Reducing Birth Injuries & Deaths
By LAURA LANDRO
As she was preparing to give birth at Columbia St. Mary's Hospital in Milwaukee last Christmas Eve, Jill Weinshel's blood pressure plunged and her baby's heart rate began to slow. The delivery team acted fast to stabilize both infant and mother. But as the situation became more risky, the decision was made to perform an emergency C-section.
The team had been through the scenario and others like it many times—in a series of training drills using a lifelike pregnant robot, named Noelle, that is programmed to simulate different types of birth emergencies. Though Ms. Weinshel was aware her baby's life was in danger, "it never seemed unmanageable because they were always one step ahead of it," she says. "Everyone knew what their role was and why they were there, and there was no hesitation." Baby Eli was born Dec. 24 at a healthy 7 pounds, 1 ounce.
The teamwork wasn't an accident: It was part of a broader effort at a handful of hospitals and health systems to bring more rigorous safety practices to the field of obstetrics, where communication and teamwork problems are the most commonly cited root cause when things go wrong. The changes, which have led to dramatic declines in birth injuries and deaths, include developing packages of procedures that have shown to produce the best results; making sure every nurse and technician is willing to speak up if they think something is wrong; and delivery-room training that uses robots as well as video cameras to capture and review each step taken, all to prepare for every imaginable scenario.
When Tragedy Strikes
Though relatively infrequent, injuries in the perinatal period—the time prior to and just after birth—can be devastating for families and lead to costly malpractice suits for hospitals. According to the latest data from the American College of Obstetricians and Gynecologists, nearly 91% of ob/gyns have had at least one liability claim filed against them, and 62% of the total claims were for obstetrics care, involving such cases as neurologically impaired or stillborn infants.
Ascension Health
An obstetrics team at Columbia St. Mary's Hospital in Milwaukee practices safety measures using a high-tech baby simulator called Hal
To help address the problem, the federal Agency for Healthcare Research and Quality has awarded grants of about $3 million each to two groups working on better obstetrics safety: Ascension Health, which includes Columbia St. Mary's, and a team comprising Minneapolis-based Fairview Health Services and the University of Minnesota School of Public Health. The two Minnesota institutions are continuing work on an obstetrics-safety program begun in 2008 by a Charlotte, N.C.-based alliance of some 2,400 hospitals known as Premier Inc.
Studies by Premier have shown that five recurring issues are responsible for the majority of delivery-related problems: failure to initiate a timely Cesarean section; failure to recognize an infant in distress; failure to properly resuscitate a baby; inappropriate use of labor-inducing drugs; and misuse of vacuums and forceps. Injuries happen when delivery teams don't act quickly enough to deal with sudden unexpected events like shoulder dystocia, which occurs when the baby's shoulder gets stuck behind the mother's pubic bone. This can lead to muscle palsy and neurological injuries to the infant and physical trauma for the mother.
To deal with such situations, Premier developed a series of protocols doctors and nurses call "care bundles"—a collection of best practices that, when used together, get better results than any individual intervention.
Starting in July 2008, a group of 16 hospitals used the protocols in the delivery room; through 2009, the group reduced injuries to infants by 11.6% from a baseline period in 2006 and 2007, and reduced cases of insufficient oxygen that often cause infant brain damage by 31.4% against the baseline period.
At Ascension Health, whose Columbia St. Mary's is one of five hospitals participating in the federally funded effort, they're getting good results, too. In fiscal 2010, the St. Louis-based nonprofit, whose hospitals deliver about 75,000 babies a year, had an infant mortality rate of 0.48 per 1,000 births, and 0.65 cases of birth trauma per 1,000 births, according to chief medical officer David Pryor.
That's a drop of more than 50% since Ascension Health started its obstetrics-safety program in 2003, Dr. Pryor says, and compares with a national rate of 4.5 deaths and 1.84 birth injuries per 1,000 births.
"We are asking bold questions about why these things happen, what may have contributed to error and what could be done differently," says Ann Hendrich, Ascension Health's vice president of clinical excellence.
Care Bundles
Care bundles are an increasingly popular way of reviewing whole processes. Take, for example, vacuum-assisted births. Babies may suffer injuries such as scalp lacerations and hemorrhages from the vacuums used in tough deliveries. As a safety feature, a vacuum suction cup will pop off if there is too much traction or if the angle is inappropriate. But the definition of how many pop-offs are safe and how long the vacuum strategy should be used before doctors abandon it for another technique such as an emergency C-section has been loose.
In the vacuum care bundle, physicians or nurse midwives are required to do several things: discuss the risks, benefits and alternatives with the patient; document the conversation; and perform an examination to ensure that the baby is properly positioned, and that there is a high likelihood of success with the vacuum. The bundle also specifies that the vacuum be stopped after a set time period—20 to 30 minutes—or a maximum number of times that the vacuum pops off the infant's head, and that a back-up plan include emergency staffers on call for a C-section.
Summa Health System's Summa Akron City Hospital, a participant in the Premier program, conducted monthly high-risk simulations using various care bundles. The Akron, Ohio-based hospital audited as many as 80 charts a month to see if doctors were following recommended practices. It issued scorecards recognizing those physicians who were in compliance—and made sure to follow up with doctors who weren't. Other than in those areas where it had no adverse incidents for the previous five years, it showed a reduction in all other incidents including respiratory problems after birth, according to Vivian E. von Gruenigen, medical director of women's health services at Summa.
The majority of reports on infant deaths or harm cite poor communication between caregivers. Fairview physician Stanley Davis in Minneapolis, lead researcher for the new phase of the Premier safety program, says teamwork will be a strong focus.
In addition to mannequins or robots, training drills use employees in the roles of patients and families to simulate high-stress scenarios such as frightened parents, a mother who has an allergic reaction to a drug, or the absence of vital equipment or emergency personnel. Doctors and nurses then watch videos of themselves responding in the simulations to learn how they might have acted differently, much like athletes reviewing game tapes.
Not Infallible
The aim to is to get doctors to recognize they aren't infallible, and to encourage all team members to speak up if they see a problem brewing.
"We still have errors when a junior person sees something and is afraid to speak up," says Phillip Rauk, a specialist in maternal and fetal medicine at University of Minnesota Medical Center.
As for physicians themselves, Dr. Rauk says, most generally believe these kinds of things don't happen in their practices. Some may not realize their routines aren't as safe as they think, he adds, or that potential risks and near misses are occurring.
Paul Burstein, who delivered Ms. Weinshel's baby at Columbia St. Mary's, says this kind of training through simulations has helped change the culture in the delivery room, and has added a dimension to his skills that he didn't learn in medical school. He still relies on his medical instincts and experience, he says, but care bundles have better prepared him for emergencies.
"I do have a mental checklist now of what to do," Dr. Burstein says. "It has given me more confidence that I'm thinking about what could happen. And I know other members of the team are on the same page."
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