Development of an Obstetric Vital Sign Alert to Improve Outcomes in Acute Care Obstetrics

Development of an obstetric vital sign alert to improve outcomes in acute care obstetrics

Diana J. Behling Michelle Renaud

Maternal morbidity and mortality is a national health problem. The 2006 to 2010 pregnancy-related mortality ratio was calculated by Creanga et al. (2015) as 16.0 deaths per 100,000 live births. This is up from the 1998 to 2005 mortality ratio of 14.5 deaths per 100,000 live births (Centers for Disease Control and Prevention [CDC] 2014), and from the ratios of 11.5 and 9.1 deaths per 100,000 live births for 1991 to 1997 and 1987 to 1990, respectively (Berg, Chang, Callaghan, & Whitehead, 2003). Additionally, considerable racial disparities in pregnancyrelated mortality exist. During the 2006 to 2007 period, the pregnancy-related mortality ratios were 11.0 deaths per 100,000 live births for white women, 34.8 deaths per 100,000 live births for black women and 15.7 deaths per 100,000 live births for women of other races (Heron et al., 2009). While maternal mortality is a relatively rare event, maternal morbidity remains a problem, with 31.1 percent of pregnant females suffering complications during hospitalized labor and delivery in 2007 (Martin et al., 2006). Causal analysis of near-miss and actual serious patient safety events within obstetric units, including those resulting in maternal death, often highlights a failure to promptly recognize and treat women who were exhibiting signs of decompensation/deterioration. Abstract: Maternal morbidity and mortality is a national health problem. Causal analysis of near-miss and actual serious patient safety events, including those resulting in maternal death, within obstetric units often highlights a failure to promptly recognize and treat women who were exhibiting signs of decompensation/deterioration. The Obstetric Vital Sign Alert (OBVSA) is an early warning tool that leverages discrete data points in the electronic health record, calculating a risk score that is displayed as a visual cue for acute care obstetric staff. When studied in a cohort of women with postpartum hemorrhage, use of the OBVSA reduced symptom-to-response time and intervention time, as well as key process and outcome measures. DOI: 10.1111/1751-486X.12185 Keywords: early warning | maternal morbidity | maternal mortality | obstetric emergency | obstetric vital sign alert | postpartum hemorrhage

Diana J. Behling, DNP, RN, MJ, CPPS, is manager of the OB Right Program and is nursing lead of the Women’s Health Clinical Team at Sentara Healthcare in Norfolk, VA. Michelle Renaud, PhD, RN, is an associate professor of nursing in the Doctor of Nursing Practice Program at Old Dominion University in Norfolk, VA. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: [email protected].

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patient safety Much attention has been paid to the concept of patient safety over the past 20 years. The Institute of Medicine (IOM) defines patient safety as freedom from injuries or harm to patients from care that is intended to help them (Kohn, Corrigan, & Donaldson, 2000). The Agency for Healthcare Research and Quality (AHRQ) defines it as freedom from potentially preventable complications, iatrogenic events, accidental injury or illness resulting from the processes of care (AHRQ, 2003). The National Quality Forum (NQF) defines patient safety practices as clearly recognizable processes or manners of providing care that have an evidence base demonstrating that they reduce the likelihood of harm due to the systems, processes or environments of care (NQF, 2010). The former Joint Commission’s National Patient Safety Goal 16 (recognize and respond to changes in a patient’s condition) now the Provision of Care, Treatment and Services standard, PC.02.01.19, is applicable to the care of women during labor and birth and requires in part for the hospital to:

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Nurse surveillance is a process through which nurses monitor, evaluate and act upon emerging indicators of a woman’s change in status (Kutney-Lee, Lake, & Aiken, 2009). Patient safety in all specialty areas is based on close surveillance and well-chosen, well-executed responses to women’s problems by an interdisciplinary team (Simpson, 2005). While care is delivered by the interdisciplinary team, bedside nurses remain the eyes and ears of the team 24 hours a day, providing assessment, intervention and communication about a woman’s condition. The background, training and experience level of nursing providers in obstetric units may vary from novice to expert. While complex cases may be assigned to more experienced staff, the case of a woman at risk for decompensation/ deterioration in the obstetric unit is often unpredictable. Patients with an “at-risk” diagnosis can be monitored on a more frequent and intense basis, but that alone doesn’t guarantee early recognition of impending problems. Likewise, women deemed “normal” are at risk to develop rapid-onset life-threatening conditions such as amniotic fluid embolism, acute postpartum hemorrhage (PPH) and pulmonary embolism, for example. Lesser experienced staff caring for these women may miss early constellations of troublesome symptomatology in rapidly developing conditions including cardiac, embolic, hemorrhagic and infectious complications. In addition to the nursing expertise at the bedside and the inherent risk of obstetric complications, the introduction of the electronic health record (EHR) has made negative patient trends at times difficult to appreciate. While some EHRs allow for a quick look at vital signs graphs and trends, the system relies on users being proactive in their habits to actually look at these trends. A large collection of clinical data points, such as temperature, pulse, respiration, peripheral oxygen saturation, level of consciousness, urine output and bleeding, exists within the EHR along with varied responses to the recognition of the woman’s condition based on the clinical data points by the interdisciplinary team. In simple terms, the EHR can make it difficult to see the forest through the trees.

