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Media Update: News from the Maryland Patient Safety Center

For Further Information
Contact Patricia Montone Charvat,
978.273.7764, cpcharvat@aol.com

Maryland Hospitals Commit to Reversing Trend in Infant Mortality, National Leaders in Efforts to Improve Health of Babies

November 14, 2008 -- Considering the fact that it is wealthiest state in the nation, it is sobering that Maryland is among the 10 states with the highest infant mortality.

Maryland hospitals are working to help reverse this trend and make care safer for mothers and babies.  The Perinatal Collaborative, sponsored by the Maryland Patient Safety Center, is successfully drawing together hospitals from across the state as well as a hospital from the District of Columbia to identify and implement clinical practices for safer birth.

Most of the hospitals in Maryland that deliver babies are participating in the Collaborative – the only known formal statewide initiative in the country wherein hospitals work together toward attaining the goal of zero preventable adverse events related to labor and delivery.

The Collaborative is a component of Babies Born Healthy, a multi-faceted effort funded by the Maryland Department of Health and Mental Hygiene (DHMH).  The DHMH’s Center for Maternal and Child Health provided a grant for the launch of the Collaborative in 2007, and recently committed to funding the second phase of this project.

Where Should Reforms Begin?
“Studies have shown that failures in communication among the care team are a common factor in adverse events that occur in labor and delivery,” said Joseph Derrough, MD, who is a key advisor for the Collaborative and an obstetrician from San Jose, California, who also serves as Medical Co-Director of Patient Safety and Chairman of the Perinatal Safety Project at Kaiser Permanente.  “The Maryland initiative is opening up channels of communication among caregivers and among hospitals—and everyone wins, especially mothers and babies.”

 Making a Difference: Hospitals Coming Together
Nearly every Maryland hospital with an obstetrics unit is participating and sharing best practices through this Collaborative.  As a result, hospitals are adopting new clinical habits, such as holding “huddles” to consistently improve communication between nurses, doctors, and others who care for babies and mothers; diligently rehearsing emergency situations through drills and simulations; and ensuring that the care provided adheres to generally accepted clinical practice guidelines, such as only inducing labor in mothers who are at least 39 weeks along in their pregnancy unless there is a clinical indication to do it earlier.

“While it’s early in the cycle right now to be able to draw definitive conclusions, there are signs that this Collaborative is having a positive impact,” said Derrough.  “Initial evidence from the hospitals is showing significant improvements in communication, electronic fetal monitoring, team training, and documentation.”

Patient safety surveys of the labor and delivery staff and providers participating in the Collaborative, which were administered in Spring 2007 and again in Spring 2008, indicate that more than 60 percent of the respondents perceive their unit to be safer than one year ago.  While only preliminary data are now available, almost 40 percent of the hospitals are showing improvement in patient safety (as measured by the rate of adverse events). 

“Really, the state of Maryland has done something that few, if any, other states have done – this is worth acknowledging,” said Ann Burke, MD, Medical Director, Obstetrics and Gynecology, Holy Cross Hospital.  “Although we certainly have room for more progress, this is a good step toward doing better.”

 Hospitals Deserve the Credit
“It’s important to note that participation in the Collaborative is on a voluntary basis,” said William Minogue, MD, Executive Director of the Maryland Patient Safety Center.  “While it’s true that the Center has played a role in galvanizing these efforts, these institutions have come together, by choice, as part of their overall commitment to patient care and a desire to help each other.  It is the institutions and their dedicated staff who will deserve the credit for this culture change – and this is just the beginning.”

Virtually every participating hospital has a story that illustrates how improvements thus far are affecting patients.  A video of some of the hospital stories from the Collaborative is available by clicking here and the following offers just a few examples of these noteworthy efforts.

St. Agnes Hospital
A major focus of the St. Agnes Hospital team has been enforcing the “39-week minimum” rule for inductions and augmentations.  “The risks are much higher for an infant less than 39 weeks old, and it is absolutely in the best interest of both mother and baby to delay the procedure until the baby is more fully developed.  It’s a matter of reminding physicians of this again and again, until it becomes second nature to them,” said Raymond Cox, MD, Chair, Obstetrics & Gynecology, St. Agnes Hospital.  “With regard to enforcing this policy, it’s all about effective and continued communication with physicians.  I can characterize it in two words: relentless persistence.”

Through participation in the Collaborative, St. Agnes Hospital has also reinforced its focus on teamwork and communication.  “Equally important, as well as exciting, has been our use of simulation drills,” said Dr. Cox.  As a result of improved communication and preparedness through simulations, St. Agnes Hospital experienced a 16-month period of zero birth traumas.

“But our work continues,” Dr. Cox stressed.  “This by no means implies the work is over – rather it infers that we are on the right track, and we’ll continue making improvements and learning more as we go along.”

According to Dr. Cox, St. Agnes’ GYN Surgery unit is now performing simulation exercises.  “As people see what we are doing and how effective it has been, they are now competing for time in the simulation room.  It’s both remarkable and thrilling.”

