Volume 5, No. 10, November 2007
Abstract of the Month
Hospital brought rapid cesarean delivery times into range of 10.9 minutes: Can you?
It's every provider's nightmare: Everything is going smoothly during labor, with normal progress, a reassuring fetal heart rate (FHR) tracing, and a dilated cervix. Suddenly there's profound bradycardia, with deceleration of the FHR to the 60s. The bedside nurse administers oxygen and IV fluids, but bradycardia persists.
A pelvic exam is performed; the cervix is unchanged, the baby is in vertex presentation and cord prolapse is ruled out. A fetal scalp electrode is placed; the monitor is picking up fetal, not maternal heart rate, and the baby has been "down" for over 5 minutes.
The charge nurse calls to the ob's answering service and the ward clerk "beeps" her as well. The ob calls back within 5 minutes, and the patient is moved to the operating room. The in-house ob physician, the OR team, and the ob anesthesiologist are paged "Stat" to the OR, and the baby is delivered by cesarean section, about 8 minutes after the move to the operating room—and 20 to 25 minutes after the onset of bradycardia. The placenta shows a partial abruption. The baby has depressed Apgar scores and cord blood gas studies show metabolic acidosis with pH less than 7.00.
Everything was done "right." The nurses took appropriate measures to try to resuscitate the baby in utero, the in-house physicians and OR team responded promptly, and the baby was delivered well within the American College of Obstetricians and Gynecologists standard of 30 minutes from "decision to incision."1 But the baby may or may not do well. Can we do better?
Sharp Mary Birch hospital in San Diego utilized an innovative approach to ob emergencies can make these unnerving episodes seem less like an avalanche and more like downhill skiing. One of the keys is replacing sequential with simultaneous activation of the ob team.
'Simultaneous team activation' as a paradigm shift
Post-hoc analysis of the time to delivery in cases of unexpected profound fetal bradycardia shows that at our institution, the nursing interventions typically require 3 to 10 minutes. Reaching the attending obstetrician by pager or phone typically requires at least 3 to 5 minutes and there may not be a response for up to 10 or 15 minutes. Even when the obstetrician is in house and decides to proceed immediately with C/S, it is unlikely that the patient and anesthesiologist will be in the OR within 10 minutes of the onset of fetal bradycardia. At our institution, delivery for intrapartum emergencies like cord prolapse and profound fetal bradycardia was historically nearly always well within 30 minutes of decision for C/S, but seldom within 15 minutes of onset of bradycardia.
First, it's necessary to activate the entire response team rapidly and simultaneously.
Even awaiting arrival of an "in-house" obstetrician prior to activation would make it virtually impossible to reach the 15-minute goal. Similarly, it's essential to empower the front-line team member—namely the L&D nurse—to make the activation decision—to pull the trigger,
-Second, the response must proceed in a coordinated, virtually choreographed fashion.
-Next, bring in the rapid response team
-Next, test your team concept
(see full article for details)
Can their program improve response times for every hospital?
Certainly, for hospitals with an in-house OR team, obstetrician, and ob anesthesiologist, a system similar to ours should be practical, and we believe it will likely have a positive impact. For hospitals without in-house teams, it may still be possible to improve response times by analyzing the timing of responses, assessing the possibility of using simultaneous rather than sequential activation, and building a feedback mechanism into the emergency response concept from the start.
As they have watched Ob Team Stat evolve, thier "choreography" has steadily improved; responding to ob emergencies feels less like being caught in an avalanche and more like downhill skiing. Many of the early skeptics have become ardent proponents of the concept. We believe that this approach has also improved unit morale and "word of mouth" dissemination to other hospitals in our area. Most importantly, it seems that every week, in the lounge "the morning after," we are hearing not about "the disaster last night" but about the "great save."
Catanzarite, V et al OB Team STAT: Developing a better L/D rapid response team.Contemporary OB/GYN, Sep 1, 2007 http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=455751
OB/GYN CCC Editorial comment:
Improve your facility’s response to emergencies through improved teamwork
As was discussed at the 2007 Women’s Health and MCH Conference in August there are simple practical steps to remove error and delay in your response to all emergencies.
We heard from speakers from Sharp Mary Birch hospital in San Diego (article above) the Institiute for Healthcare Improvement,and from your colleagues, e. g., PIMC, Zuni, ANMC, and many others…about do-able methods to improve the system to improve the outcome.
This article highlights these concepts…
-Empowering all staff to ‘pull the trigger’ on a rapid response
-Simultaneous team activation as a paradigm shift
-Testing the new system
…but there are many other methods.
The lecture notes and presentations from the 2007 Women’s Health and MCH Conference will be available here soon: http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