• Have a process for recognizing and responding as soon as a patient’s condition appears to be worsening; • Develop written criteria describing early warning signs of a change or deterioration in a patient’s condition and when to seek further assistance; • Based on the hospital’s early warning criteria, have staff seek additional assistance when they have concerns about a patient’s condition (The Joint Commission, 2010).

failure to rescue The concept of failure to rescue (failure to recognize, or act upon, early signs of distress) was first introduced in the 1990s as a measure of hospital performance in the care of the adult postsurgical patient population (Clarke & Aiken, 2003). Recently, failure to rescue (e.g., failure to diagnose and treat in time) has been used for evaluating quality and quantity of nursing care by comparing the number of surgical patients who develop common complications and survive to those who don’t (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002). Nurses are often the first members of the health care team to detect subtle signs and symptoms of developing complications; thus, their

Causal analysis of near-miss and actual serious patient safety events within obstetric units, including those resulting in maternal death, often highlights a failure to promptly recognize and treat women who were exhibiting signs of decompensation/deterioration contribution to the rescue process is crucial. A nurse’s role in alerting the team and mobilizing its response has a direct impact on the ultimate outcome. Supporting that detection via meaningful use of the EHR could be a key factor in reducing maternal morbidity and mortality. Attempts to develop descriptive models of preventability for maternal morbidity and mortality that can be used in quality assurance and morbidity and mortality review processes have

figuRe 1

Anatomy of an Obstetric Safety Event Anatomy of an Obstetric Safety Event LATENT FAILURES Every step in the care delivery process has the potential for failure, to some degree, whether individual or team error.

Failure to Communicate Changes in Maternal Condition Failure to Create Shared Mental Model – Situational Awareness

Failure to Appreciate Subtle Vital Sign Changes

Failure to Relate Vital SignsSymptoms to Condition

Failure to SBAR Failure to Stop For Safety Failure to Escalate

Failure to Question Assumptions, Continue on Erroneous Path

Failure to Make Correct, Timely Diagnosis

OUTCOME DEFENSES For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error.

Maternal Morbidity -Mortality

Original figure based on Swiss Cheese Model concept from Reason, J. (1990) Human Error. Cambridge: University Press, Cambridge.

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been made. In one analysis of 237 women, there were 79 women with preventable events attributable to provider or system factors. The most common types of preventable events were inadequate diagnosis/recognition of high risk (54.4 percent), treatment (38.0 percent) and documentation (30.7 percent; Geller, Cox, & Kilpatrick, 2006). The Swiss Cheese Model of Reason provides a conceptual framework to “see” an evolving obstetric near-miss or actual patient safety event (see Figure 1). Highly reliable teams form shared mental models of the care delivery process. Within the care delivery process, the interdisciplinary team collects and assimilates much data in ever-changing conditions of patient volume and acuity as situational awareness. Detrimental changes

Nurses are often the first members of the health care team to detect subtle signs and symptoms of developing complications; thus, their contribution to the rescue process is crucial in a woman’s condition are often subtle at the start and may be underappreciated or missed altogether. Within the team varying levels of expertise may lead to varying levels of response to these changes. Clinical staff with good intent to provide excellent care may miss the opportunity to intervene early in the evolution of deterioration. Defenses to these types of latent failures include monitoring, leadership and critical thinking, all of which optimize staff awareness and response into reproducible care delivery models. These care delivery models include clear policies and procedures and care pathways for clinical situations—such as treatment of severe hypertension or hemorrhage—that guide a nurse to the appropriate interventions.

