Inducement rules part of broader effort
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BY MARK ANDERSEN / Lincoln Journal Star
Local hospital restrictions on inducing labor for convenience fit into a larger package designed to improve birth outcomes.
Spearheaded by the Institute for Healthcare Improvement, the goal is to overhaul the culture of delivery care: redefining the roles of physician, nurse and patient, creating a common language for all and developing systemic approaches to decrease error.
The tendency in perinatal care is to analyze the catastrophies, said Sue Gullo, managing director of the Institute for Healthcare Improvement. It typically ends with a promise to work harder or in a pointing of fingers, “The name and blame that we focus on in health care.”
For this initiative, the Cambridge-Mass.-based institute examined underlying systems, the weak signals of everyday care that usually don’t result in harm but can.
It’s similar to the institute’s 100,000 Lives Campaign, which looks to save 100,000 lives annually — mostly through better infection control and other small things.
An examination of everyday processes, Gullo said, shows that, lo and behold, “The system really does give us the results that we’ve created.”
Historically, labor and delivery has operated like a feudal network of autonomous kingdoms. The potential for miscommunication existed every time kingdoms interacted.
For example, a stand-in nurse calls a back-up physician in the middle of the night to describe a pregnancy.
Poor communication was cited in 84 percent of reports of bad outcomes in labor and delivery detailed to the Joint Commission on Accreditation of Healthcare Organizations.
Nurses want to paint the whole picture, said Kate Smid, manager of labor and delivery at BryanLGH Medical Center in Lincoln. Doctors want a concise summary.
Worse, the kingdoms use the same words but in some cases assign them alternate meanings.
Managing use of the drug Pitocin to initiate or augment contractions provides an example. It’s cited as a factor in 50 percent of adverse events in labor and delivery.
A risk of the drug is overly strong, rapid contractions, called hyperstimulation. As the uterus contracts, it squeezes the baby’s vascular system, said Debbie Chambers of the Family Birth Center at Saint Elizabeth Regional Medical Center.
“If the baby is strong, it will tolerate it,” she said. “If not, they tolerate it for a while, and then they don’t.”
That can lead to a cesarean or to birth trauma.
An initial objective, Gullo said, was to agree upon a definition of hyperstimulation (five or more contractions in 10 minutes).
New guidelines for managing hyperstimulation appear to work.
“Since July, there have been no instances of hyperstim (at St. E),” Chambers said.
It’s not a big change, Gullo said.
“It makes such common sense, why haven’t we done it before?”
Because of culture, she said.
Universally defining hyperstimulation makes its management the responsibility of the entire team.
The inherent reliance on teamwork resulted in early pushback from physicians, Gullo said. Doctors like to point out that they don’t do cookbook medicine. Every case is unique.
Gullo, who spent more than 20 years directing hospital obstetrics, understands the argument.
“But for 80 percent of the things we do in labor and delivery, there’s a standardization,” she said. “(By using standards) practitioners can then focus on the individual.”
The approach of the Institute for Healthcare Improvement, Gullo said, is to bring together three to five systemic practices that — based on expert opinion — should be done for every patient, every time. The practices must be based on evidence, be doable by hospitals and have low failure rates.
To standardize the delivery of information, the initiative borrowed the practice of SBAR from Navy nuclear submarines.
S – Situation
B – Background
A – Assessment
R – Recommendation
Always delivered in that order.
The system is used whenever patient information is passed — from nurse to nurse, from nurse to doctor.
Before, said Smid of BryanLGH, a nurse might be tempted to hold back a recommendation. Conversations now end, she said, with the inquiry: What is the next step?
For nurses, Gullo said, it has opened up the channels of communication. In return, it requires nurses to have a high degree of proven competency.
The initial pushback by physicians eventually melted away and was replaced by broad acceptance, Gullo said, in part, because the potential for lawsuits should diminish.
That’s no small consideration. Obstetricians and gynecologists have an average of 2.6 claims filed against them during their career, according to the American College of Obstetricians and Gynecologists.
As hospitals and physicians adopt evidence-based standards, the risks grow for the physician who wanders off path and ends up with a bad result — regardless of whether there was a medical connection. The converse is also true: If a doctor does everything right and the result is bad, it’s tougher to fault the doctor.
In Lincoln, just reaching an agreement on the initiative was an exercise in team building.
“There were some bumps in the road,” said Dr. George Hansen.
Cooperation among the hospitals was a key component, he said.
It was especially important that people didn’t have the option of changing hospitals at the last minute so they could schedule a delivery.
“Most importantly,” Hansen said, “we’re going to be able to provide better, safer care for patients.”
Reach Mark Andersen at 473-7238 or mandersen@journalstar.com.
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