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Designing and Implementing a Perinatal Quality, Risk and Safety Program
INNOVATIVE PROGRAMS Proceedings of the 2017 AWHONN Convention
Simulation Education to Enhance Nurse Knowledge and Improve Response to Postpartum Hemorrhage Jeanne L. Ings, MSN, RNCOB, University of California, Davis Medical Center and Children’s Hospital, Sacramento, CA Keywords postpartum hemorrhage obstetrics severe bleeding
Obstetric Poster Presentation
Purpose for the Program o increase perinatal nurses’ ability to recognize and respond to postpartum hemorrhage (PPH) emergencies. Specifically, the program aimed to educate nurses regarding risk factors for hemorrhage, provide for rapid mobilization of staff, familiarize nurses with the contents of a PPH cart, and teach ways to more accurately quantify blood loss. Improved recognition and response to PPH emergencies has been demonstrated to decrease maternal morbidity and mortality from this largely preventable occurrence.
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Proposed Change To increase perinatal nurses’ critical thinking skills and proficiency in responding to PPH emergencies, all bedside perinatal nurses would complete an educational presentation and participate in PPH simulation scenarios.
Implementation, Outcomes and Evaluation The didactic course was implemented using lecture and PowerPoint slides, followed by simulation scenarios with case studies in PPH. The team approach included bedside registered nurses, obstetricians, and anesthesia personnel. Debriefing sessions were conducted after the simulation and allowed for self-reflection. Pretest and posttest outcomes demonstrated an increase in nursing knowledge after completing the course. Nurses retained the newly acquired knowledge when retested after a 3-month evaluation period. Implications for Nursing Practice Educating bedside nurses on the tools needed for rapid response to PPH emergencies decreases confusion and increases communication between team members. Implementation of a PPH cart allowed team members to coordinate efforts, more accurately quantify maternal blood loss, and respond more quickly to PPH emergencies.
Designing and Implementing a Perinatal Quality, Risk and Safety Program Kathleen DeMarco, MSN, RN, Purpose for the Program NE-BC, CPHQ, NYU Langone ost cases of maternal mortality are preMedical Center, New York, NY
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Jessica Deeb, MS, RN, WHNPBC, IBCLC, LCCE, NYU Langone Medical Center, New York, NY Keywords severe maternal morbidity perinatal quality risk & safety program obstetric hemorrhage
Obstetric Poster Presentation
ventable, making it important to study severe maternal morbidity events in order to find areas of improvement. In 2015, the Joint Commission expanded its definition of sentinel event to include cases of severe temporary harm. For obstetrics, this includes cases of severe maternal morbidity, defined as a patient receiving four or more units of packed red blood cells and/or admission to an intensive care unit. Proposed Change To improve quality and safety, NYU Langone launched the Perinatal Quality, Risk & Safety Program (the Quality Program) in January of 2016 with the goal of using robust data analysis and multidisciplinary team collaboration to study our severe morbidity cases and opportunities for improvement. Implementation, Outcomes and Evaluation In the first 9 months since its inception, the Quality Program has produced detailed analysis
JOGNN 2017; Vol. 46, Supplement 3S
on more than 200 obstetric hemorrhage cases and identified areas for staff education and practice change. The program also developed a physician scorecard to track individual obstetrician and group performance across key quality metrics. Additionally, a process was implemented to conduct extensive reviews on cases of severe maternal or fetal morbidity at monthly multidisciplinary quality assurance meetings. To date, the Quality Assurance Committee has reviewed more than 40 cases, and several projects are being implemented based on the committee’s recommendations. Implications for Nursing Practice The Quality Program has produced valuable tools and systems to evaluate our practice and make improvements based on the data. Sharing our experience will benefit others who wish to implement similar programs at their institutions.
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Simulation Education to Enhance Nurse Knowledge and Improve Response to Postpartum Hemorrhage Jeanne L. Ings, MSN, RNCOB, University of California, Davis Medical Center and Children’s Hospital, Sacramento, CA Keywords postpartum hemorrhage obstetrics severe bleeding
Obstetric Poster Presentation
Purpose for the Program o increase perinatal nurses’ ability to recognize and respond to postpartum hemorrhage (PPH) emergencies. Specifically, the program aimed to educate nurses regarding risk factors for hemorrhage, provide for rapid mobilization of staff, familiarize nurses with the contents of a PPH cart, and teach ways to more accurately quantify blood loss. Improved recognition and response to PPH emergencies has been demonstrated to decrease maternal morbidity and mortality from this largely preventable occurrence.
T
Proposed Change To increase perinatal nurses’ critical thinking skills and proficiency in responding to PPH emergencies, all bedside perinatal nurses would complete an educational presentation and participate in PPH simulation scenarios.
Implementation, Outcomes and Evaluation The didactic course was implemented using lecture and PowerPoint slides, followed by simulation scenarios with case studies in PPH. The team approach included bedside registered nurses, obstetricians, and anesthesia personnel. Debriefing sessions were conducted after the simulation and allowed for self-reflection. Pretest and posttest outcomes demonstrated an increase in nursing knowledge after completing the course. Nurses retained the newly acquired knowledge when retested after a 3-month evaluation period. Implications for Nursing Practice Educating bedside nurses on the tools needed for rapid response to PPH emergencies decreases confusion and increases communication between team members. Implementation of a PPH cart allowed team members to coordinate efforts, more accurately quantify maternal blood loss, and respond more quickly to PPH emergencies.
Designing and Implementing a Perinatal Quality, Risk and Safety Program Kathleen DeMarco, MSN, RN, Purpose for the Program NE-BC, CPHQ, NYU Langone ost cases of maternal mortality are preMedical Center, New York, NY
M
Jessica Deeb, MS, RN, WHNPBC, IBCLC, LCCE, NYU Langone Medical Center, New York, NY Keywords severe maternal morbidity perinatal quality risk & safety program obstetric hemorrhage
Obstetric Poster Presentation
ventable, making it important to study severe maternal morbidity events in order to find areas of improvement. In 2015, the Joint Commission expanded its definition of sentinel event to include cases of severe temporary harm. For obstetrics, this includes cases of severe maternal morbidity, defined as a patient receiving four or more units of packed red blood cells and/or admission to an intensive care unit. Proposed Change To improve quality and safety, NYU Langone launched the Perinatal Quality, Risk & Safety Program (the Quality Program) in January of 2016 with the goal of using robust data analysis and multidisciplinary team collaboration to study our severe morbidity cases and opportunities for improvement. Implementation, Outcomes and Evaluation In the first 9 months since its inception, the Quality Program has produced detailed analysis
JOGNN 2017; Vol. 46, Supplement 3S
on more than 200 obstetric hemorrhage cases and identified areas for staff education and practice change. The program also developed a physician scorecard to track individual obstetrician and group performance across key quality metrics. Additionally, a process was implemented to conduct extensive reviews on cases of severe maternal or fetal morbidity at monthly multidisciplinary quality assurance meetings. To date, the Quality Assurance Committee has reviewed more than 40 cases, and several projects are being implemented based on the committee’s recommendations. Implications for Nursing Practice The Quality Program has produced valuable tools and systems to evaluate our practice and make improvements based on the data. Sharing our experience will benefit others who wish to implement similar programs at their institutions.
S17