- Email: [email protected]
Interdisciplinary team training identifies discrepancies in institutional policies and practices
Reviews
www. AJOG.org
PATIENT SAFETY SERIES
Interdisciplinary team training identifies discrepancies in institutional policies and practices Pamela Andreatta, PhD; Jennifer Frankel, MD; Sara Boblick Smith, MD; Alexandra Bullough, MD; David Marzano, MD
The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n ⫽ 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety. Key words: health care quality and safety, interdisciplinary team training, institutional policies and procedures, obstetric emergencies
I
n the United States, communication failures account for 72% of the sentinel events occurring in perinatal units.1 Simulation-based training can benefit patient safety initiatives by providing the opportunity to develop clinical competencies in the context of interdisciplinary practice around rare or infrequent clinical events where both individual and team performances are critical for preventing patient morbidity or mortality.2-13 The aim of simulation-based team training is to analyze teamwork during enactments of real-life patient scenarios, detect areas of deficiency or From the Departments of Obstetrics and Gynecology (Drs Andreatta and Marzano), Emergency Medicine (Dr Frankel), Pediatric Medicine (Dr Boblick Smith), and Anesthesiology (Dr Bullough), University of Michigan Medical School, Ann Arbor, MI. Received Nov. 23, 2010; revised Jan. 15, 2011; accepted Feb. 4, 2011. This project was funded by a GME Innovations Grant from the University of Michigan Medical School Office of Graduate Medical Education. Reprints not available from the authors. 0002-9378/$36.00 © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.02.022
298
excess, and through immediate debriefing initiate performance improvements that will transfer to applied patient care. However, at this time, research evaluating the impact of interdisciplinary obstetric team training on systems-based practices is not well reported. The purpose of the this study was to evaluate the impact of an interdisciplinary team training program in obstetric emergencies on identifying and seeking to remedy existing systems-based practice weaknesses.
Materials and methods We hypothesized that simulation-based interdisciplinary training would reveal system-level and specialty-specific procedural and policy conflicts with the potential to adversely impact patient care. We designed the OBEMAN (Obstetrics, Emergency Medicine, Anesthesiology, and Neonatology) Program as an intervention targeting interdisciplinary teams of physicians, nurses, and ancillary health professionals tasked with managing obstetric emergencies at the University of Michigan. The program received an exemption from our institutional review board. A sample of clinical professionals
American Journal of Obstetrics & Gynecology OCTOBER 2011
(n ⫽ 79) participated in the program, with equivalent representation from all targeted groups at each session. Teams met weekly for 2 hours over 6 months, with no more than 3 participants from each clinical specialty per week. The training included aspects of team-based reasoning and decision making, communication, management, and follow-up in the provision of clinical care for a pregnant patient and her fetus during an emergency event. In addition to the simulation-based sessions, we created a web-based reference portal that included links to institutional policies and procedures, departmental policies and procedures, state and federal regulations, and professional practice guidelines for each specialty involved in the program. We designed presenting cases to include unusual and challenging attributes to explore system-based practices that are seldom evaluated in day-to-day patient care. Examples from the case library include a 43-year-old woman with multiple failed in vitro fertilization (IVF) pregnancies in preterm labor at 23 ⫹ 4 weeks; a 12-week pregnant 14-year-old girl presenting with injuries sustained from rape by a male relative; a 32-yearold woman at 28 ⫹ 6 weeks presenting with measles; a motor vehicle accident with multiple unconscious pregnant and pediatric patients to manage concurrently; a patient who refuses care against the recommendations of her providers; and other parallel situations requiring ancillary personnel and knowledge of institutional practices (policies, protocols, and procedures) that are infrequently used. All scenarios were built around obstetric emergencies presenting to the emergency department and were designed to require consultation from the participating departments, as well as ancillary specialty services such as respira-
Reviews
Patient Safety Series
www.AJOG.org
TABLE
Incidence of discrepant policy type per training case Category incidence per case Policies Policies certatim impossibilia
Synopses of obstetric and neonatal cases
Policies Policies casualis oblivio
Policies absens
32 y G1P0 at 28 wks, diabetic progresses to septic shock
5
1
6
2
4
23 y G1P0 at 38 0/7 wks, fetal distress, cord prolapse
3
1
6
4
3
34 y G2P1 at 28 wks, congestive heart failure
4
1
5
6
2
16 y G1P0 postpartum hemorrhage after home birth; limp, unresponsive neonate
3
5
5
2
32 y G5P4 after prolonged second stage shoulder dystocia home delivery requiring McRoberts maneuver, third degree laceration, postpartum hemorrhage
5
7
6
2
25 y G2P1 at 20 wks, unresponsive; measles (rubeola)
4
1
6
6
4
22 y obese G0, denies possible pregnancy, progresses to shoulder dystocia delivery of limp and apneic neonate; postpartum hemorrhage; does not acknowledge neonate
5
1
6
8
5
34 y, G1P0 a 37 0/7 wks, BMI 41, MPIII, vehemently refuses epidural catheter; fetal distress, progresses to emergency cesarean delivery w/o spinal/epidural possible
5
27 y G1P0 at 34 2/7 wks, blood type A⫺, brought by EMS after MVA; fetal distress, progresses to acute placental abruption and emergency cesarean delivery of limp apneic neonate