obstetric early Warning scoring The development of early warning systems from routinely collected patient parameters arose from the knowledge that physiologic abnormalities precede critical illness (Goldhill, White, & Sumner, 1999). These tools have been utilized in a variety of medical-surgical settings to prevent out-of-unit codes, for example. In the United Kingdom, the 2003 to 2005 Confidential Enquiry into Maternal and Child Health report recommended the introduction of the modified early obstetric warning system (MEOWS) in all obstetric inpatients to track maternal physiologic parameters, and to aid early recognition and treatment of deteriorating obstetric patients (Lewis, 2007). In one study of the

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MEOWS, 200 obstetric patients (30 percent) triggered and 86 patients (13 percent) had morbidity according to criteria, including hemorrhage (43 percent), hypertensive disease of pregnancy (31 percent) and suspected infection (20 percent). The MEOWS was 89 percent sensitive (95 percent CI, 81 percent to 95 percent) and 79 percent specific (95 percent CI, 76 percent to 82 percent), with a positive predictive value 39 percent (95 percent CI, 32 percent to 46 percent) and a negative predictive value of 98 percent (95 percent CI, 96 percent to 99 percent), suggesting that MEOWS is a useful bedside tool for predicting morbidity (Singh, McGlennan, England, & Simons, 2012). Quality improvement projects’ use of paper early warning tools has been trialed utilizing specific trigger scores to prompt charge nurse, midwife and/or physician notification of a woman’s status and mobilization of the rapid response team (Lynch & Davila, 2010). There’s a dearth of studies that tie obstetric early warning scores to actual health outcomes, none of which were found to utilize an autocalculation feature available in the EHR.

obstetric vital sign alert (obvsa) project While a body of knowledge has evolved in the application of early warning scoring systems in the medical-surgical population to prevent out-of-unit codes, there are currently limited attempts to extrapolate their usefulness in the obstetric population. In 2011, the Sentara Women’s Health Clinical Effectiveness Council sought a method to automate the scoring and trigger tools, and optimize use of the EHR and the team response to changing patient conditions while building on the work of MEOWS and other early warning systems. To provide a robust review from multiple clinical perspectives, an interdisciplinary collaborative was formed and included maternalfetal medicine physicians, OB/GYN generalists, clinical nurse specialists from high-risk and community settings and bedside obstetric nurses. A review of literature in the obstetric and medical specialty areas, as well as a review of near-miss and patient safety events, was completed over the prior years. The OBVSA project sought to address the inadequate recognition of deteriorating patient conditions by examining the potential to leverage data collection and nursing documentation in the EHR into a meaningful, useful tool to support surveillance, critical thinking and situational awareness among the interdisciplinary treatment team. OBVSA, an electronic autocalculated tool similar to others described in nursing literature, was developed with parameters appropriate to the obstetric population, vetted through maternal-fetal medicine experts, built into the EPIC® EHR and implemented it in all acute care obstetric units.

scoring system The OBVSA scoring system utilizes six critical variables, each of which is assessed and scored according to established ranges,

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two deviations above and below identified normal ranges. Variables are updated in real time by suspension of the vital sign validation requirement in EPIC® and display as distinct data points on an electronic dashboard that includes all unit patients, location and the last resulted hemoglobin and platelet count, along with the estimated blood loss documented for women who have given birth. As each individual data point is collected electronically, the overall score updates and adjusts the display accordingly. For example, if pulse measurement increased to 130 beats per minute (bpm), as might be the case in hemorrhage, the pulse parameter would cause recalculation of the overall score. The dashboard is visible at each nurses’ station, as is the homepage view of the nursing patient list. The dashboard display feature allows anyone on the interdisciplinary team to see any change in the woman’s condition in real time, prompting the team to act. The OBVSA aggregate score corresponds to an action algorithm. Aggregate scores of ≤2 are considered normal and require no additional intervention other than the established treatment plan. Scores of 3 to 4 signify modest deviations from expected normal, and scores ≥5 signify moderate to severe deviations from expected value. Nursing protocol requires documentation of the OBVSA score as well as interventions utilized on admission, at handoff when level of care is changing and when the OBVSA fires yellow or red. OBVSA documentation also includes baseline

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sepsis assessment, which was not a primary focus of this research. OBVSA algorithm directed interventions are shown in Figure 2. Beyond the OBVSA algorithm, specific interventions appropriate to a woman’s diagnosis and condition are contained in the related documents, such as the Health System Postpartum Hemorrhage Care Pathway or the Procedure for

