2015 MOREOB Patient Safety Award Winner
The Fraser Health Authority is located in southwestern British Columbia and provides obstetrical services to approximately one third of BC's childbearing families. Spanning the communities across metro Vancouver and the Fraser Valley, obstetrical services are concentrated in eight of the twelve hospitals and provide community through tertiary level services. All eight sites operate within the same maternal-infant program and have implemented MOREOB.
Delayed recognition of clinical deterioration in obstetric patients has been associated with morbidity and mortality. It is well known that physiological abnormalities precede critical illness. Pregnant and postpartum women have different physiological responses to acute illness when compared to the general population. It is, therefore, challenging to determine appropriate criteria that should alert health care providers to the need for escalation of care. Early obstetric warning systems and normal vital sign ranges have been proposed to aid in early recognition of deterioration, however, these criteria are based on limited scientific evidence and only one system has been internally validated.
Across the program, several patient safety reviews have identified that delay in recognition of deteriorating obstetric patients was a contributing factor to maternal morbidity. This prompted the development of a protocol for early recognition of the deteriorating obstetric patient which included the Obstetric Trend and Trigger Tool (ObT&T). A human body systems approach was used to facilitate nurses' clinical decision-making, prompt escalation of care and, thus, optimize patient outcomes. By coordinating key information onto one page, a broad range of patient assessment findings can be collectively analyzed and trended to determine the patient's clinical course and degree of stability. Cut-off values for escalation of care were informed by published obstetric early warning criteria and are embedded in the ObT&T. When two or more abnormal values or one critical value are found on assessment there is immediate escalation of care. Because one abnormal criterion may reflect normal physiology for a particular patient, the team would individualize an assessment and action plan for persistence of a single abnormal value. This protocol was implemented across all eight perinatal sites in March of 2015 with the plan to obtain user feedback and re-implement in the fall of 2015.
Prior to the March implementation, MOREOB team members from one tertiary and one community site (Royal Columbian and Peace Arch Hospitals) collaborated to conduct a failure mode and effect analysis (FMEA), examining the process of initiating the OBT&T and escalating care as outlined in the associated protocol. The purpose of conducting a collaborative analysis was to identify both the common barriers to protocol compliance as well as the potential problems unique to sites with different service provision levels. The interprofessional team of nine was diverse, led by two clinical nurse specialists and comprised of an obstetrician, midwife, three front-line nursing leaders (two patient care coordinators and one clinical nurse educator), and two bedside perinatal nurses. Several failure modes were identified and many strategies to prevent the failures were recommended prior to the initial implementation. User-feedback and regular quality reviews have allowed us to evaluate the effectiveness of some FMEA actions and further action has been taken in preparation for the reimplementation phase. A formal evaluation will occur in 2016.
The Obstetric Trend and Trigger tool (OBT&T) is one of five elements that comprise the Early Recognition of the Deteriorating Obstetric Patient protocol. Other protocol components include structured communication using CHAT, an obstetric fluid balance record, a suspected sepsis preprinted physician's order, and an escalation algorithm. Since appropriate application and completion of the OBT&T is necessary to trigger escalation, the team chose to concentrate the FMEA on the process of applying the OBT&T and using it to effectively escalate care. This included examining the potential failures to successful communication between all care providers.
The module 3 orientation provided the participants with brief exposure to the FMEA process and one team member had previous experience conducting a FMEA. Since the new protocol had not yet been launched, the FMEA team had limited understanding of how care would change following implementation so the team mapped the process as it existed without the OBT&T and accompanying protocol. Identifying gaps where failures had been documented as adverse events or near misses enabled the team to more effectively map the new process and recognize the failure modes. Overall, there were ten failure mode categories identified for which root-cause analyses were conducted for potential effects and consequences. Assigning the risk prioritization number was especially useful as it revealed fewer differences between tertiary and community sites than previously anticipated. This unexpected finding allowed the team to develop feasible strategies related to:
- leadership education on deterioration and protocol navigation
- front-line staff education (including basic assessments, techniques, & equipment usage)
- standardization of messaging to primary care providers
- tool creation to facilitate protocol use
- equipment standardization
- communication improvement strategies between team members and between sites
- modifications to the final protocol draft prior to launch
These strategies were communicated to the practitioners at all professional levels at each site through the medical department heads, and MOREOB core team members. The team conducted the FMEA three months prior to the scheduled implementation so there was adequate time to incorporate the strategies to mitigate the identified failure modes into the roll-out plan. (see attached appendix detailing examples of the FMEA process points)
In addition to running the work shop we also selected 10 RN's that worked various shifts to spend a day in the Main OR buddied with an anesthesiologist Here they would refresh their skills in assisting with intubation, extubation and initial recovery following general anesthetic. This allowed the nurses to feel more comfortable and competent in this skill with these patients. It also allowed them experience different working environments and work together with other nurses and respiratory therapists from the Main OR.
The FMEA process learnings were integrated into the year-end workshops to benefit the whole MOREOB team at the two collaborating sites. MOREOB content outlining FMEA, root cause analysis, and adverse event review was interactively incorporated by engaging the participants in the mapping process, identifying failures in the existing system, and in discussion of the FMEA recommendations being carried out through the case studies and ACE exams. By integrating this material we were able to achieve one of the identified failure mode strategies to improve understanding of why the new protocol was necessary. Aspects of this activity was also incorporated into the workshops at the remaining six sites so all obstetrics practitioners had the benefit of the experience.
The program medical director, executive director, and clinical operations directors for the maternal-infant program in Fraser Health all supported this initiative. This was evidenced by the value they placed on the time required to conduct the FMEA and the accountability for following through on the strategies identified. Financial support was provided to all employed participants for time spent conducting the FMEA, training champions to provide consistent front-line messaging, and participating MOREOB workshops. Also, the medical and nursing leadership at each of the sites participated in disseminating the information required to achieve some of the failure mode strategies through their professional networks.
In 2016, the obstetrics program will undergo accreditation, of which a prospective analysis is required. While the FMEA has exposed all teams to the benefits of identifying potential failures in a new system, continued evaluation is necessary to assess the success of the implemented strategies and the protocol itself in improving patient safety. So far, all practitioners have had opportunity to be involved in the ongoing PDSA (Plan Do Study Act) cycle through participating in or learning from the FMEA, following through strategies to prevent the identified failure modes prior to implementation, or by providing feedback on the initial version of the protocol. The accreditation process involves the whole obstetric team at all eight sites therefore there will be ongoing support to participate in this protocol's PDSA cycle well into 2016. Moving forward, practitioners will be involved in conducting compliance audits on the OBT&T application. As well, near misses and adverse events of which delay in escalation is identified as a contributing factor will be tracked, reviewed, and discussed through the robust patient safety event review structure currently in place.
The collaboration between MOREOB teams at Royal Columbian and Peace Arch hospitals exemplifies the exceptional commitment to improving patient safety for childbearing women receiving care everywhere in Fraser Health. By conducting a failure mode and effect analysis, these teams prospectively assessed a new protocol to enhance early recognition of the deteriorating obstetric patient. The teams' commitment to share the process learnings within their sites and throughout the network was integral to the implementation and engagement throughout the project launch and set the stage for ongoing participation in continuous improvement. Leading their whole teams in carrying out strategies to remove not only the systemic, but also the cultural barriers to successful realization of the protocol personifies the 1-1,k0 philosophy we strive to incorporate into practice on our obstetric units.