Improving maternal outcomes is a relevant focus on a global scale, as evidenced by the United Nations Millennium Development Goals. As the United States' maternal morbidity and mortality rates increase, emphasis on patient safety is also increasing. The post-partum patient with medical complications requires specialized interprofessional team involvement. Knowledge of the spectrum, characteristics and complications of disease involving this group of patients is the first step towards patient safety, however team communication and collaboration is crucial to improving processes and outcomes.
At Long Island Jewish Medical Center (LIJMC), standardized escalation processes for use in the division of obstetrics included the hospital Rapid Response Team (RRT) and the Obstetric Modified Early Warning Scale (OB MEWS) algorithm, which specified indications and processes for escalation. In 2016-2017, as LIJMC’s obstetrical adverse events were investigated (Average OB Adverse Outcomes Index: 2.4), it was observed that there was an opportunity to improve utilization of RRT and OB MEWS to improve patient outcomes.
Objectives for this initiative were to improve both process and outcome metrics, including: increased utilization of shock index and the OB MEWS algorithm when indicated, increased rapid response calls in response to change in patient status, earlier/proactive transfer of patients to a higher level of care when necessary, and overall decrease in obstetrical adverse events.
Methods:
An educational program was developed by an interprofessional (nurses, physicians, physician assistants, educators, administrators) and interspecialty (obstetrics, critical care, education) team. The team collaboratively determined course objectives, content and format based on the perspectives of each specialty. The target audience included staff nurses, nurse leaders, obstetricians and mid-level providers in the division of obstetrics. Content was focused on symptoms of patient decline: acute changes in heart rate, blood pressure, and respiratory status. These specific criteria, cited in the OB MEWS Algorithm, were dissected and presented in depth to include anatomy and physiology, pathophysiology, assessment, interventions and rationale, and anticipated diagnostics. Learners were given the opportunity to practice application of knowledge using escalation processes, such as the OB MEWS algorithm and RRT system. In the final section of the course, interdisciplinary review of case studies was facilitated within the context of the algorithm and the concepts discussed within the course, allowing the learner to synthesize course content.
Results:
Rate of LIJMC's OB RRTs increased: 0.2% of deliveries Sep. ‘16- Jun. ‘17 (pre-intervention) to 0.55% of deliveries Jul. ‘17-Mar. ‘18 (post-intervention). Rate of patients transferred from OB to ICU increased: 0.25% of deliveries pre-intervention to 0.47% of deliveries post-intervention. Average OB Adverse Outcome Index improved by 18.7%: 2.4 (Sep. ‘16) to 1.95 (Mar. ‘18).
Conclusion:
These results indicate improved outcomes correlating with early identification and interprofessional coordination in response to changes in patient acuity. This suggests that innovative education programs which target critical thinking and interprofessional practice support safety processes and improved patient outcomes.