Rather than looking for “big saves”, the teams were able to recognize a shift in perspective to managing those subtle changes that, if unchecked, could mean increased risk for morbidity or even mortality Management of Severe Hypertension. Identification and communication with the clinical team prompted by the OBVSA algorithm allows for further evaluation and the establishment of individualized plan of care for subsequent monitoring, notification and clinical review that is beyond the scope of the basic algorithm. Some women’s conditions may call for subsequent vital sign assessments every 5 minutes while others may allow for every 15 or 30 minutes. Ultimately the treatment team will reestablish a shared mental model about the

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figuRe 2

Action Protocol Associated With OBVSA Scoring The OBVSA algorithm prompts nursing action based on a woman’s aggregate OBVSA score.

Assess Patient

Take Action

Score 0-2

Score 3-4

Score 5-8+

Continue to monitor and assess patient at ordered intervals

 Check equipment function and troubleshoot as needed  Perform assessment of the patient, critically thinking about potential etiology of the score  View vital sign trend line  Implement Nursing interventions as appropriate  Notify Charge Nurse of OBVSA score and trend  Document assessment, intervention and outcome

 Check equipment function and troubleshoot as needed  Perform assessment of the patient, critically thinking potential etiology of the score  View vital sign trend line  Implement Nursing interventions as appropriate  Notify Charge Nurse of OBVSA score and trend  Notify MD/CNM of patient score, condition and assessment  Consider calling Medical Response Team  Document assessment, intervention and outcome

patient condition that integrates the historical patient information with the recognized changes in patient vital signs, and formulates next steps in the care plan.

implementation Before OBVSA was implemented, educational sessions were delivered to nurses, residents and attending physicians. Sessions were designed to build the case for an early warning scoring methodology and obtain buy-in of the clinical staff. An “elevator speech” was developed to succinctly convey the objective of the project: If the project is successful, women at risk for clinical compromise will be identified quickly, with critical thinking guiding interventions carried out to address the clinical issue resulting in improvement in outcomes. Case studies were utilized to demonstrate not only the path of clinical deterioration often seen in women with developing illness but also the benefit of early intervention in preventing harm. Comparisons to similar projects in the medical-surgical

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Monitor vital signs at more frequent intervals until they return to baseline or score is less than 3

about

Monitor vital signs at more frequent intervals until they return to baseline or score is less than 3

environment to prevent out-of-unit codes as well as those designed to “strike out sepsis” were discussed. There was a general sense of agreement among the interdisciplinary team that the project was worthy of implementation and study. Following the OBVSA go-live, adjustments were made to the low temperature and low pulse oximetry scores that triggered a score of “1,” as it was felt that those factors were not clinically significant. Removal of these two scores, (1) for low temperature and (1) for low pulse oximetry, decreased trigger that was considered white noise without added value. Anecdotal stories of cases in which the staff noted the OBVSA score alerting them to a woman’s condition in a significant way were collected and shared at departmental staff and safety meetings (see Box 1). Sharing stories such as these over time helped build the case for the value of real-time surveillance and notification of the team via the dashboard versus relying on each individual assessment to be assimilated by team members into an overall picture of the patient and unit acuity. Rather than looking for “big saves”, the teams were able to recognize a shift in perspective to

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Within In Range

Box 1

Case Examples of OBVSA in Action Patient 1, a 39-week G1 P0, is admitted with pre-eclampsia on magnesium sulfate at 2 g/hour, undergoing cervical ripening, demonstrated a “3” OBVSA, scoring 1 point for systolic blood pressure and 2 points for sPO2 at 93 percent at 09:00 a.m. The score was noted by the RN, the equipment was checked, assessment of the woman was done, and her lungs were auscultated, among other interventions. Prompted by the yellow OBVSA and assessment date, the team was at a higher state of vigilance, adjusting the standard pre-eclampsia pathway and performing more frequent assessments related to respiratory function. Within the hour, the woman went on to develop crackles in her left lung along with decreased reflexes and somnolence. The team quickly recognized the change in status and was able to respond with appropriate intervention. In the absence of the OBVSA alert, it is unknown if the subtle sign of a lower pulse oximetry reading would have been recognized and attended to in a busy unit full of women, many of whom have pulse oximetry consistently providing data. Patient 2 is a 30-year-old G2 P0010 at 30- and 0/7week gestation initially presenting to an outlying facility, BP range 160-170/100 seconds, started on magnesium sulfate and betamethasone and given labetalol for blood pressure management; she was then transported to a tertiary facility and admitted for severe pre-eclampsia to rule out HELLP. She underwent cesarean surgical birth, during which she received spinal narcotics for pain relief. She remained on magnesium sulfate in the postoperative period with labile blood pressure documented in notes. The OBVSA score demonstrated a “5”, scoring 1 point for systolic blood pressure, 2 points for diastolic blood pressure and 2 points for low sPO2 at 86 percent. Her postoperative cesarean status, clinical diagnosis and body habitus put her at risk for respiratory compromise. She required coverage with labetalol and nifedipine to manage pressures resulting from worsening pre-eclampsia with developing HELLP syndrome. In this case, OBVSA identified a woman of interest who, while already identified as high risk, was demonstrating a change in her clinical status prompting more frequent assessments of respiratory status and some intervention to optimize respiratory function.

