Embed Size (px)
Citation preview
7/16/2012
1
Southern California Patient Safety
Collaborative - Track III
Post Partum Care:An Obstetrical Stepchild?
Larry Veltman, MD
Southern California Patient Safety Collaborative
July 17, 2012
7/16/2012
2
Have you ever…
Post Partum Nurse Image
Perpetuating the Stereotype
• “All they do is sit around and push on the fundus.”
• “‘Words with friends’ is big over there.”
• “They’re a different breed.”
• “If I get a call from them, it’s never important.”
• “They always call for Tylenol or a laxative at 11:30pm or 5 am.”
• “They procrastinate discharges…obviously so they won’t get another patient.”
7/16/2012
3
July 17, 2012
• The golden hour – immediately post delivery • Hand offs / communications
• The post partum spectrum of care• Routine: teaching and screening
• Maternal medical conditions: maternal illness, medications, L & D complications, bariatrics,
• Breastfeeding issues
• Emergencies / skillful anticipation
In Addition:
There is the baby!
The Golden Hour -Immediately Post Delivery
Standardization of the recovery period; including tasks to be
completed and a time frame in which to complete them.
7/16/2012
4
Goals
• Establish tasks that compose the vaginal and cesarean birth recovery period
• Determine time frame in which recoveries should be completed
• Outline who is to perform tasks including primary RN, backup RN, and HUCs
The Process?
• Task force representing all shifts and AHNs
• Brainstorming of all factors that impact how long a recovery might take
• Narrowing of those tasks that are required to be done within the immediate recovery period
• Attached time needed for each task
• Determined which tasks needed to be done by primary RN vs someone else
Vaginal Delivery Tasks:Mother
• Assist MD with repair• Sponge counts• Vital signs• PP assessments and
recovery assessment• Pain management• Epidural pump and
catheter removal
• IV and oxytocinmanagement
• Review and fax orders• Complete labor
charting• Teaching• Clean up room• Transfer patient
7/16/2012
5
Vaginal Delivery Tasks:Baby
• Apgars• Vitals and
assessments• ID bands & barcode
bands• Weigh and measure• Medication
administration and charting
• Initial feeding
• Review and sign orders
• Charting and paperwork
• Transfer and admit baby
Other Tasks (but not by primary RN or necessarily in recovery time period)
• Menus
• Empty garbage and linens
• Feed mom
• Remove table and clean up room
• Sign and fax orders
• Notify pediatrician
• Assist mom to bathroom and change bed linens
• Bring scale, ice pack, warm blankets, beverage, and clean linens to room
• Bath & prints
Delivery Complications And OutliersMust Be Included in the Handoff
• Hemorrhage
• Retained placenta
• Extensive repair
• Resuscitation
• Blood sugar protocol
• Immediate PPBTL
• NB anomalies
• Insulin infusion
• Demise
• Multiples
• Magnesium sulfate infusion
• General anesthesia
7/16/2012
6
Other Outliers To Consider
• Non-English speaking patient
• Adoption
• Family social difficulties
• Home birth or failed home birth
• Precipitous delivery
• Transfer of newborn directly to NICU
Determined average recovery time for vaginal delivery:
2 HOURSStart time is birth time
Determined average recovery time for cesarean delivery:
3 HOURS
Start time is birth time
7/16/2012
7
Cesarean BirthsHow It Is Different: Why The Extra
Hour?
Cesarean Birth Tasks: Operating Room
• Counts
• SCUDs
• Intra operative and Post operative charting
• Dressing tape and lotion remover
• I&Os
• Transfer pt to bed then to room
Cesarean Birth Tasks: Patient Room
• Manage Foley catheter
• Anesthesia considerations
• Post operative charting
• Vital signs and post operative assessments
• Manage SCUDs and positioning patient Oxygen saturation management
7/16/2012
8
Making It Work!
• Communicate with Charge RN any complications or outliers that may affect your recovery timeline
• Team effort and support
• Accountability: Establishing who is responsible to complete each task and following through with assigned tasks
Backing Up Deliveries
• WHO? Every RN on our unit. We do not have to be labor trained to backup because we all have NRP certification!!
• This is an expectation. RNs who have concerns or do not feel comfortable with backup responsibilities should contact their AHN for learning opportunities.
Back Up RN ResponsibilitiesFirst & foremost…be there to back up the delivery…..and….
• B-ring scale, linen pack* and menus & 2 stickers for placenta basin
• A-lert pharmacy of NB orders (this means you fax them )
• C-old beverage(or warm…) and ice pack
• K-lean up room and remove table/garbage/pump etc…
• U-pdate HUC on delivery info (HUC checklist)*
• P-ass it on if you can’t complete the tasks
7/16/2012
9
*HUC ChecklistWill be included in NB pack in baby bedFill in the blanks and hand it to the HUC
HUC Delivery Info & Checklist
Name__________________________
Room # ______
Delivery Date & Time_____________
Male Female
Baby's Provider_________________
Labs (if necessary):
ABC Cord Gases Cord Blood
Other_______________________
___ Admit Baby
___ Order food for Mom
___ Bring baby barcode to room
___ Notify provider
___ Assemble baby chart
___ Order labs (if necessary)
__ Other:
HUC’s tasksUsing Checklist From RN
• Order food for mom
• Admit baby
• Assemble baby chart
• Print baby barcode and deliver to RN
• Notify pediatrician
• Order labs PRN
What??? Another Piece Of Paper!!
