Welcome to the Atlantic City SUN! PROMOTING TEAMWORK AND - PowerPoint PPT Presentation

Welcome to the Atlantic City SUN!

PROMOTING TEAMWORK AND COMMUNICATION IN PERINATAL CARE Stan Davis MD, FACOG Laerdal SUN Conference Atlantic City 2016

Objectives 1) Discuss the medical/legal environment in the perinatal area 2) Identify issues specific to perinatal care 3) Describe the role of simulation in providing safe, reliable care 4) Discuss collaboration with multidisciplinary leadership 5) Describe how to plan and implement in-situ simulation

The Current State of Communication

It’s Hard to Communicate When There Are More Pressing Issues

Why Teamwork? Suburban Hospital How many C/S teams are possible with these staff Obstetricians 81 numbers? L&D Nurses 50 Anesthesiologists 16 381 Million NNPs 12 Scrub Techs 14 CRNAs 35

Maternal Mortality Biggest decrease of any mortality statistic in past 100 yrs.

Performance Over Time Performance Stafford Beer, “Brain of the Firm” John Wiley & Sons, 1981, p5-13 Time 10

11 TeamSTEPPS ™

OB Claim Impact on Physicians Claims H it OB’s Hardest of All Specialties* 23% of total payouts in healthcare Malpractice insurance costs rank first or second highest ACOG Poll: Litigation Impact Average age to quit obstetrics-48 70 % changed practice in some way due to insurance issues Average 2.62 claims* 65% changed/reduced practice due to liability concerns: 37.1% increased cesarean section rates 33.1% decreased number of high risk deliveries 32.7% stopped offering/performing VBACs 14.5% decreased deliveries 8.3% stopped obstetrics *Physician Insurers Association of America Data Sharing Report 10/31/06

OB Claims Pose the Largest Risk to Re-insurer Birth injury claims generate the highest payouts to Re-insurers and pose the greatest challenge for estimating future losses. Other Other 43% OB 45% 55% OB 57% 57% of Re-insurer losses paid are OB claims 55% of Reserve dollars are for OB claims 13

High Severity is the Problem • Severity of “costs” prompts the drive for change • Victims and families pay lifetime costs of care • Hospital systems battling low margins lose revenue and pay claims • Insurers pay over 200% more on average for OB claims • OB exposure is significant for all participants* • Total $147,947,631 paid and incurred historic exposure • Amounts to a “liability tax” of $ 380 per birth due to litigation costs • study of 407 OB claims (1999 to 2003) arising from 389,255 births. 14

Addressing a “Low Frequency” “High Severity” Problem A “blind spot” to the need for change may arise due to the few bad OB outcomes any one person sees in a career * (assuming 140 deliveries per year by physician) 1 bad brachial plexus injury 33 years 1 hypoxia-related case of CP 48 years 1 case of asphyxia from VBAC-uterine rupture 403 years Claim frequency reflects cumulative experience: Chances of paying a claim 1 per 4,545 births Paying a claim over $100,000 1 per 5,882 births Paying a claim over $1,000,000 1 per 12,500 birth Study of 407 OB claims (1999 to 2003) arising from 389,255 births *Journal of Maternal-Fetal and Neonatal Medicine 2003. 13:203 15

The Bottom Line Saving One Baby from Serious Injury Saves Serious Money Jury Verdict Research national average OB paid loss (all injury types) = $2,500,000 Re-insurer average loss (2003-2006) for OB “brain damage” claims = $3,702,810 16

Improving Neonatal Outcome Through Practical Shoulder Dystocia Training Obstetrics and Gynecology , July/2008 Draycott et. al. 4 years of data before and after simulation training of • shoulder dystocia in one L&D unit Use of correct maneuvers went from 29% to 87% • Reduction in neonatal injury at birth after shoulder dystocia • from 9.3% to 2.3%

18 TeamSTEPPS ™

Individual Communication & Teamwork Skills  Situational Awareness “Me”  Standardized Language (ex: SBAR) “You”  Closed-Loop Communication “You”  Shared Mental Model “US”

Loss of Situational Awareness 20

Human Factors SBAR

Human Factors CLC

Human Factors SMM 23

Team Skills  Briefing  Huddle  Debriefing  Handoff’s

ER Checklist 25

Sterile Cockpit 26

Debriefing with CNM Coaching

In a Complex and Frustrating System Communication is That Much More Important!

