{OB CORE STEPS

Implementation strategies

Identify OB emergencies requiring structured team emergency procedures

Identify and discuss strategies to implement STEPs in the OB setting

Objectives

November 2nd , 1998

April 3rd, 2011

In 2004, the Joint Commission began to focus on risk reduction strategies in an attempt to decrease perinatal adverse outcomes.

In 2007, they recommended that all accredited facilities with perinatal services implement team training and mock emergency drills for: Emergency c-sections Shoulder dystocia Maternal Hemorrhage

(Sorenson 2007)

Perinatal Safety Initiatives Mock Drills

“The goal of standardized response and rapid effective recognition and correction of problems is better met with a small stable group.”

OB Code One REsponse

Structured Team

Emergency ProcedureSSVH OB CORE

STEPS

GOALPromote positive

perinatal outcomes by optimizing

resource utilization

Recognition Activation

Action Debriefing

4 Areas of Focus

Emergency cesarean section Emergent Vacuum/Forceps delivery Shoulder dystocia Prolapsed umbilical cord Maternal cardiopulmonary arrest Maternal Hemorrhage Preterm precipitous delivery Maternal seizures

Recognition of the OB emergency

Skunk PhenomenonWhen a skunks around, everyone pays attention!

(An approach taken from the defense aerospace industry)

Lockheed Martin’s “Skunk Works” is synonymous in the business world with rapid and focused technical innovation.

“A Skunk Works is a group of people who, in order to achieve unusual results work on a project in a way this is out-side the usual rules.”1

1http://whatis.techtarget.com/definition/0,289893,sid9_gci214112,00.htm

How did we do it?

“Deconstructed” and redesigned our

response to obstetric

emergencies!

Identified each key step that needed to be performed up to the point of:Delivery of the babyStabilization of the mother

Conducted a walk through from one step to the next to determine which person should ideally perform the task. Assigned these to 4 main people:1. Primary L&D/MNCU RN2. Second L&D/MNCU RN3. Clinical Supervisor/Third RN4. L&D/MNCU Unit Clerk

Code I Cesarean Section Primary RN In L&D Room Initiate OB Code I Cesarean Section IV access (if not in place) Draw T&S, CBC (if placing IV) IV bolus of LR Transfer to OR  In Operating Room Assist anesthesia/STA with:  

o applying monitorso cricoid pressure for induction of general anesthesia

Elevate fetal head with vaginal exam if needed Assist with transfer of patient to recovery or ICU as ordered by

Physician/Anesthesia

Code I Cesarean Section SECOND RN

In L&D Room Obtain emergency IV fluid Abdominal/suprapubic clip Foley catheter Transfer patient to OR

In OR

Transfer patient to OR table Right hip roll External fetal monitors Abdominal prep Cautery Suction Obtain medications when requested by anesthesia/OB Assist with blood products transfusions if indicated

Code I C-Section CLINICAL SUPERVISOR/ THIRD RN

In L&D Room Obtain clippers Administer Bicitra upon anesthesia order 

In Operating Room Surgical field lights Whiteboard - Record initial times Blanket to lower extremities Safety straps Surgical count (if time allows)

x-ray needed if no count done Perform timeout

Code I C-Section PART ONE WARD CLERKNotify the following people, via Page Gate, of OB Code I Cesarean Section:

o OB provider (as indicated, family practice or certified nurse midwife patient)

o 1st call Anesthesiologisto L&D Clinical Supervisoro Scrub techo STAo NICU Clinical Supervisoro L&D/MNCU staffo On call Neonatologist (0800-1700); On call Pediatrician (1700-

0800)o If no response within 5 minutes, repage 1st and 2nd call

Anesthesiologist. If no response within 10 minutes, repage 1st, 2nd , 3rd, and 4th call anesthesiologists; page MFM/ESPC OB backup.

Obtain all paperwork: o Obtain new Anesthesia orderso Verify consents are signedo Pre-procedure printed for Nursery and Anesthesia

Developed formal protocols for staff to follow.

Developed tools/job aids for support: Flipcharts Kardex for checklist cards Pocket cards (to be designed) Medical Supplies

Maternal hemorrhage cart Emergency C-Section kit Cord Prolapse kit

Rapid and simultaneous activation of the entire team.

Activation

Preset/Standardized Messages

Action

Test

• Revise

Test

• Revise

Educate

• Practice

Proceed in a coordinated,

virtually choreographed fashion.

http://youtu.be/gzbhpHfqJiI

In this setting complexity can breed chaos.

Therefore, the code team structure and

organization should be natural, clinically

relevant, easily reinforced and must augment rather

than distract team member focus.

Encouraged an informal debriefing following the OB emergency.

Developed a formal debriefing report to be filled out by the clinical supervisor .

Debriefing

http://youtu.be/rA_BQorRBms

Since obstetric teams typically assemble using any available personnel, in response to stressful and unpredictable circumstances, forming teams with consistent membership is improbable and impractical; thus, it is important for all team members to be able to adapt dynamically and then clearly understand their roles and responsibilities required in an emergent situation.

Conclusion