Yale obstetrics safety plan cuts adverse events by 40%

Hospital adds safety nurse position, increases training for doctors, nurses. A national perinatal safety initiative will expand this fall.

By Kevin B. O’Reilly — Posted May 18, 2009

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Yale-New Haven Hospital in Connecticut cut adverse obstetrics outcomes by about 40% after implementing a comprehensive patient safety program.

The results, published in the May American Journal of Obstetrics & Gynecology, are the latest to show the positive effect of strategies such as training doctors and nurses in electronic fetal heart monitoring interpretation, properly using oxytocin for inducing labor and reducing elective inductions before 39 weeks' gestation.

Experts say three in 1,000 deliveries involve serious perinatal injuries that can result in cerebral palsy, birth asphyxia or permanent neurological disability. Many of these adverse outcomes, they add, can be prevented using evidence-based guidelines developed by the American College of Obstetricians and Gynecologists and the Assn. of Women's Health, Obstetric and Neonatal Nurses.

An outside review in 2002 showed that the Yale-New Haven obstetrics unit lacked institutional guidelines, had poor communication and chain of command, and lacked a quality assurance mechanism.

To help collect data and improve adherence to three dozen protocols and guidelines, the hospital created the position of obstetrics safety nurse. The nurse's job includes running the anonymous event reporting system, reviewing neonatal logs daily, formally evaluating obstetrics outcomes, and identifying adverse-event cases and systemic weaknesses.

"It would be very difficult to accomplish this improvement without a patient safety nurse," said Christian M. Pettker, MD, the study's lead author and Yale-New Haven's medical director of labor and birth. "To implement the changes piecemeal and not have a perceived leader would make it very difficult for all the stakeholders -- nurses, physicians and ancillary staff -- to buy into the project."

The study reports adverse outcomes for 13,622 deliveries at Yale-New Haven from September 2004 to August 2007. Because the outcomes being tracked -- maternal and fetal death or intensive care unit admission, for example -- are so rare, the study authors used an index to aggregate 10 indicators that is more likely to show change over time. In addition to a 43% drop in that metric, doctors' and nurses' perceptions of a "good teamwork climate" jumped 46% and 81%, respectively.

Approaches differ

One element of the Yale-New Haven strategy that other hospitals are not implementing is the obstetrics safety nurse, with cost being a factor.

In May 2008, 16 hospitals began collaboration on a perinatal safety initiative organized by Premier Inc., a 2,000-hospital health care-improvement alliance. While the Yale-New Haven program cost $250,000 the first year and $150,000 annually thereafter, it costs $50,000 annually for hospitals to take part in the Premier initiative, said project director Kathy Connolly, RN.

"Sometimes if you think one person, the obstetrics safety nurse, is going to make the difference -- it's not always the case," said Connolly, principal of women's services with Premier's consulting division. "Now, with the economic downturn, a lot of places can't hire new staff or they are only there for a certain amount of hours."

The Premier initiative's results will not be released until next spring, but Connolly said the early results are encouraging enough that the nonprofit will start accepting more hospitals in the project in September.

All of this patient-safety activity is overdue in the world of labor and delivery, said Edmund F. Funai, MD, Yale-New Haven's obstetrics chief and senior author of the new study.

"Obstetrics and gynecology tends to lag other disciplines in safety-oriented research, and there's relatively little standardization because it's tough to do randomized controlled trials in pregnant women," Dr. Funai said. "But we shouldn't be frozen like deer in the headlights because of that."

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Index measures these rare outcomes

Physicians at the Yale-New Haven Hospital in Connecticut used an aggregated index that expresses the number of deliveries in which one of the following 10 outcomes occurs:

  • Blood transfusion
  • Maternal death
  • Maternal intensive care unit admission
  • Maternal return to operating room or labor and delivery
  • Uterine rupture
  • Third- or fourth-degree laceration of mother's vaginal tissue, perineal muscles or anal sphincter
  • Apgar score less than 7 at five minutes after birth
  • Fetal traumatic birth injury
  • Intrapartum or neonatal death in a normal birth weight baby
  • Unexpected admission to neonatal ICU of a normal birth weight baby, with a stay of longer than 24 hours

Source: "Impact of a comprehensive patient safety strategy on obstetric adverse events," American Journal of Obstetrics & Gynecology, May (link)

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External links

"Impact of a comprehensive patient safety strategy on obstetric adverse events," American Journal of Obstetrics & Gynecology, May (link)

Premier Inc.'s Perinatal Safety Initiative (link)

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