4
24 y G2P1 at 32 4/7 wks, gestational diabetes, brought by EMS after MVA; head injury, vaginal leaking, cannot feel fetal movement
3
25 y, G1P0 at 28 3/7 wks brought by EMS after MVA, drifting in/out of consciousness, progresses to placental abruption and aortic disruption, absent fetal heart tones
4
29 y G1P0 at 39 3/7 wks with gestational diabetes, progresses to shoulder dystocia delivery
2
14 y at 10 wks’ gestation presents alone, reports beating and rape by stepfather
1
42 y G1P0 at 40 0/7 wks obstructed home labor, SROM of meconium stained fluid ⬎24 h prior; fetal distress
3
40 y G3P0 at 27 4/7 wks with blunt trauma to the abdomen, unresponsive, broken protruding left femur, progresses to placental abruption
3
37 y G1PO at 33 2/7 wks progresses to eclamptic seizure
3
1
8
2
2
57
22
111
77
44
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
1
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
3
8
5
3
................................................................................................................................................................................................................................................................................................................................................................................
3
8
4
3
................................................................................................................................................................................................................................................................................................................................................................................
1
9
7
4
................................................................................................................................................................................................................................................................................................................................................................................
3
13
5
3
................................................................................................................................................................................................................................................................................................................................................................................
1
5
2
1
................................................................................................................................................................................................................................................................................................................................................................................
2
10
8
2
................................................................................................................................................................................................................................................................................................................................................................................
3
3
................................................................................................................................................................................................................................................................................................................................................................................
1
9
3
3
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
ALL CASES (24 wks)
................................................................................................................................................................................................................................................................................................................................................................................
BMI, body mass index; EMS, emergency medical services; MVA, motor vehicle accident; SROM, spontaneous rupture of membranes. Andreatta. Interdisciplinary policies and practices. Am J Obstet Gynecol 2011.
tory therapy, social work, and SANE (Sexual Assault Nurse Examiner). In addition to issues associated with clinical management, we emphasized the importance of working collaboratively to determine best practices that would inform system-level quality improvements. Participants engaged in debriefing activities after each case that were designed to identify and discuss systemslevel strengths and challenges, and if merited provide recommendations for policy or procedural improvements. We used transcriptions from the debriefing sessions to identify system-level and spe-
cialty-specific practices, policies, and procedures that conflicted with each other or had the potential to adversely impact patient care. We describe these findings using narrative form, which is congruent with qualitative data.
Results Transcripts from the debriefing sessions identified 5 main types of system-level and specialty-specific practices, policies, and procedures that could potentially cause conflict within the clinical team or adversely impact patient care. We named these categories and illustrate each type
with an example below: (1) policies certatim, (2) policies impossibilia, (3) policies casualis, (4) policies oblivio, and (5) policies absens. The frequency with which an occurrence from each category arose during the obstetric and neonatal cases, and the total number of occurrences for each type during the 24 weeks of data collection is shown in Table. We prepared a report informing our health system administrators of our findings with recommendations for implementing change solutions to eliminate ineffective policies and consider formulating others where merited.
