-470. • The Joint Commission (2012). National Patient Safety Goals Effective January 1, 2012. • The Joint Commission: “Preventing maternal death.”Sentinel Event Alert, Issue 44, January 26, 2010. Retrieved from http://www.jointcommission.org/SentinelEvents/Sentinel EventAlert/sea_44.htm (Accessed September 20, 2011) • Williams, P. M. (2001). Techniques for root cause analysis. Baylor University Medical Center Proceedings, 14(2), 154-157

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