Zero Birth Injury Initiative

1
Zero Birth Injury Initiative

• Phillip N. Rauk, MD
• Associate Professor, Division of Maternal-Fetal
  Medicine, Department of Obstetrics, Gynecology,
  and Womens Health, University of Minnesota
  Medical School
• and
• Medical Director of the Birthplace at
  UMMC-Fairview Hospital

2
Objectives

• Basic safety improvement strategies
• Definition of birth trauma
• Brief story from Ascension Health
• Bundle science and IHI obstetrics bundles
• Impact of shoulder dystocia
• Where are we at Fairview?

3
Why are we doing this?

• Overall goal of the initiative is to reduce birth
  injury
• UMMC birth injury rate 2007 0.03
• Birth injury is devastating to all involved
• Right thing to do
• Improve patient safety
• Improve perinatal outcomes
• Reduce medical and nursing errors

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Preventable Perinatal Harm and Obstetrical
Liability

• Failure to recognize fetal distress/non-reassuring
  fetal status
• Failure to effect a timely cesarean section
• Failure to properly resuscitate a depressed baby
• Inappropriate use of oxytocin/misoprostol
• Inappropriate use of vacuum/forceps
• Failure to manage shoulder dystocia

5
Characteristics of a Successful Safety Change
Initiative

• High functioning team rather than expert
  individuals
• Shared mental models
• Situational awareness
• Common language
• Policies and order sets support these initiative

6
Strategy to create Highly Reliable Teams within a
culture of organizational learning
Stan Davis, MD, FACOG Kristi K Miller RN, MS
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Adverse Outcome Index Measure and Weighting Score
Index Measure Score Maternal Death
750 Intrapartum and Neonatal Death
400 Uterine Rupture 100 Maternal
Admission to ICU 65 Birth Trauma
60 Return to OR/LD 40 Admission to NICU
35 APGAR lt7 25 Blood
Transfusions 20 3rd and 4th degree
perineal laceration
5
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Birth Trauma as defined for the AOI Measure

• In-born infants only and diagnosis of
• 767.0 Subdural and Cerebral Hemorrhage (due to
  trauma or to intrapartum anoxia or hypoxia)
• 767.11 Epicranial subaponeurotic hemorrhage
  (massive)
• 767.3 Injuries to skeleton (excludes clavicle)
• 767.4 Injury to spine and spinal cord
• 767.5 Facial nerve Injury
• 767.6 Injury to brachial plexus
• 767.7 Other cranial and peripheral nerve injuries
• Not used in AHRQ PSI 17 measure for Birth
  Trauma Infant

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AHRQ Patient Safety Indicator (PSI) 17 - Birth
Trauma

• Numerator
• Discharges among cases meeting the
  inclusion and exclusion rules
• for the denominator with ICD-9-CM code for
  birth trauma in any
• diagnosis field
• Exclude infants
• With any diagnosis code of pre-term infant
  (denoting birth weight of
• less than 2,000 grams)
• With any diagnosis code of osteogenesis
  imperfecta (756.51)
• With any diagnosis code of injury to brachial
  plexus (767.6)

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Birth Trauma as defined by the AHRQ PSI 17Birth
Trauma Infant
767.0 Subdural and Cerebral Hemorrhage (due to
trauma or to intrapartum anoxia or hypoxia)
767.11 Epicranial subaponeurotic hemorrhage
(massive) 767.3 Injuries to skeleton (excludes
clavicle) 767.4 Injury to spine and spinal
cord 767.5 Facial Nerve Injury 767.7 Other
cranial and peripheral nerve injuries 767.8
Other specified birth trauma Not used in AOI
Birth Trauma Measure
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Story at Ascension Health

• Three hospital sites were selected for
  implementation of
• Standardized order sets specific to augmentation
  and induction of labor
• Complete adherence to a IHI induction,
  augmentation and operative delivery bundles
• Best practices sharing across all disciplines
• Effective communication strategies using SBAR and
  culture change