OCTOBER 2011 American Journal of Obstetrics & Gynecology
299
Reviews
Patient Safety Series
Policies certatim This category of policy occurred at least once during every training session, and includes policies that either compete or conflict with each other. We identified several well-intended departmental policies that conflicted with institutional policies, leading to compromised decision making. A case involving a pregnant patient experiencing cardiac arrest revealed that apart from the obstetric personnel, many participants did not know about, or were unclear how to use, our Birth Center (BC) paging system. The BC paging system is distinct from the paging system used to call a rapid response (code) team. The majority of nonobstetric participants did not know how to activate the BC pager, the circumstances that would necessitate its activation, what information to include in the BC page, who receives the BC page, or the response protocols for those receiving a BC page. To further complicate the discussion, no participants other than those affiliated with neonatal intensive care unit (NICU) knew that although they receive all BC pages, the NICU team’s policy is to not respond unless the page specifically requests NICU personnel, equipment, instruments, and supplies. Policies impossibilia This category included ineffective policies that are practically unfeasible to adhere to. For example, our teams found it impossible to adhere to an institutional policy mandating that all emergent (crash) cesarean deliveries be performed in an operating room. Transport time between our emergency department and the closest operating room is optimally 10 minutes, not including patient and clinician preparation time. Although participants agreed that the policy is an excellent guideline, they voiced concern over its implications for clinical decision making. In an event where best clinical practice calls for cesarean delivery before transport to an operating room is possible, the provision of best clinical practice would be noncompliant with hospital policies. There were vibrant discussions around these issues, especially related to the medicolegal implications for provid300
ing medically indicated clinical care that counters institutional regulations. Policies casualis This policy category was the most prevalent and occurred multiple times during every training session, There were many informal policies within each of the clinical departments that could adversely impact patient care. These were typically verbal protocols that although commonly understood within the specialty, were virtually indecipherable by team members from other specialties. Their uses during interdisciplinary case management led to great confusion when coordinating clinical care. For example, although managing a simulated patient, an emergency medicine resident requested a “rainbow,” much to the bemusement of the rest of the clinical team who were not familiar with the term. Similarly, although practicing a simulated crash cesarean delivery, the emergency medicine faculty directed the resident to intubate the patient by saying, “Go.” However, “Go” is also the phrase that our anesthesiologists use when alerting obstetricians that it is safe to make an incision. If it had been an actual patient, she would have been awake when the incision was made. Policies oblivio There were numerous policies with which the participants were unfamiliar, again in evidence during every training session. This was not unexpected and most participants indicated that they assumed policies would be in place, although they did not know how to find them. More importantly, they did not consider them when providing patient care in the simulated scenarios. For example, the above referenced case of a 14-year-old rape victim necessitated following specific policies for treating unaccompanied minors, victims of domestic abuse and rape, and for dealing with security concerns in the clinical space. Yet, none of the clinicians participating in the case adhered to the policies or asked to know what they were. Similarly, infectious disease management policies were not
American Journal of Obstetrics & Gynecology OCTOBER 2011
www.AJOG.org addressed for the measles case. The areas with the most discrepant awareness of policies regarding pregnant patients were for treatment of infectious diseases, an unaccompanied minor, domestic abuse and rape victims, as well as patient ownership, conditions for transfer between services, and management of edge of viability cases. Policies absens Finally, we identified areas where policies were either vague or nonexistent, but were strongly advised to alleviate inter/intrateam conflict that could lead to less than optimal patient care. For example, conflict between the emergency medicine participants and the anesthesiology participants over airway management, particularly who would intubate a patient, was ubiquitous and frequently contentious even between associated faculty members. When consulting institutional policies, there were no clear designated lines of authority specified for airway management during an obstetric emergency. However, by continuing to discuss the issue multiple times over many months of interdisciplinary team engagement, the polarizing positions of the specialty-specific groups yielded to a common understanding of each group’s concerns and an agreeable compromise was reached. We formulated a protocol wherein anesthesiology would provide training to emergency medicine residents about the potential challenges associated with obstetric patients’ airways and those residents would demonstrate competency during training to assure safe patient management. We viewed this as an important attitude-related outcome as well as a policy-related system benefit.