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managing those subtle changes that, if unchecked, could mean increased risk for morbidity or even mortality. It was also important to reinforce the screening (with the primary purpose to detect early disease or risk factors for disease in large numbers of apparently healthy individuals) versus diagnosis (to establish presence/absence of disease) aspect of the tool and goals, which adjust to fit a woman’s changing presentation and the intensity and frequency of monitoring and evaluation; initiation of resuscitative and diagnostic interventions and consider the evolving differential until a diagnosis is confirmed, or until the condition is resolved or a woman is transferred to a higher level of care, such as the ICU. For example, scoring tachycardia outside of the normal range at 126 bpm can mean different things at different points of time in the care of a woman. Transient pain of contractions in a woman experiencing natural childbirth can produce a tachycardia that requires no specific intervention, as it doesn’t indicate deterioration or disease. Contrast that with a woman who has a blood pressure of 80/46 mmHg and is in the compensatory stages of early shock with a tachycardia of 126 and rightfully requires more frequent and scrutinous monitoring. In each case, the OBVSA will get the team’s attention to begin planning for what, if anything, should be done to address the score components. Ongoing audit and follow-up for compliance with the tool and algorithm were conducted by system safety specialist and unit educators in all facilities.

stuDy setting The five site facilities varied in designation, size and resources. The facilities consisted of a level-one trauma center with quaternary obstetric services and four community hospitals. The level-one hospital has residents and attending physicians onsite 24 hours daily; the community hospitals do not. None of the physician practices are health system–owned, and none cross-cover at places other than the primary facility. Nursing staff members vary in experience and educational level. The database consisted of 413 patient records of women with the diagnosis of PPH from the 8 months pre- and postOBVSA implementation period. A total of 319 records were excluded, as the hemorrhage was discovered and treated in the delivery-operating room without postdelivery sequelae; estimated blood loss was below threshold of 500 cc for vaginal birth or 1,000 cc for cesarean, or records didn’t meet the threshold to fire the OBVSA to yellow or red. This left 94 records, 44 from the preimplementation and 50 from the postimplementation periods, to evaluate against the OBVSA tool. These remaining cases were hemorrhages that evolved outside of the immediate delivery period, either in the recovery room phase of care or after transfer to postpartum. Variations of PPH as defined by estimated blood loss, from mild to severe, were included in the database. The database did not account for comorbidities.

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In between-group comparisons, the use of the OBVSA reduced symptom-to-intervention time in the population experiencing PPH (see Figure 3). The postintervention outcomes of maximum pulse and estimated blood loss demonstrated statistically significant improvement (see Table 1). Optimizing

optimizing staff recognition of changes in a woman’s condition is considered a cornerstone in early intervention and support for best health outcomes staff recognition of changes in a woman’s condition is considered a cornerstone in early intervention and support for best health outcomes. In between-group comparisons, the postintervention outcomes of minimum blood pressure, lowest hemoglobin, units of blood products transfused and length of stay showed some improvement that did not rise to statistical significance. The failure of the intervention to produce statistically significant improvements in these measures may be related to differences in practice patterns of individual providers versus actual value of the OBVSA tool. Interventions to standardize evidence-based

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care pathways for management of PPH may improve the results in further study.

