2018 Salus Global Patient Safety Award Winner
Objectives: To facilitate best practice and excellent care in the delivery of twins at a level 1b hospital. To ensure optimal outcomes and nursing satisfaction with the process of delivering uncomplicated term twins.
Delivery of uncomplicated term twins can be accomplished safely in a level 1b hospital provided adequate support and where an obstetrician is available. By providing twin deliveries, Boundary Trails Health Centre (BTHC) meets the Society of Obstetricians and Gynecologist of Canada’s recommendation of providing high quality maternity care as close to home as possible. Prior to this initiative, patients with uncomplicated (diamniotic/dichorionic) twins were required to travel more than an hour to the closest tertiary centre.
Existing issues: The delivery of twins was a new program in 2018 that required extensive research, collaboration between service areas and staff education. Collaboration was needed between obstetrical staff, operating room (OR) staff, Diagnostic services and Respiratory Therapy. The BTHC surgical program shares the operating rooms with the obstetrical program. Due to this fact, interdisciplinary and interdepartmental cooperation was imperative to the success of this program. Obstetricians, Family Physicians, Managers, Clinical Resource Nurses (CRN’s) and the MOREOB core team collaborated with the operating room surgeons, anesthetics, staff and management, along with the regional obstetrical educator, to develop a policy and then to train all involved parties on how to safely accomplish uncomplicated twin deliveries at BTHC.
Success: Success will be measured by reviewing all twin deliveries. After every twin delivery a debrief is done. Expression of the staff’s skill & comfort in providing the best possible care in the twin delivery is assessed on an ongoing basis. The OR staff, as well as the obstetrical staff, are asked to freely express their thoughts and/or concerns with the developed process. Any feedback received is considered and changes implemented, if validated, on an ongoing basis.
Key strategies: Environmental survey was done initially to see if BTHC would be to provide this service and maintain excellent and safe care. Once it was determined that BTHC would be able to provide this service, the next step was to obtain reginal and provincial approval. After this, a policy was drafted and approved by the reginal obstetrical team, the regional surgical team, the regional medical advisor committee and finally to the executive director for final approval. Staff education in regards to twin deliveries was initially accomplished at the annual MOREOB workshops/ACE days. From there, twin delivery simulations, including all stakeholders, were planned.
Body of Submission
- From the beginning, front line staff were encouraged to give their thoughts to the MOREOB core team so they could be brought forward to the Best Practice Committee. The draft policy was reviewed by the front line staff prior to finalization.
- Senior leadership expressed full support of this initiative from the start. They immediately saw the benefit of keeping these deliveries in the community and that BTHC has the ability to make this possible.
- MOREOB reports were used to ensure staff has reviewed the twin chapter as the policy was largely based on the best practice evidence in the MOREOB chapter.
- The progress and success is shared on a monthly basis locally, as well as at the regional obstetrical team. It was also posted on the MOREOB website for staff to read. The MOREOB core team sent out the debriefs for the simulations via e-mail to all involved parties.
- The Regional Obstetrical Educator worked with an obstetrician to initially develop the policy. It was then reviewed by the surgical team as well as the respiratory therapist, managers and CRN’s. All input was evaluated to ensure that the obstetricians and the anesthetists are aware and consulted and that the hospital is notified.
- In planning the simulations, the OR management and staff collaborated with the obstetrical team to ensure OR availability & staff availability so that the simulation could be done in the safest, most efficient manner possible. All actions that came out from the simulations were addressed.
- The OR staff was very helpful instructing obstetrical staff to the OR principles in maintaining sterility, OR set up and procedure. In return the obstetrical staff educated the OR staff on vaginal delivery procedures, maternal & fetal monitoring practices and post delivery care. By doing so, staff from both areas are better able to appreciate the roles and responsibility that each area has.
- Satisfaction and greater understanding was expressed by all participants of the simulations. All felt that the simulations were a great learning experience and actions items were addressed, making the staff feel much more confident providing care. Specific action items that were identified include a formal role assignment for all staff involved; ensuring the number of staff involved does not exceed the number of staff actually needed; ensuring the proper notification process is developed; development of a job aid; as well as educating the staff on the obstetrician’s personal references for twin delivery set up.
The impact of this initiative is that BTHC now provides excellent care for uncomplicated twin deliveries, keeping these patient from having to travel to a far away community to have their delivery. Prior to this initiative, unexpected twin deliveries were occurring and the staff anxiety surrounding these occurrences has now greatly decreased. The staff are better informed in regards to the twin pregnancies in the area as a referral process has been set up where the obstetricians are made aware of all twin pregnancies and this information is then relayed to the obstetrical ward and the anesthetists.
By providing this service to our community we have been able to decrease ambulance costs, decrease costs to the region and the patient as well as increase patient satisfaction, all while providing safe and excellent care.