Comments The results of this study demonstrate that simulation-based interdisciplinary team training can serve to identify systems-based policy discrepancies that remain undiscovered because of the relative infrequency with which they are required. We identified 5 types of incongruent policies governing clinical practice in the management of obstetric emergencies, each of which was in evi-
Patient Safety Series
www.AJOG.org dence during every training session and often at multiple occurrences within the session. Our results provide evidence in support of interdisciplinary team training for system-level improvement that builds off previous work evaluating its impact on team-level behaviors.2-13 In addition to providing a channel for the acquisition and maintenance of clinical skills, interdisciplinary team training can serve to identify system-level needs that might otherwise remain obscured. A weakness of this study is that the information was garnered from a relatively small sample at a single institution. This necessarily reduces the generalizability of the findings themselves; however, the overall implications of the methodology for identifying systems-based discrepancies are transferable to any institution. That we identified multiple and significant inconsistencies between institutional and departmental policies and actual clinical practice is likely something many health systems could replicate and remedy in favor of patient safety. Several studies have documented the benefits of interdisciplinary obstetric team training on improvements in the application of knowledge and skills in simulated clinical contexts; however, our results demonstrate that such interventions are also valuable for identifying hidden system-level problems that could
adversely impact patient care. Likely, there will always be specialty and discipline specific protocols, acronyms, and colloquial phrases, however, interdisciplinary team-based programs may help to alleviate some of the confusion around their uses in applied practice. We reported these findings and their potential impact on patient safety and quality of care to our health system administration for review and policy considerations. We hope that other institutions do likewise, and collectively we can establish a foundation for building a library of best practice guidelines to inform continuous quality monitoring and keep patient safety and quality of care at the forefront f of clinical management. ACKNOWLEDGMENTS We thank the Department of Obstetrics and Gynecology Center for Education at the University of Michigan. Mr Randall Richter, Mr Woojin Shim, and the staff at the University of Michigan Clinical Simulation Center (UMCSC).
REFERENCES 1. The Joint Commission. Preventing infant death and injury during delivery. Sentinel Event Alert, Issue 30, July 21, 2004. 2. Daniels K, Lipman S, Harney K, et al. Use of simulation base team training for obstetric crises in resident education. Simul Healthc 2008;3:154-60. 3. Deering S, Brown J, Hodor J, Satin A. Simulation training and resident performance of sin-
Reviews
gleton vaginal breech delivery. Obstet Gynecol 2006;107:86-9. 4. Draycott T, Crofts J, Ash J, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008;112:14-20. 5. Maslovitz S, Varkai G, Lessing J, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007;109:1295-300. 6. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclamptic drills. BMJ 2004;328:269-71. 7. Crofts J, Bartlett C, Ellis D, et al. Patient-actor perception of care: a comparison of obstetric emergency training using mannekins and patient actors. Qual Health Care 2008;17:20-4. 8. Crofts J, Fox R, Ellis D, Winter C, Hinshaw K, Draycott T. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol 2008;112:906-12. 9. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG 2006;113:177-82. 10. Ellis D, Crofts J, Hunt L, Read M, Fox R, James M. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008;111:723-31. 11. Pratt S, Mann S, Salisbury M, et al. Impact of CRM-based team training on obstetric outcomes and clinicians’ patients safety attitudes. Jt Comm J Qual Patient Saf 2007;33:720-5. 12. Scholefield H. Embedding quality improvement and patient safety at Liverpool Women’s NHS Foundation Trust. Best Pract Res Clin Obstet Gynaecol 2007;21:593-607. 13. Siassakos D, Crofts J, Winter C, Weiner C, Draycott T. The active components of effective training in obstetric emergencies. BJOG 2009;116:1028-32.
OCTOBER 2011 American Journal of Obstetrics & Gynecology
301
www. AJOG.org
PATIENT SAFETY SERIES
Interdisciplinary team training identifies discrepancies in institutional policies and practices Pamela Andreatta, PhD; Jennifer Frankel, MD; Sara Boblick Smith, MD; Alexandra Bullough, MD; David Marzano, MD
The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n ⫽ 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety. Key words: health care quality and safety, interdisciplinary team training, institutional policies and procedures, obstetric emergencies
I
n the United States, communication failures account for 72% of the sentinel events occurring in perinatal units.1 Simulation-based training can benefit patient safety initiatives by providing the opportunity to develop clinical competencies in the context of interdisciplinary practice around rare or infrequent clinical events where both individual and team performances are critical for preventing patient morbidity or mortality.2-13 The aim of simulation-based team training is to analyze teamwork during enactments of real-life patient scenarios, detect areas of deficiency or From the Departments of Obstetrics and Gynecology (Drs Andreatta and Marzano), Emergency Medicine (Dr Frankel), Pediatric Medicine (Dr Boblick Smith), and Anesthesiology (Dr Bullough), University of Michigan Medical School, Ann Arbor, MI. Received Nov. 23, 2010; revised Jan. 15, 2011; accepted Feb. 4, 2011. This project was funded by a GME Innovations Grant from the University of Michigan Medical School Office of Graduate Medical Education. Reprints not available from the authors. 0002-9378/$36.00 © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.02.022
298
excess, and through immediate debriefing initiate performance improvements that will transfer to applied patient care. However, at this time, research evaluating the impact of interdisciplinary obstetric team training on systems-based practices is not well reported. The purpose of the this study was to evaluate the impact of an interdisciplinary team training program in obstetric emergencies on identifying and seeking to remedy existing systems-based practice weaknesses.
