1. { OB CORE STEPS Implementation strategies

2.  Identify OB emergencies requiring structured team emergency procedures  Identify and discuss strategies to implement STEPs in the OB setting Objectives

3. November 2 nd, 1998

4. April 3 rd, 2011

5.  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) (Sorenson 2007) Perinatal Safety Initiatives Mock Drills

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

9. RecognitionActivation ActionDebriefing 4 Areas of Focus

10.  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

11. Skunk Phenomenon When 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 1 http://whatis.techtarget.com/definition/0,289893,sid9_gci214112,00.htm

12. How did we do it? “Deconstructed” and redesigned our response to obstetric emergencies!

13. Identified each key step that needed to be performed up to the point of:  Delivery of the baby  Stabilization of the mother

14. 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 RN 2. Second L&D/MNCU RN 3. Clinical Supervisor/Third RN 4. L&D/MNCU Unit Clerk

15. 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 o applying monitors o o 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

16. 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

17. 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

18. Code I C-Section PART ONE WARD CLERK Notify the following people, via Page Gate, of OB Code I Cesarean Section: o o OB provider (as indicated, family practice or certified nurse midwife patient) o o 1 st call Anesthesiologist o o L&D Clinical Supervisor o o Scrub tech o o STA o o NICU Clinical Supervisor o o L&D/MNCU staff o o On call Neonatologist (0800-1700); On call Pediatrician (1700- 0800) o o If no response within 5 minutes, repage 1 st and 2 nd call Anesthesiologist. If no response within 10 minutes, repage 1 st, 2 nd, 3 rd, and 4 th call anesthesiologists; page MFM/ESPC OB backup.   Obtain all paperwork: o o Obtain new Anesthesia orders o o Verify consents are signed o o Pre-procedure printed for Nursery and Anesthesia

19. Developed formal protocols for staff to follow.

20. 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

27. Rapid and simultaneous activation of the entire team. Activation

28. Preset/Standardized Messages

29. Action Test Revise Test Revise Educate Practice

30. Proceed in a coordinated, virtually choreographe d fashion.

32. http://youtu.be/gzbhpHfqJiI

33. 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.

34. Encouraged an informal debriefing following the OB emergency. Developed a formal debriefing report to be filled out by the clinical supervisor. Debriefing

36. http://youtu.be/rA_BQorRBms

37. 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