Just two weeks before she was due to deliver her first child this past fall, Cortney Myer visited her obstetrician's office in Akron, Ohio, for what she assumed would be a routine ultrasound. But her OB discovered she had a low level of amniotic fluid, which both protects the infant and helps it grow, and she was admitted for induction to Summa Akron City Hospital the next day.
During induction, a rare but potentially fatal complication occurred: Cortney experienced a prolapsed umbilical cord, which can cut off the infant's oxygen supply. As her baby's heart rate fell, Cortney was rushed to the OR for an emergency cesarean section. A Summa resident physician was by her side, gently lifting her baby's head. It was the only thing keeping Cortney's baby alive.
Thankfully, this story has a happy ending. The cesarean section was successful, and both Cortney and baby Adison are healthy today.
We're lucky to live in a country where adverse events during labor and delivery are rare, with serious adverse events such as a prolapsed cord even rarer. Think about it — there's no area within a hospital as complex as labor and delivery. Nowhere else are care providers treating two distinctly different people at the same time.
When a serious adverse event does occur it is often unavoidable, triggered by pre-existing conditions or other risk factors. But we know some are preventable, and communication gaps between care providers are often the main culprit.
In an effort to lower the incidence of preventable birth injuries, 14 hospitals across 12 states, including Summa Akron City Hospital, collaborated on the Premier Perinatal Safety Initiative. These hospitals are large and small, teaching and non-teaching, system-based and stand-alone, with employed and non-employed physicians — a type of diversity conducive to replication at hospitals nationwide.
PPSI hospitals use powerful methods to create high reliability healthcare teams prepared for perinatal emergencies.
One method called TeamSTEPPS was originally developed by the Department of Defense in collaboration with the Agency for Healthcare Research and Quality. It's a teamwork system designed to produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes for patients. This system can be implemented in various care settings to improve communication and other crucial teamwork skills among healthcare professionals.
Emergency simulation drills are also conducted using TeamSTEPPS principles, featuring mannequins presenting the types of serious complications this project is working to prevent. Known as "Mama Noelle" and "Baby Hal," the mannequins are also programmed to transition between physiologic states that mothers and babies undergo during the birthing process.
Another method is increased adherence to evidence-based care processes. "Bundling" these processes together helps clinical staff remember to take all the necessary steps to provide optimal care to every patient, every time. Although many hospitals have long followed some or all of these individual care practices to improve perinatal outcomes, the key is consistently using them in concert.
For instance, the goal of one process is to reduce the risks associated with the use of Pitocin, a labor-inducing drug. This process has four elements. If a team doesn't document fetal weight before administering the medication, for example, it would not receive credit for the work, even if the other three process elements are performed. By increasing compliance by up to 467 percent, almost 106,000 additional mothers received these evidence-based care processes at participating hospitals over the initiative's first three years.
So far, results are encouraging. Over the first three years of the five-year initiative, which began in 2008 and concluded at the end of 2012, participating hospitals reduced already rare instances of harm to mothers and babies by up to 25 percent. This includes neonatal asphyxia, which can be caused by a prolapsed umbilical cord such as in Cortney's case. Because of these improvements, approximately 110 fewer mothers and babies experienced various rare though serious adverse events at participating hospitals during this timeframe
In instances where comparisons are available, participating hospitals are excelling compared to non-participants. A recent Centers for Disease Control and Prevention study showed that the rate of serious perinatal complications such as severe bleeding and cardiac issues roughly doubled among U.S. women from 1998 through 2009. In contrast, PPSI hospitals are actually seeing improvements in these areas — they've reduced severe bleeding by 5.4 percent, with cardiac issues dropping 15 percent.
Serious perinatal adverse events are rare, but they do occur. And when they do, they have significant physical and emotional consequences for all involved. For those adverse events that can be prevented, we're learning that consistently following proven bundles of care, and applying strategies from our military that emphasize communication and teamwork during emergency situations, can lead to positive outcomes.
When things don't go as planned, this concept of high reliability cannot be understated. Just ask Cortney Myer.