Materials and methods We hypothesized that simulation-based interdisciplinary training would reveal system-level and specialty-specific procedural and policy conflicts with the potential to adversely impact patient care. We designed the OBEMAN (Obstetrics, Emergency Medicine, Anesthesiology, and Neonatology) Program as an intervention targeting interdisciplinary teams of physicians, nurses, and ancillary health professionals tasked with managing obstetric emergencies at the University of Michigan. The program received an exemption from our institutional review board. A sample of clinical professionals
American Journal of Obstetrics & Gynecology OCTOBER 2011
(n ⫽ 79) participated in the program, with equivalent representation from all targeted groups at each session. Teams met weekly for 2 hours over 6 months, with no more than 3 participants from each clinical specialty per week. The training included aspects of team-based reasoning and decision making, communication, management, and follow-up in the provision of clinical care for a pregnant patient and her fetus during an emergency event. In addition to the simulation-based sessions, we created a web-based reference portal that included links to institutional policies and procedures, departmental policies and procedures, state and federal regulations, and professional practice guidelines for each specialty involved in the program. We designed presenting cases to include unusual and challenging attributes to explore system-based practices that are seldom evaluated in day-to-day patient care. Examples from the case library include a 43-year-old woman with multiple failed in vitro fertilization (IVF) pregnancies in preterm labor at 23 ⫹ 4 weeks; a 12-week pregnant 14-year-old girl presenting with injuries sustained from rape by a male relative; a 32-yearold woman at 28 ⫹ 6 weeks presenting with measles; a motor vehicle accident with multiple unconscious pregnant and pediatric patients to manage concurrently; a patient who refuses care against the recommendations of her providers; and other parallel situations requiring ancillary personnel and knowledge of institutional practices (policies, protocols, and procedures) that are infrequently used. All scenarios were built around obstetric emergencies presenting to the emergency department and were designed to require consultation from the participating departments, as well as ancillary specialty services such as respira-
Reviews
Patient Safety Series
www.AJOG.org
TABLE
Incidence of discrepant policy type per training case Category incidence per case Policies Policies certatim impossibilia
Synopses of obstetric and neonatal cases
Policies Policies casualis oblivio
Policies absens
32 y G1P0 at 28 wks, diabetic progresses to septic shock
5
1
6
2
4
23 y G1P0 at 38 0/7 wks, fetal distress, cord prolapse
3
1
6
4
3
34 y G2P1 at 28 wks, congestive heart failure
4
1
5
6
2
16 y G1P0 postpartum hemorrhage after home birth; limp, unresponsive neonate
3
5
5
2
32 y G5P4 after prolonged second stage shoulder dystocia home delivery requiring McRoberts maneuver, third degree laceration, postpartum hemorrhage
5
7
6
2
25 y G2P1 at 20 wks, unresponsive; measles (rubeola)
4
1
6
6
4
22 y obese G0, denies possible pregnancy, progresses to shoulder dystocia delivery of limp and apneic neonate; postpartum hemorrhage; does not acknowledge neonate
5
1
6
8
5
34 y, G1P0 a 37 0/7 wks, BMI 41, MPIII, vehemently refuses epidural catheter; fetal distress, progresses to emergency cesarean delivery w/o spinal/epidural possible
5
27 y G1P0 at 34 2/7 wks, blood type A⫺, brought by EMS after MVA; fetal distress, progresses to acute placental abruption and emergency cesarean delivery of limp apneic neonate
4
24 y G2P1 at 32 4/7 wks, gestational diabetes, brought by EMS after MVA; head injury, vaginal leaking, cannot feel fetal movement
3
25 y, G1P0 at 28 3/7 wks brought by EMS after MVA, drifting in/out of consciousness, progresses to placental abruption and aortic disruption, absent fetal heart tones
4
29 y G1P0 at 39 3/7 wks with gestational diabetes, progresses to shoulder dystocia delivery
2
14 y at 10 wks’ gestation presents alone, reports beating and rape by stepfather
1
42 y G1P0 at 40 0/7 wks obstructed home labor, SROM of meconium stained fluid ⬎24 h prior; fetal distress
3
40 y G3P0 at 27 4/7 wks with blunt trauma to the abdomen, unresponsive, broken protruding left femur, progresses to placental abruption
3
37 y G1PO at 33 2/7 wks progresses to eclamptic seizure
3
1
8
2
2
57
22
111
77
44
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
1
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
3
8
5
3
................................................................................................................................................................................................................................................................................................................................................................................
