Transcript Document
OB CORE STEPS
{
Implementation strategies
Objectives
Identify OB emergencies requiring
structured team emergency
procedures
Identify and discuss strategies to
implement STEPs in the OB setting
November
nd
2
, 1998
April
rd
3 ,
2011
Perinatal Safety Initiatives
Mock Drills
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)
“The goal of
standardized
response and
rapid effective
recognition and
correction of
problems is
better met with a
small stable
group.”
Promote positive
perinatal outcomes by
optimizing resource
utilization
Recognition
Activation
Action
Debriefing
4 Areas of Focus
Recognition of the OB emergency
Emergency cesarean section
Emergent Vacuum/Forceps delivery
Shoulder dystocia
Prolapsed umbilical cord
Maternal cardiopulmonary arrest
Maternal Hemorrhage
Preterm precipitous delivery
Maternal seizures
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
1http://whatis.techtarget.com/definition/0,289893,sid9_gci214112,00.htm
“Deconstructed” and
redesigned our
response to obstetric
emergencies!
How did we do it?
Identified each key step that
needed to be performed up to
the point of:
Delivery of the baby
Stabilization 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 RN
2.
Second L&D/MNCU RN
3.
Clinical Supervisor/Third RN
4.
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
o
applying monitors
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
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
SECOND RN
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 CLERK
Notify the following people, via Page Gate, of OB Code I Cesarean
Section:
o OB provider (as indicated, family practice or certified nurse
midwife patient)
st
o 1 call Anesthesiologist
o L&D Clinical Supervisor
o Scrub tech
o STA
o NICU Clinical Supervisor
o L&D/MNCU staff
o On call Neonatologist (0800-1700); On call Pediatrician (17000800)
st
nd call
o If no response within 5 minutes, repage 1 and 2
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 orders
o Verify consents are signed
o 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
Activation
Rapid and
simultaneous
activation of
the entire
team.
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.
Debriefing
Encouraged an informal debriefing
following the OB emergency.
Developed a formal debriefing
report to be filled out by the clinical
supervisor .
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