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Story at Ascension Health

• From February 2004 to June 2006
• Bundle compliance achieved the goal of 95
  compliance
• Elective inductions before 39 weeks fell to zero
• Operative delivery rate fell from 7.4 to 4.8
• Birth trauma rate fell from 0.2 to 0.03
• Primary cesarean rate remained unchanged at 22.5

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Ascension Health Birth Trauma
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Quality Care in Obstetrics Addressing Harm
Using Bundles

• The Bundle Science
• Individual components supported by evidence based
  medicine/professional guidelines
• Required to be performed for every patient, every
  time
• Bundle compliance measured by fulfilling all
  parts of the bundle
• Focus on system

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Bundle Science

• A bundle is a group of evidence-based
  interventions related to a disease or care
  process that, when executed together, result in
  better outcomes than when implemented
  individually.
• All components of the bundle must be met to
  achieve the desired better outcome

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The Oxytocin Bundles

• Augmentation Bundle
• Documentation of Estimated Fetal Weight
• Reassuring Fetal Status
• Pelvic Exam prior to the start of Oxytocin
• Recognition and management of
  Hyperstimulation

• Elective Induction Bundle
• Gestational Age gt 39 weeks
• Reassuring Fetal Status
• Pelvic Exam prior to the start of Oxytocin
• Recognition and management of
  Hyperstimulation

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No Elective Inductions at lt 39 weeks No Elective
Late-Preterm Infants

• RDS
• TTN
• Pulmonary infection
• Unspecified respiratory failure
• Recurrent apnea
• Temperature instability
• Jaundice that delays discharge
• Bilirubin induced brain injury

• Hypoglycemia
• Rehospitalization for any cause
• Rehospitalization for neonatal dehydration
• Death
• Feeding difficulties
• Long term behavioral problems

(Pediatrics, September 2006. 1181207)
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Vacuum Bundle

• Alternative labor strategies considered
• Prepared patient
• Informed consent discussed and documented
• High probability of success
• EFW, fetal position and station known
• Maximum application time and number of pop-offs
  predetermined
• Exit strategy available
• Cesarean and resuscitation team available

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Vacuum Delivery

• Incidence of operative vaginal delivery is
• 10 15
• Compared with SVD (SVD vs Vacuum)
• Rate of Death is 1/5000 vs 1/3333
• Rate of IVH is 1/1900 vs 1/860
• Rate of all injury is 1/216 vs 1/122
• Includes nerve injury, seizure, CNS depression,
  mechanical ventilation
• Vacuum and Forceps rate of death is 1/1666 and
  rate of IVH is 1/280.

ACOG 2000
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Pop-Offs

• Pop-offs are defined as a sudden complete
  detachment of the vacuum from the head with a
  rapid loss of pressure from the green zone to
  zero pressure.
• The number of pop-offs correlates with birth
  trauma, ranging from abrasions to subgaleal
  hemorrhage
• Generally gt 3 increases the risk for birth injury

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Maximum Pulls

• A pull is defined as use of traction during each
  contraction not the number of pulls within each
  contraction.
• There is no clear definition of the maximum pulls
  that should be attempted before the procedure is
  abandoned.
• Most experts feel up to 3-4 pulls is appropriate
  if progression in descent is noted with each
  subsequent pull.
• Failure to abandon the procedure when progress
  has not occurred is associated with an increase
  in birth trauma

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Application Time

• There is limited data on application time
• Longer application times are associated with an
  increased risk for failure and for neonatal
  morbidities
• Most experts believe that consistent with other
  guidelines in the use of vacuum (i.e maximum
  pulls and progress) that 10 20 minutes is
  appropriate and that failure of any descent after
  10 minutes predicts a high rate of failure