• YES!!!• Patient safety
• HUC happiness (they get the whole story in writing)
• Communication is more complete – eliminates distractions and interruptions
7/16/2012
10
Other Helpful Ideas For The Back-up RN
• Clean up patient room while pt in OR for C/S, empty garbage/linens, remove pumps, etc.
• Utilize housekeepers and HUCs when available to help with linen changes
• If you are unable to complete backup tasks pass it along or alert primary RN if unable to find help
The Tangible Handoff
Source: M. Block, J. F. Ehrenworth, V. M. Cuce, et al., “The Tangible Handoff: A Team Approach for Advancing Structured Communication in Labor and Delivery,” The Joint Commission Journal on Quality and Patient Safety, Vol. 36, No. 6, June 2010, pp. 282-7, 241.
Source: K. L. Kyser, X. Lu, D. A. Santillan, et al., “The Association Between Hospital Obstetrical Volume and Maternal Postpartum Complications,” American Journal of Obstetrics & Gynecology, Vol. 207, July 2012, pp. 42.e1-42.e17.
7/16/2012
11
The Post Partum Experience• Recovery• Documentation – EMR• Calling the physician• Teaching
• Inpatient and post discharge• Screening
• Depression• Social issues
• Medical illnesses, labor and delivery complications• Breastfeeding• Medication issues
• Breastfeeding issues• Health maintenance
• Vaccination – tDAP, influenza, TBC
Prepare for the Rare
• Post partum cardiomyopathy
• Cerebral venous thrombosis
• Post partum psychosis
• Thyroid storm, post partum thyroiditis
• Post anesthesia complications
• Sheehan’s syndrome
• Pulmonary embolism
Drugs Contraindicated with Breastfeeding
Source: G.G. Briggs, R. K. Freeman and S.J. Yaffe, Drugs in Pregnancy and Lactation, Ninth Edition, Lippincott Williams and Wilkins, Philadelphia, PA, 2011.
7/16/2012
12
Depression Screening
Postpartum Maternal Behavior Score in Six Breed Groups of Beef Cattle
Source: Z. B. Johnson and A. W. Kellogg (Eds.), Research Series 522: Arkansas Animal Science Department Report 2004.
Emergency Preparedness
PPH
Eclampsia
Maternal and Neonatal Arrest
Thyroid Storm
Diabetic Ketoacidosis
Abduction
7/16/2012
13
Being Prepared:Self Environment
Knowing:PatientColleaguesPlan
Envisioning theWhole Picture:
Situational PotentialOperational Context
Source: A. Lyndon, “Skillful Anticipation: Maternity Nurses' Perspectives on Maintaining Safety,” Quality & Safety in Health Care, Vol. 19, No. 5, 2010, p. e8.
7/16/2012
14
Eclampsia
Codes: maternal, Neonatal
Prevention of Abduction
7/16/2012
15
Source: L. Gabal and E. Musheno, “Understanding the Special needs of the Bariatric Population: Design, Innovation, and Respect,” Presentation, August 25, 2010, http://www.ki.com/pdfs/Understanding Needs Bariactric Population.pdf, 07/01/2012.
7/16/2012
16
Why it is Easy to Get in Trouble
• Complacency:• Fostered by many normals; few abnormals
• When things go wrong infrequently, we can forget the hazards of the job, take shortcuts
• Lack of Learning Organization culture• Failure to take advantage of near misses with lessons
learned
• Failure to be able to “speak up” with safety concerns
• “Oppressed group” behaviors d/t horizontal hostility from other units
Silence Kills
The undiscussables:
• Dangerous Shortcuts
• Incompetence
• Disrespect
Source: Lee Gutkind (Ed.), Silence Kills: Speaking Out and Saving Lives, Southern Methodist University Press, Dallas, TX, 2007.
Why it is Easy to Get in Trouble
Common allegations against post partum nurses:
• Failure to monitor
• Failure to notify
• Failure to respond to an emergency
• Failure to screen
• Medication errors
All of the above complicated by documentation failures
7/16/2012
17
The Safe Post Partum Unit
• Leadership
• Education
• Learning organization behaviors
• Foster the ability to “speak up”
• Drills / simulations / readiness
• Unit pride
Questions
Save the DatesOn-site Dates
• October 23rd
Webinar Dates• August 23rd
• November 19th
7/16/2012
18
Questions
Contact Information:Data Entry Website: http://nhfca.org/PatientSafetyFirst
Julia Slininger, Hospital Association of Southern California
Mia Arias, National Health Foundation
Karen Arriaga, Hospital Association of Southern California
Mary Ellen Filbey, Risk Management & Patient Safety Institute
Tramaine Watson, Risk Management & Patient Safety Institute
7/16/2012
19