Only 3 Questions! 1) What went well? …and why? 2) What could have gone better? 3) What could I/We do better next time?

ICU handoff

Sterile Cockpit 31

Identified Gaps/Learning’s from InSitu Simulation • • Orders/Tasks being called out to the air, not directed No formalized code process • OB/GYN and Pediatrician not on code c-section to someone paging list • Entire team needs to understand sterile technique • Unable to access resuscitation supplies • Didn’t have the help needed as code was not called • Infant resuscitation supplies not in the OR • Unable to apply suprapubic pressure as no step stool • Unclear role definition was accessible • Orders were not clear and concise • Team members didn’t have the same understanding of • Extra staff members needed to handle spoken words emergency situation • Importance of Armband • No documentation • Code blue call system didn’t work in the OR • CPR stopped to assemble equipment • Telephone system not working in the OR • Hierarchy • Team did not have the same understanding of the • Unclear communication situation • Patient Information wasn’t shared • CPR not being done correctly • Not enough space for staff to resuscitate the • Ceiling light fell during surgery baby • Unable to hear call system when in another room • Staff unsure about where to go when a code • Lack of defined leadership c/s is called • Unsure of who everyone was and what their role was • Lack of trust with in the team • Inability to get emergency blood products • Locked out of the OR

Improvements/Solutions Made Resulting from InSitu Simulation • Identical Newborn Resuscitation Carts now in NRP OR and Nursery • Code process formalized • Pediatrician and Obstetrician added to the code • Step stools added to every labor and delivery c/section paging list room • Standardized language developed and • Closed Loop Communication being utilized implemented • Emergency Release of Blood Products Policy/ • Orientation to the OR Procedure implemented • Mocked codes moved to a regular basis • Shared mental models being discussed • Code Blue system fixed in the OR • Utilization of briefing/ huddles/ debriefing used • Telephone system fixed to improve patient care • • Defined roles now included in policy/ procedure Concise documentation forms for obstetrical emergencies being utilized • Newborn Code Blue Resuscitation Policy created • and implemented Teams verbalized improved trust in their units • • Newborn Code Blue documentation form Verbalized change culture within the unit created and implemented • Respiratory Therapists now encouraged to have

Got blood?

Creating High Reliability Teams In Situ Simulation Identify Errors Experiential learning & application, test for gaps Understand and Manage Errors Mitigate Errors High Just Culture™ Reliability TeamSTEPPS ™ Principles of risk, Define the team, Accountability, Use the tools, Behavior coach Stan Davis, MD, FACOG & Kristi K Miller RN, MS

Markers of Nursing Behaviors 17 in situ simulations videotaped for evaluation at 4 OB sites Situational Awareness : ? SBAR: at critical junctures of team formation or reformation: range 35%to 54% Closed Loop Communication : range 14-69% Shared Mental Model: range 56-87% Conclusion: Skills not consistently observed during critical events and constitute breaches in safety. Miller, K; Riley, W; Davis, S: “ Identifying Key Nursing and Team Behaviors to Achieve High Reliability”. Journal of Nursing Management. March 2009

“Non Technical skills and Team Training to Improve Perinatal Patient Outcomes in a Community Hospital ” The Joint Commission Journal on Quality and Patient Safety, 2010 Redwing WAOS 2.5 2 1.5 1 0.5 0 2005.Q1 2005.Q2 2005.Q3 2005.Q4 2006.Q1 2006.Q2 2006.Q3 2006.Q4 2007.Q1 2007.Q2 2007.Q3 2007.Q4 2008.Q1 2008.Q2 2008.Q3 2008.Q4 37% WAOS reduction after Saturation of In Situ Simulation and TeamSTEPPS training. Riley, W, Davis, S, Miller, K, Hansen, H, Sainfort F , Sweet, R “Non Technical skills and Team Training to Improve Perinatal Patient Outcomes in a Community Hospital ”, 2010 The Joint Commission Journal on quality and Patient Safety

In Situ Simulation at a Small Rural Hospital 46.6 percent Decrease in Safety Breeches/ Simulation 20 15 2007-2008 10 2009-2010 5 0 2007-2008 2009-2010

InSitu Overall Trend at Red Wing Breeches 26 24 23 17 17 15 14 11 11 10 10 9 8 6 4 Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim Sim 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

“the only thing required for learning … …is humility”

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