stuDy limitations The actual sample could be affected by other factors not controlled for, such as volume and acuity of the labor and delivery and postpartum units, experience level of the registered nurses, attention to the new tool, attendance at the learning module at the time of implementation and buy-in and compliance of the nursing and physician groups. Some limitations in scoring were noted. While all parameters are scored for women in the labor and delivery unit, there is currently limited pulse oximetry in the postpartum unit, with the exception of women who have received spinal narcotics for cesarean birth in the first 24 hours. This may figure into overall decreased early warning for women who have mild variation from vital sign normal. If only single vital sign parameters are severe enough to be scored, but not severe enough to fire in a group, and go ignored, severely ill patients can be missed. For instance, women who demonstrate decreased blood pressure but have passed beyond compensatory tachycardia would artificially decrease the OBVSA ability to fire. Scoring systems have the potential to increase workload—if scoring is inaccurate or thresholds are incorrect, a cascade of unnecessary events will be triggered (Cuthbertson & Smith, 2007).

implications for clinicians Nursing education has emphasized critical thinking as an essential nursing skill for more than 50 years (Dressel & Mayhew,

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results

1954). Within the myriad of tasks that nurses perform while on shift, simply recording assessment data such as vital signs is not enough. Patient safety is more than filling in boxes in the health record; rather, it relies on nurses’ assessment and critical thinking to influence and optimize health outcomes. Critical thinking includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application and creativity (American Association of Colleges of Nursing, 1998). Identifying specific triggers for responding to changes in maternal vital signs and clinical condition in the setting of complications such as PPH, hypertension and embolic events is key to optimizing outcomes and reducing preventable harm. Nurses are at the bedside 24×7, recording all vital signs and a host of other patient data in the EHR. Systems such as the OBVSA, which support critical thinking by providing basic screening, may help nurses recognize the urgency of a situation, mobilize evaluation by the interdisciplinary team, communicate concerns clearly and provide advocacy and assertion when necessary to assure a woman receives optimal care. Research has long demonstrated that using evidence-based guidelines in practice improves patient outcomes (Estabrook, 1998). Adoption and implementation of standardized screening protocols in obstetrics could affect quality outcomes and mortality. Triggers reflective of developing high-risk conditions, including temperature, increased heart and respiratory rates, oxygen saturation and increased or decreased systolic

blood pressure, could be identified in the electronic documentation that alerts not only nurses but also physicians to the potential for deterioration; this could also provide a link to the standardized order set for treatment pathways. Using tools such as the OBVSA in conjunction with evidence-based practice guidelines for the major causes of maternal morbidity and mortality may offer the best chance to improve health outcomes. Organizations such as the Council for Patient Safety in Women’s Health Care and regional Health Engagement Networks have laid a framework for strengthening evidence-based practice in the areas of obstetric hemorrhage and embolic and hypertensive disorders. All such clinical guidelines rely on rapid identification of changing patient conditions, similar to that offered by the OBVSA, as a cornerstone to care improvement. Finally, the OBVSA project was implemented in the EPIC® EHR at the five facilities identified as a customization to the basic EPIC® documentation package currently utilized. A robust maternal-child collaborative practice committee consisting of nursing and information technology professionals preexisted in this project and were utilized in the design, testing and implementation move to production, making it difficult to calculate the actual costs of the project. Subsequent to the go-live in EPIC®, the tool was built into Meditech® without the dashboard feature. Further work to recreate and revise the tool into Meditech® is planned. In hospitals within the health system without EHR

taBle 1

Dependent Variables Before and After Implementing OBVSA VArIABleS

Pre-OBVSA Mean SD

POSt-OBVSA Mean SD

IndePendent t-teSt t p

Response time (minutes)

7.75

3.901

2.64

1.174

8.826

.000

Time to intervention (minutes)

11.25

4.656

5.03

0.504

6.6772

.000

Total estimated blood loss (cc)

1,323.86 839.86

1,029.62 480.240

2.116

.037

PRBC units transfused

1.59

1.957

1.690

1.690

1.039

.301

Maximum pulse (bpm)

121.14

18.311

118.12

21.634

0.742

.471

Lowest hemoglobin

7.868

1.6784

7.680

1.4391

0.585

.560

Lowest systolic blood pressure (mmHg)

95.36

23.342

97.40

22.482

0.430

.668

Lowest diastolic blood pressure (mmHg)

55.27

12.760

55.58

12.672

0.117

.907

Length of stay (days)

4.80

2.358

4.25

1.639

1.290

.200

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capabilities, a paper scoring tool utilized at the time of vital sign documentation may prove useful, provided that the vital signs are documented close to the time they are collected for maximum impact. Delays in documentation would likely lessen the reliability and usefulness of the “real-time” element of the tool.