3
8
4
3
................................................................................................................................................................................................................................................................................................................................................................................
1
9
7
4
................................................................................................................................................................................................................................................................................................................................................................................
3
13
5
3
................................................................................................................................................................................................................................................................................................................................................................................
1
5
2
1
................................................................................................................................................................................................................................................................................................................................................................................
2
10
8
2
................................................................................................................................................................................................................................................................................................................................................................................
3
3
................................................................................................................................................................................................................................................................................................................................................................................
1
9
3
3
................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................
ALL CASES (24 wks)
................................................................................................................................................................................................................................................................................................................................................................................
BMI, body mass index; EMS, emergency medical services; MVA, motor vehicle accident; SROM, spontaneous rupture of membranes. Andreatta. Interdisciplinary policies and practices. Am J Obstet Gynecol 2011.
tory therapy, social work, and SANE (Sexual Assault Nurse Examiner). In addition to issues associated with clinical management, we emphasized the importance of working collaboratively to determine best practices that would inform system-level quality improvements. Participants engaged in debriefing activities after each case that were designed to identify and discuss systemslevel strengths and challenges, and if merited provide recommendations for policy or procedural improvements. We used transcriptions from the debriefing sessions to identify system-level and spe-
cialty-specific practices, policies, and procedures that conflicted with each other or had the potential to adversely impact patient care. We describe these findings using narrative form, which is congruent with qualitative data.
Results Transcripts from the debriefing sessions identified 5 main types of system-level and specialty-specific practices, policies, and procedures that could potentially cause conflict within the clinical team or adversely impact patient care. We named these categories and illustrate each type
with an example below: (1) policies certatim, (2) policies impossibilia, (3) policies casualis, (4) policies oblivio, and (5) policies absens. The frequency with which an occurrence from each category arose during the obstetric and neonatal cases, and the total number of occurrences for each type during the 24 weeks of data collection is shown in Table. We prepared a report informing our health system administrators of our findings with recommendations for implementing change solutions to eliminate ineffective policies and consider formulating others where merited.
OCTOBER 2011 American Journal of Obstetrics & Gynecology
299
Reviews
Patient Safety Series
Policies certatim This category of policy occurred at least once during every training session, and includes policies that either compete or conflict with each other. We identified several well-intended departmental policies that conflicted with institutional policies, leading to compromised decision making. A case involving a pregnant patient experiencing cardiac arrest revealed that apart from the obstetric personnel, many participants did not know about, or were unclear how to use, our Birth Center (BC) paging system. The BC paging system is distinct from the paging system used to call a rapid response (code) team. The majority of nonobstetric participants did not know how to activate the BC pager, the circumstances that would necessitate its activation, what information to include in the BC page, who receives the BC page, or the response protocols for those receiving a BC page. To further complicate the discussion, no participants other than those affiliated with neonatal intensive care unit (NICU) knew that although they receive all BC pages, the NICU team’s policy is to not respond unless the page specifically requests NICU personnel, equipment, instruments, and supplies. Policies impossibilia This category included ineffective policies that are practically unfeasible to adhere to. For example, our teams found it impossible to adhere to an institutional policy mandating that all emergent (crash) cesarean deliveries be performed in an operating room. Transport time between our emergency department and the closest operating room is optimally 10 minutes, not including patient and clinician preparation time. Although participants agreed that the policy is an excellent guideline, they voiced concern over its implications for clinical decision making. In an event where best clinical practice calls for cesarean delivery before transport to an operating room is possible, the provision of best clinical practice would be noncompliant with hospital policies. There were vibrant discussions around these issues, especially related to the medicolegal implications for provid300
