1. Joseph Teel, MD, FAAFP Assistant Professor of Clinical Family Medicine Director of Family Medicine Obstetrics Medical Director Department of Family Medicine and Community Health Perelman School of Medicine University of Pennsylvania Safe Passage: Improving Transitions to Labor and Delivery

2. 2 A Great Team…  Alyssa Covelli Colwill, MD (PGY-4 OB Resident)  Holly Cummings, MD  Stephanie Cusack, RN (Staff Nurse)  Mary Ann Diamond, MSN, CNM  Daniel Lee, MD (PGY-4 OB Resident)  Erica McClelland, RN (Staff Nurse)  Wayne Marquardt, BS RPh (Pharmacy)  Rich Month, MD (Director of OB Anesthesia)  Kathleen O'Rourke, MSN, RNC-OB  April Romanos, MSN, RN (OB Quality and Safety Nurse)  Sindhu Srinivas, MD, MSE (Director of Obstetrics)  Joseph Teel, MD (Director of FM Obstetrics)

3. 3 National Backdrop  Preventable medical errors are the No. 3 killer in the U.S. 1 400,000 people each year  Eighty percent of serious medical errors involve miscommunication during the hand-off between medical providers. 2 1)James. JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety: 2013; Vol 9: p122-128 2)Solet DJ, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 2005;80:1094-9

4. 4 Local Care Model  Hospital of the University of Pennsylvania admits and transfers over 300 patients per month from OB triage (Perinatal Evaluation Center - PEC) to the Labor and Delivery Unit.  PEC located geographically adjacent to L+D. (Separate ED located elsewhere in the hospital)  Prenatal patients directed to present directly to PEC.  Three distinct services patients may be admitted to: FM L+D Service / OB L+D Service / Antepartum Service  Multiple EMR Systems Out-Patient: EPIC In-Patient (L+D): Centricity Perinatal Ordering / Results: Sunrise Clinical Manager In-Patient (Postpartum): Paper Charts

5. 5 Origins of the Project

6. 6 Current State Concerns  Staff concerns about incomplete hand-offs.  Missed information (e.g. GBS status)  Delayed care (e.g. penicillin administration).  Near-Misses / Potential for Poor Outcomes

7. 7 Initial Metrics  Staff Perceptions On-line Survey of all providers and staff who work on L+D  Patient Flow Time Studies Directly Observed Tracked Electronically

8. 8 Initial Metrics  Staff Perceptions Incomplete hand-off’s “sometimes, often or always” affected the staff’s ability to care for their patients 64% of the time.

9. 9 Initial Metrics  Decision for admission to communication of plan of care:  2:35 (155 min).  Decision for admission to start of induction:  3:22 (202 min).

10. 10 National Comparison https://projects.propublica.org/emergency/

11. 11 Root Cause Analysis

12. 12 Root Cause Analysis

13. 13 Root Cause Analysis  Major themes identified on why information was incomplete upon admission: Coordinating provider and RN availability is difficult Roles & Responsibilities not clearly defined Unnecessary redundancy built into current process

14. 14 Root Cause Analysis

15. 15 Root Cause Analysis  Observations of process revealed: Steps were not always followed Information was missing or duplicated Missing information led to more travel (steps) for staff

16. 16 Proposed Countermeasures

17. 17 Proposed Countermeasures (1)  Standardized communication Involves a scripted transfer of information from the triage provider to the L+D attending or chief resident (referred to as an “admitting provider”) Previously any provider (including an intern) could take report from triage. This lead to mis-communication and inappropriate admissions.

18. 18 Proposed Countermeasures (2)  Implement an admission huddle at bedside to include primary RN, admitting MD, and patient. Hard stop prior to plan of care. Patient-centered / inclusive. Ensures full exchange of information

19. 19 Huddles, So Hot Right Now.

20. 20 Huddle “Script”  INFORMATION TO INCLUDE IN ADMISSION HUDDLE: Patient’s name Age G/Ps Gestational age Allergies Reason for admission PMH (include meds) (*Note, does not have to be as detailed as the board presentation if very detailed information is not necessary) PSH (include prior C/S) POB/GYN hx Social hx (ETOH, tobacco, illegal drugs, domestic violence)* STDs * Significant labs (blood type, GBS, other significant labs?) Membranes Most recent SVE For IUD or BTL? Presentation- Vertex? (team should clarify if US was completed) Other concerns? (ex: abnormal VS, fhr tracing, pain, any barriers that may delay POC?) POC

21. 21 Tracking Adherence  How do we know the huddles are happening?

22. 22 Improved Workflows

23. 23 Improved Workflows

24. 24 Proposed Countermeasures (3)  Safety Board

25. 25 “Fake Front End”

26. 26 Outcomes (Post-Pilot)

27. 27 Outcomes (Post-Pilot) 155 min 87 min

28. 28 Outcomes (Post-Pilot) 202 min 155 min

29. 29 Outcomes (Post-Pilot)

30. 30 On-Going Monitoring

31. 31 On-Going Monitoring

32. 32 On-Going Monitoring

33. 33 On-Going Monitoring

34. 34 On-Going Monitoring

35. 35 On-Going Monitoring  Making sure we don’t slip…

36. 36 Six Month F/U

37. 37 Six Month F/U 155 min 87 min 88 min

38. 38 Six Month F/U

39. 39 Six Month F/U

40. 40 Lessons Learned  Get the right people involved from the start  Standardize communication  Empower nursing (the gatekeeper)  Monitoring is key until it becomes SOP

41. 41 Questions?