implications for research/funDing Although health care spending is greater in the United States than any other country in the world, the United States ranks 50th, with a maternal mortality rate higher than 49 countries worldwide (Amnesty International, 2011). The critical need for continued research and supported funding is reflected in maternal morbidity and mortality statistics, particularly regarding preventability. The United States has no nationally implemented comprehensive guidelines and protocols for maternal health care and for preventing and managing obstetric emergencies. This results in significant variation of care and use of procedures from hospital to hospital and state to state in obstetric practice across the country (Amnesty International, 2011). According to the CDC, approximately half of all maternal deaths in the United States are preventable (Bacak, Berg, Desmarais, Hutchins, & Locke, 2006). A CDC study of pregnancyrelated mortality in the United States between 1991 and 1997 found the leading causes of maternal death to be hemorrhage,

hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection and preexisting chronic conditions, such as cardiovascular disease. The study also indicated a fourfold increased risk of pregnancy-related death for African American women and increased risks for older women and women with no prenatal care. Prevention, early recognition and prompt appropriate intervention are the keys to minimizing its impact (Berg et al., 2005). Further study on the OBVSA tool is warranted. Linking the OBVSA to improved outcomes in the leading causes of maternal mortality is the end goal. In the meantime, study in other diagnostic categories such as hypertension, as well as a more vigorous look at specificity, or how often the score correlated with a significant change in a woman’s condition, is indicated. Additionally, opportunities to investigate the intervention and escalation aspects of care with an eye to further development of standard care pathways or clinical pearls such as those suggested by Clark and Hankins (2012) may be useful.

implications for interprofessional teamWork Since the publication of the IOM report To Err Is Human, national hospitals have worked to make health care safer (Leape & Berwick, 2005). According to a Joint Commission evaluation of root-cause analyses, communication problems caused almost 70 percent of sentinel events in accredited health care

figuRe 3

Symptom-to-Response and Intervention Times After OBVSA Intervention OBVSA Pre-Post Comparison 12

11.25

10 8

7.75 6

5.03

4 2

2.64

0

Time to Response (minutes)

Time to Intervention (minutes) PreOBVSA

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PostOBVSA

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organizations (The Joint Commission, 2006). In the past 5 years, organizations have begun to explore the concept of team competency as it relates to care delivery, patient outcomes, safety, quality and satisfaction through programs such as TeamSTEPPS™. Reproducible, highly reliable team response to deteriorating patient conditions likely combines both the communication aspects of team competency with reliance on structured tools, care pathways and treatment algorithms to decrease varied performance in similar patient cohorts. In no other hospital area are staff functioning in the physician and nursing specialty roles of emergency room, postanesthesia recovery room, labor room, antepartum, postpartum, adult intensive care, neonatal intensive care, newborn nursery and anesthesia provider all in one location while caring for two patients—a woman and newborn. Obstetric patients encounter a variety of care delivery models and disciplines in the acute care setting. The obstetric care team is generally composed of nurses, physicians, obstetricians, anesthesiologists and consultants as needed, respiratory therapists and technicians. The primary obstetric nurse must be competent in assessment skills and in recognizing the signs of deterioration. The charge nurse must provide oversight and collaboration with the primary nurse providing direct care and must be knowledgeable and competent in initiating immediate collaboration with the assigned physician, up to and including escalation of issues via chain of command, if the appropriate clinical care is not rendered. Women considered low risk can become acutely ill with

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engaging leadership focuses on the critical importance of team work and emphasizes the benefits of collaboration that create a culture where dialogue is open and new ways of thinking and doing are encouraged, listened to and truly appreciated little warning, requiring rapid assessment, emergent mobilization of the team and intervention to support the optimal outcomes. Women may have obstetric or nonobstetric conditions, which can be complicated by the presence of a fetus and a myriad of potential comorbidities. Clinical reasoning and decision-making occurs within social relationships or situations involving a woman, her family and a team of health care providers. Structural systems such as the OBVSA may provide a platform to navigate the complexity of experience level, tenure and prior relationships within the function of the team’s clinical agenda, supporting the early recognition of changing patient condition and prompting collaboration and changes to the patient’s treatment plan as necessary.