ing medically indicated clinical care that counters institutional regulations. Policies casualis This policy category was the most prevalent and occurred multiple times during every training session, There were many informal policies within each of the clinical departments that could adversely impact patient care. These were typically verbal protocols that although commonly understood within the specialty, were virtually indecipherable by team members from other specialties. Their uses during interdisciplinary case management led to great confusion when coordinating clinical care. For example, although managing a simulated patient, an emergency medicine resident requested a “rainbow,” much to the bemusement of the rest of the clinical team who were not familiar with the term. Similarly, although practicing a simulated crash cesarean delivery, the emergency medicine faculty directed the resident to intubate the patient by saying, “Go.” However, “Go” is also the phrase that our anesthesiologists use when alerting obstetricians that it is safe to make an incision. If it had been an actual patient, she would have been awake when the incision was made. Policies oblivio There were numerous policies with which the participants were unfamiliar, again in evidence during every training session. This was not unexpected and most participants indicated that they assumed policies would be in place, although they did not know how to find them. More importantly, they did not consider them when providing patient care in the simulated scenarios. For example, the above referenced case of a 14-year-old rape victim necessitated following specific policies for treating unaccompanied minors, victims of domestic abuse and rape, and for dealing with security concerns in the clinical space. Yet, none of the clinicians participating in the case adhered to the policies or asked to know what they were. Similarly, infectious disease management policies were not
American Journal of Obstetrics & Gynecology OCTOBER 2011
www.AJOG.org addressed for the measles case. The areas with the most discrepant awareness of policies regarding pregnant patients were for treatment of infectious diseases, an unaccompanied minor, domestic abuse and rape victims, as well as patient ownership, conditions for transfer between services, and management of edge of viability cases. Policies absens Finally, we identified areas where policies were either vague or nonexistent, but were strongly advised to alleviate inter/intrateam conflict that could lead to less than optimal patient care. For example, conflict between the emergency medicine participants and the anesthesiology participants over airway management, particularly who would intubate a patient, was ubiquitous and frequently contentious even between associated faculty members. When consulting institutional policies, there were no clear designated lines of authority specified for airway management during an obstetric emergency. However, by continuing to discuss the issue multiple times over many months of interdisciplinary team engagement, the polarizing positions of the specialty-specific groups yielded to a common understanding of each group’s concerns and an agreeable compromise was reached. We formulated a protocol wherein anesthesiology would provide training to emergency medicine residents about the potential challenges associated with obstetric patients’ airways and those residents would demonstrate competency during training to assure safe patient management. We viewed this as an important attitude-related outcome as well as a policy-related system benefit.
Comments The results of this study demonstrate that simulation-based interdisciplinary team training can serve to identify systems-based policy discrepancies that remain undiscovered because of the relative infrequency with which they are required. We identified 5 types of incongruent policies governing clinical practice in the management of obstetric emergencies, each of which was in evi-
Patient Safety Series
www.AJOG.org dence during every training session and often at multiple occurrences within the session. Our results provide evidence in support of interdisciplinary team training for system-level improvement that builds off previous work evaluating its impact on team-level behaviors.2-13 In addition to providing a channel for the acquisition and maintenance of clinical skills, interdisciplinary team training can serve to identify system-level needs that might otherwise remain obscured. A weakness of this study is that the information was garnered from a relatively small sample at a single institution. This necessarily reduces the generalizability of the findings themselves; however, the overall implications of the methodology for identifying systems-based discrepancies are transferable to any institution. That we identified multiple and significant inconsistencies between institutional and departmental policies and actual clinical practice is likely something many health systems could replicate and remedy in favor of patient safety. Several studies have documented the benefits of interdisciplinary obstetric team training on improvements in the application of knowledge and skills in simulated clinical contexts; however, our results demonstrate that such interventions are also valuable for identifying hidden system-level problems that could
adversely impact patient care. Likely, there will always be specialty and discipline specific protocols, acronyms, and colloquial phrases, however, interdisciplinary team-based programs may help to alleviate some of the confusion around their uses in applied practice. We reported these findings and their potential impact on patient safety and quality of care to our health system administration for review and policy considerations. We hope that other institutions do likewise, and collectively we can establish a foundation for building a library of best practice guidelines to inform continuous quality monitoring and keep patient safety and quality of care at the forefront f of clinical management. ACKNOWLEDGMENTS We thank the Department of Obstetrics and Gynecology Center for Education at the University of Michigan. Mr Randall Richter, Mr Woojin Shim, and the staff at the University of Michigan Clinical Simulation Center (UMCSC).
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Reviews
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