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Use of Checklists to Standardize Oxytocin Administration
INNOVATIVE PROGRAMS Proceedings of the 2017 AWHONN Convention
Implementation of a Maternal Early Warning System in an Academic Medical Center Purpose for the Program he Maternal Early Warning System (MEWS) includes abnormal parameters that act as triggers. The goal is early recognition of signs of deterioration. Early signs of decline are often subtle and challenging to identify since physiologic compensatory mechanisms can mask signs. This system expedites recognition and action for worsening maternal condition.
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Proposed Change The following criteria are used: systolic blood pressure less than 90 mm Hg or greater than 160 mm Hg, diastolic blood pressure greater than 100 mm Hg, heart rate less than 50 beats per minute or greater than 120 beats per minute, respiratory rate less than 10 breaths per minute or more than 30 breaths per minute, oxygen saturation less than 95%, oliguria 35 mL or more per hour for 2 hours, confusion. Implementation, Outcomes and Evaluation When a trigger is identified, a nurse initiates supportive interventions and a health care pro-
vider is notified and performs timely bedside evaluation and necessary diagnostic and therapeutic interventions. Surveillance is maintained until resolution or transfer to higher level of care occurs. Nurses are empowered to activate the rapid response team at their discretion. Education includes who to notify, nursing interventions, and the chain of command as indicated. A pocket card with triggers was distributed to staff. After the implementation, the average time of arrival of the health care provider decreased from 60 minutes to 8 minutes. Most events were for elevated blood pressure. Activations of the rapid response team increased from three events in 2012 and 2013 to five in 2104 and 2015. Implications for Nursing Practice Standardization of early warning triggers decreases variation and increases patient care reliability. Timely evaluation led to a decrease in maternal morbidity. Outcomes include nurse descriptions of a heightened safety culture.
Stacey L. Richards, MA, RN, CPPS, C-OB, C-EFM, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Marilyn Mapp, MA, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Gilda Ubina-Abrenica, MSN, MHA, RN, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Keywords early warning systems maternal mortality maternal morbidity maternal safety
Obstetric Poster Presentation
Use of Checklists to Standardize Oxytocin Administration Purpose for the Program o standardize oxytocin administration among health care providers through the use of a standard oxytocin protocol using pre-use and inuse checklists.
T
Proposed Change To use Lewin’s change model to implement the pre-use and in-use checklists as part of the oxytocin protocol. Implementation, Outcomes and Evaluation A multidisciplinary team developed a new oxytocin protocol using pre-use and in-use checklists developed by the Hospital Corporation of America in 2007. Establishing the oxytocin protocol pilot was the first step in the development phase of the implementation. The protocol consisted of a standardized oxytocin concentration, standardized dosage regimen, pre-use and
S24
in-use checklists, and an algorithm for the management of tachysystole. A pilot program was initiated to evaluate the oxytocin protocol. Nursing staff were permitted to practice with the protocol checklists while evaluating their ease of use and efficacy. The pilot program consisted of 200 patients whose use of oxytocin was managed with the new protocol. This pilot group of patients showed a significant decrease in the rate of cesareans from 38% to 18% during the pilot period. Based on the success of the pilot, Lewin’s change model was used to guide implementation of the oxytocin protocol.
Patricia A. Heale, DNP, RNCOB, CNS, Children’s Memorial Hermann Hospital, Houston, TX Keywords oxytocin protocol pre-use oxytocin checklist in-use oxytocin checklist
Obstetric Poster Presentation
Implications for Nursing Practice Use of an oxytocin protocol, including the pre-use and in-use checklists, provides the bedside nurse with specific criteria for consistent minute-tominute management of oxytocin administration.
JOGNN, 46, S6–S35; 2017. http://dx.doi.org/10.1016/j.jogn.2017.04.005
http://jognn.org
Implementation of a Maternal Early Warning System in an Academic Medical Center Purpose for the Program he Maternal Early Warning System (MEWS) includes abnormal parameters that act as triggers. The goal is early recognition of signs of deterioration. Early signs of decline are often subtle and challenging to identify since physiologic compensatory mechanisms can mask signs. This system expedites recognition and action for worsening maternal condition.
T
Proposed Change The following criteria are used: systolic blood pressure less than 90 mm Hg or greater than 160 mm Hg, diastolic blood pressure greater than 100 mm Hg, heart rate less than 50 beats per minute or greater than 120 beats per minute, respiratory rate less than 10 breaths per minute or more than 30 breaths per minute, oxygen saturation less than 95%, oliguria 35 mL or more per hour for 2 hours, confusion. Implementation, Outcomes and Evaluation When a trigger is identified, a nurse initiates supportive interventions and a health care pro-
vider is notified and performs timely bedside evaluation and necessary diagnostic and therapeutic interventions. Surveillance is maintained until resolution or transfer to higher level of care occurs. Nurses are empowered to activate the rapid response team at their discretion. Education includes who to notify, nursing interventions, and the chain of command as indicated. A pocket card with triggers was distributed to staff. After the implementation, the average time of arrival of the health care provider decreased from 60 minutes to 8 minutes. Most events were for elevated blood pressure. Activations of the rapid response team increased from three events in 2012 and 2013 to five in 2104 and 2015. Implications for Nursing Practice Standardization of early warning triggers decreases variation and increases patient care reliability. Timely evaluation led to a decrease in maternal morbidity. Outcomes include nurse descriptions of a heightened safety culture.
Stacey L. Richards, MA, RN, CPPS, C-OB, C-EFM, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Marilyn Mapp, MA, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Gilda Ubina-Abrenica, MSN, MHA, RN, Morgan Stanley Children’s Hospital of NY Presbyterian, Columbia University Medical Center, New York, NY Keywords early warning systems maternal mortality maternal morbidity maternal safety
Obstetric Poster Presentation
Use of Checklists to Standardize Oxytocin Administration Purpose for the Program o standardize oxytocin administration among health care providers through the use of a standard oxytocin protocol using pre-use and inuse checklists.
T
Proposed Change To use Lewin’s change model to implement the pre-use and in-use checklists as part of the oxytocin protocol. Implementation, Outcomes and Evaluation A multidisciplinary team developed a new oxytocin protocol using pre-use and in-use checklists developed by the Hospital Corporation of America in 2007. Establishing the oxytocin protocol pilot was the first step in the development phase of the implementation. The protocol consisted of a standardized oxytocin concentration, standardized dosage regimen, pre-use and
S24
in-use checklists, and an algorithm for the management of tachysystole. A pilot program was initiated to evaluate the oxytocin protocol. Nursing staff were permitted to practice with the protocol checklists while evaluating their ease of use and efficacy. The pilot program consisted of 200 patients whose use of oxytocin was managed with the new protocol. This pilot group of patients showed a significant decrease in the rate of cesareans from 38% to 18% during the pilot period. Based on the success of the pilot, Lewin’s change model was used to guide implementation of the oxytocin protocol.
Patricia A. Heale, DNP, RNCOB, CNS, Children’s Memorial Hermann Hospital, Houston, TX Keywords oxytocin protocol pre-use oxytocin checklist in-use oxytocin checklist
Obstetric Poster Presentation
Implications for Nursing Practice Use of an oxytocin protocol, including the pre-use and in-use checklists, provides the bedside nurse with specific criteria for consistent minute-tominute management of oxytocin administration.
JOGNN, 46, S6–S35; 2017. http://dx.doi.org/10.1016/j.jogn.2017.04.005
http://jognn.org