Eight tools for improving obstetric patient safety and unit performance

Related Article: Sound strategies to avoid malpractice hazards on labor and delivery
 Martin L. Gimovsky, MD, and Alexis C. Gimovsky, MD (December 2010)

TOOL 7: SMART MEDICAL RECORDS
In obstetrics we are fortunate that there is a limited range of issues that recur repeatedly, such as gestational hypertension, placental abruption, and fetal distress. One soon gains experience in managing these conditions and, with the help of best-practice protocols, optimal care almost always can be provided.

Still, many clinical presentations can pose diagnostic challenges, especially in atypical cases. Moreover, clinicians managing a patient’s care may not immediately remember the best means of evaluating and treating a certain condition in specific circumstances. For example, at 3:00 am it may be difficult to recall whether it is nifedipine or labetalol that should be avoided with asthmatic patients or which antibiotic formulation is currently recommended for prophylaxis in a patient with premature rupture of membranes at 30 weeks’ gestation who is allergic to penicillin.

Smart medical records, already widely used in other fields of medicine, are an antidote to this problem. When certain diagnoses, physical findings, clinical details, or laboratory data are entered into specific fields in an electronic medical record, templates that have been added to the record automatically appear to show relevant information, such as tests that should be performed, treatments that should be administered, and alternative diagnoses that should be considered. Such reminders are not presented as obligations or “hard stops”; they are usually displayed in the form of easily dismissible pop-ups or “reminder bubbles” that appear on the screen and serve solely to jog memory and provide information.

Such smart electronic medical record features can be provided either by the main electronic medical record vendor or added as subprograms by other providers.

Related Article: EHRs and medicolegal risk: How they help, when they could hurt Martin L. Gimovsky, MD; Baohuong N. Trans, DO (March 2013)

TOOL 8: MATERNITY UNIT ON-SITE CONSULTATIONS
Every labor and delivery unit has its own culture, a combination of institutional history and the personality of the doctors and nurses working there. Some units function efficiently, have the most modern equipment, and provide superb medical care. Other units have less than adequate facilities, remain entrenched in older practices, and have disruptive or uncooperative personnel that interfere with the smooth running of the unit. Moreover, each maternity unit, based on its resources, patient population, and staff skills, devises its own solutions to the same sorts of problems that all other obstetric units share. Unfortunately, there is little collaboration between units to discuss common problems and trade best practices. The result is that all too often each unit invents its own “wheel” when many excellent “wheels” already have been developed for the same issues around the country.

An on-site visit by an outside consultant—an obstetrician, an obstetric nurse, or both—can identify ongoing institutional problems, point out care deficiencies the unit may not be aware of, and provide resources and ideas to help solve the issues identified. Moreover, an outside consultant can offer unbiased and authoritative opinions to help move initiatives that may be stalled by local personalities or institutional politics.

Some features that a well-conducted on-site consultation will evaluate are:

• adequacy of obstetric triage
• capacity to perform stat cesarean sections 24/7
• 24-hour availability of obstetricians, anesthesiologists, pediatricians, and operating room teams
• preparation for handling various obstetric emergencies
• oxytocin administration protocols and compliance
• adequacy of physician and nurse charting
• ongoing skills assessment of fetal heart-rate monitor interpretation
• presence of practitioners whose disruptive behavior compromises the safety of the unit
• preparation for nonmedical emergencies, such as infant abduction, natural disaster; fire; shooter; or disruptive patients, visitors, or staff.

IMPLEMENTATION CAN EQUAL SAFER CARE
As long as people have babies, less than desirable outcomes will occasionally occur. As long as care providers are human beings, the provision of obstetric care will continue to be imperfect.

It is up to those entrusted with the responsibility of caring for mothers and their babies to provide as much support and backup as possible to obstetricians and obstetric nurses, all of whom sincerely desire to do everything possible to deliver safe care to their patients.

Tools for providing such support and backup are available and can be implemented fairly easily on most obstetric units. They do involve an expenditure of both time and money. However, the most important requirement for success is an institutional willingness to 1) acknowledge that the care a given unit provides can be improved, 2) perform an in-depth evaluation of the quality of care currently being administered, and 3) move ahead with the sorts of tools discussed in this article that will enable clinicians to provide optimal care for mothers and babies.