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Other Considerations

• Poor technique also effects maternal and neonatal
  morbidity and mortality
• Improper application both with respect to
  placement on the head and station/position
• Lack of training and credentials to perform the
  procedure
• Use of a rocking motion or rotation
• Inattention to number of pop-offs and pulls

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Shoulder Dystocia Facts And Strategies

• Most often unpredictable 0.2 3.0 of
  deliveries
• Most brachial plexus injuries will resolve within
  a year but you cant be sure in advance which
  ones will.
• Standard of care is to perform correctly when it
  is encountered. (In Situ Simulations)
• When there are risk factors, it is probably
  prudent to inform the parents and discuss
  options. It is also reasonable and acceptable to
  make a recommendation based on your knowledge and
  experience.
• Get credit for meeting the standard with
  appropriate documentation
• Shift to the management of bad results mode of
  care when injury occurs.

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What Does ACOG Say?

• November, 2002. The following recommendations
  are based on limited or inconsistent scientific
  evidence
• Shoulder Dystocia cannot be predicted or
  prevented because accurate methods for
  identifying which fetuses will experience this
  complication do not exist.
• Elective induction of labor or elective cesarean
  delivery for all women suspected of carrying a
  fetus with macrosomia is not appropriate.

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What Does ACOG Say?

• November, 2002. The following recommendations
  are based primarily on consensus and expert
  opinion
• In patients with a history of shoulder dystocia,
  EFW, gestational age, maternal glucose
  intolerance, and the severity of the prior
  neonatal injury should be evaluated and the risks
  and benefits of cesarean delivery discussed with
  the patient.
• Planned cesarean delivery to prevent shoulder
  dystocia may be considered for suspected fetal
  macrosomia with estimated fetal weights exceeding
  5,000 grams in women without diabetes and 4,500
  grams in women with diabetes.
• There is no evidence that any one maneuver is
  superior to another in releasing an impacted
  shoulder or reducing the chance of injury.
  However, performance of the McRoberts maneuver is
  a reasonable initial approach.

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Are We There Yet?

• Induction and Augmentation Bundles
• Everyone knows about it but still not at 100
• Problems with EFW
• Operative Vaginal Delivery Bundle
• gt70 compliance but not integrated into system
  practice yet.
• We do have a 70 reduction in birth trauma and
  30 reduction in AOI at UMMC-Riverside

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Acknowledgements

• Becky Gams, R.N., M.S., A.P.N.L., University of
  Minnesota Medical Center, Fairview
• Phillip Rauk, M.D., University of Minnesota
  Medical Center, Fairview
• Samantha Sommerness, R.N., M.S.N., C.N.M.,
  A.P.N.L., Fairview Southdale Hospital
• Ann Page, R.N., M.S.N., C.N.M. , University of
  Minnesota Medical Center, Fairview
• Charlie Hirt, M.D., Fairview Southdale Hospital
• Kristi Miller, R.N., M.S., Fairview Hospitals,
  Patient Safety
• Stan Davis, M.D., Fairview Hospitals, Patient
  Safety
• Carol Clark, R.N., M.S.N., C.N.P., Fairview
  Ridges Hospital
• Suzin Cho, M.D., Fairview Ridges Hospital
• Cass Dennison, R.N., B.S.H.A., Fairview Lakes
  Medical Center
• Ralph Magnusson, M.D., Fairview Lakes Medical
  Center
• Jan Gilmore, R.N.C, M.S,H.A., Fairview Red Wing
  Medical Center
• William Saul, M.D., Fairview Red Wing Medical
  Center
• Char Dekraker, R.N., I.B.C.L.C., Fairview
  Northland Medical Center
• Kathy Abrahamson, M.D., Fairview Northland
  Medical Center
• Tom George, M.D., University of Minnesota Medical
  Center, Fairview
• Ted Thompson M.D., University of Minnesota
  Medical Center, Fairview
• Michelle OBrien, M.D., University of Minnesota
  Medical Center, Fairview