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implications for the business of practice Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health. The most severe complications of pregnancy, generally referred to as severe maternal morbidity (SMM), affect more than 50,000 women in the United States every year. Based on recent trends, this burden has been steadily increasing (Callaghan, Creanga, & Kuklina, 2012). The consequences of the increasing SMM prevalence are wide-ranging and include higher health service use, higher direct medical costs, extended hospitalization stays and longterm rehabilitation.

existing nursing and information technology committees and staff were utilized to design, test and implement the oBVSa, including building obstetric templates and triggers and educating the obstetric team about resources to monitor implementation and results both clinical and financial Data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) on pregnancy and childbirth hospitalizations with complicating conditions in 2008 document the enormous costs of obstetric complications. Stays with pregnancy-related complications tended to be longer (2.9 days for nondelivery stays and 2.7 days for delivery stays) than birth stays without complications (1.9 days). Maternal stays with complicating conditions were also about 50 percent costlier ($4,100 for nondelivery stays and $3,900 for delivery stays) than birth stays without complications ($2,600). Maternal stays with pregnancy and birth-related complicating conditions accounted for $17.4 billion, or nearly 5 percent of total hospital costs in the United States (Elixhauser & Wier, 2011). Innovation in clinical care that provides for early risk identification and treatment may mitigate these escalating costs by optimizing outcomes and thereby decreasing costs related to morbidity and mortality. The OBVSA templates for screening and treatment can be easily and widely assimilated in the EHR. Costs implementing the OBVSA are relatively low compared to the high financial and human costs of SMM. Existing nursing

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and information technology committees and staff were utilized to design, test and implement the OBVSA, including building obstetric templates and triggers and educating the obstetric team about resources to monitor implementation and results both clinical and financial.

conclusion Redesigning health care will require strong leadership with leaders who seek to create and inspire change (Zaccagnini & White, 2011). Engaging leadership focuses on the critical importance of team work and emphasizes the benefits of collaboration that create a culture where dialogue is open and new ways of thinking and doing are encouraged, listened to and truly appreciated. The interdisciplinary team bears the ultimate accountability for achievement of optimal patient outcomes. Effective team leaders will encourage clinical innovation such as the OBVSA screening tool endorsing action plan with goals, time milestones and accountability for achievement. Clinical innovators can work together with the team toward the common goal of safety for women in obstetrics while establishing realistic, reproducible and sustainable plans for improving communication about women’s health status and care. NWH

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Centers for Disease Control and Prevention (CDC). (2014). Pregnancy-related mortality surveillance. Atlanta, GA: Author. Retrieved from www.cdc.gov/reproductivehealth/Maternal InfantHealth/PMSS.html Clark, S. L., & Hankins, G. D. (2012). Preventing maternal death: 10 clinical diamonds. Obstetrics & Gynecology, 119(2 Pt. 1), 360– 364. doi:10.1097/AOG.0b013e31824119 Clarke, S. P., & Aiken, L. H. (2003). Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing, 103(1), 42–47. Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, C., Callaghan, W. M. (2015). Pregnancy-related mortality in the United States, 2006–2010. Obstetrics & Gynecology, 125, 5–12. doi:10.1097/AOG.0000000000000564 Cuthbertson, B. H., & Smith, G. B. (2007). A warning on earlywarning scores. British Journal of Anaesthesia, 98(6), 704–706. Dressel, P. L., & Mayhew, L. B. (1954). General education: Exploration of evaluation. Washington, DC: American Council on Education. Elixhauser, A., & Wier, L. M. (2011). Complicating conditions of pregnancy and childbirth, 2008 (Agency for Healthcare Research and Quality Statistical Brief #113). Rockville, MD: U.S. Agency for Healthcare Research and Quality. Retrieved from www.hcupus.ahrq.gov/reports/statbriefs/sb113.pdf Estabrooks, C. A. (1998). Will evidence-based nursing practice make practice perfect? Canadian Journal of Nursing Research, 30(1), 15–36. Geller, S. E., Cox, S. M., & Kilpatrick, S. J. (2006). A descriptive model of preventability in maternal morbidity and mortality. Journal of Perinatology, 26(2), 79–84. doi:10.1038/sj.jp.7211432 Goldhill, D. R., White, S. A., & Sumner, A. (1999). Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesthesia, 54(6), 529–534. Heron, M., Hoyert, D. L., Murphy, S. L., Xu, J., Kochanek, K. D., & Tejada-Vera, B. (2009). Deaths: Final data for 2006. National Vital Statistics Reports, 57(14), 1–134.

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