For more details about the St. Agnes Hospital initiative, click here.

Holy Cross Hospital
The Collaborative has enabled hospitals like Holy Cross Hospital to network with other professionals throughout the state.  “Developing personal relationships with physician leaders, nurse leaders, and others in similar as well as dissimilar hospitals has been invaluable,” noted Ann Burke, MD, Medical Director, Obstetrics and Gynecology, Holy Cross Hospital.  “For instance, when we look at the policy regarding the 39-week minimum for induction and augmentation, we can say that it isn’t just Holy Cross enforcing such a policy – this is being done at many, if not most of our area hospitals.  Having that kind of weight behind the policy is significant.”

The Collaborative has also provided motivation and impetus to expand upon Holy Cross’s critical event team training, according to Dr. Burke.  Such training has now been extended to the facility’s high risk perinatal center and maternity suites (post-partum area).  “The critical event team training, which began in the labor and delivery unit, has served as a seed to other hospital units—maternity suites, high risk perinatal, and, now pediatrics—and I anticipate this to continue spreading throughout the hospital,” said Burke.

For more details about the Holy Cross Hospital initiative, click here.

Franklin Square Hospital Center
Franklin Square Hospital Center’s first goal as a participant in the Collaborative was to improve communication through the implementation of “huddles,” now called “patient safety rounds”.  Under its new scenario, caregivers have committed to meet four times a day (10 a.m., 4 p.m., 10 p.m., and 3 a.m.), in addition to between-shift “hand-off” meetings that have been in place for years.

This extra face time allows for open communication among the entire health care team, rather than being confined to doctor-to-doctor or primary nurse-to-doctor interactions.  The strength of this approach is that every member of the health care team knows the plan for every single patient.

“There is a lot to be gained by this synergy,” said James Chisum, MD, Director of OB Operations, Franklin Square Hospital Center.  “A very positive by-product of these efforts has been a marked improvement in staff satisfaction in our department.  The inclusiveness of this [huddle] approach is definitely a win-win for all involved.  Everyone’s input is heard and valued and reminds us that we are in this together, working for the patient.”

“The huddles were a first step towards improving communication and now we are focusing on simulation training, multi-disciplinary education, and the use of communications techniques, such as of SBAR, to ensure that we are all communicating in the same way” said Jennifer Smith, RNC, BSN, Patient Care Manager - Labor and Delivery.  “It’s all about team work and communication.”

For more details about the Franklin Square Hospital Center initiative, click here.

Upper Chesapeake Medical Center
Upper Chesapeake Medical Center has focused on improving and strengthening communication and accountability among all team members, with powerful results, according to Nancy Howard, MS, RN, Project Coordinator, Performance Improvement.

“Through our participation in the Collaborative, we have had many opportunities to work on team building and communication.  Because of this, nurses feel that their input is valued and, as a result, communication is improved.  Improved communication and teamwork benefit both the mother and baby,” continued Howard.

Also largely resulting from participation in the Collaborative, Howard reported an “improved, more organized response to emergent situations.  Through regular drill trainings, team members practice their responses and strengthen their teamwork.  When a real situation arises, they are prepared to handle it.”

Howard described the results thus far of enforcing the recommended 39-week minimum rule for inductions except in cases of medical necessity.  “The policy was implemented a year ago and although not all providers embraced the policy there was acceptance of it.  As a result, there has been 100 percent compliance with this policy in the past seven months.  Many practitioners actually appreciate the fact that this policy is now in writing.  When patients ask, they can explain that this is hospital policy and is in the best interest of patient safety,” said Howard.

For more details about the Upper Chesapeake Health initiative, click here.

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About the Maryland Patient Safety Center
The Maryland Patient Safety Center, jointly operated by the Maryland Hospital Association and the Delmarva Foundation, brings together hospitals and health care providers to improve patient safety and health care quality for all Marylanders.  The goal of the Patient Safety Center is to make Maryland's health care the safest in the nation by focusing on the systems of care, reducing the occurrence of adverse events, and improving the culture of patient safety at Maryland health care facilities.  For further information, visit www.marylandpatientsafetycenter.org/html/collaboratives/perinatal/stories/.

About the Maryland Hospital Association
MHA is a membership organization for Maryland hospitals and health systems.  Its membership is comprised of community and teaching hospitals, health systems, specialty hospitals, veterans hospitals, and long-term care facilities. For more information, visit www.mdhospitals.org.

About The Delmarva Foundation
Delmarva Foundation is a national, not-for-profit organization dedicated to improving healthcare quality in over 20 states.  Since 1973, Delmarva has assisted in improving care in hospitals, nursing homes, home health agencies, medical practices and health plans.  Delmarva performs quality improvement, quality assurance, utilization review, external quality review and Program Safeguard activities.  The company's corporate headquarters are located in Easton, Maryland with other offices in Columbia, Maryland; Washington, DC; Columbia, South Carolina; Tampa, Florida; and Tallahassee, Florida.  For more information, visit Delmarva Foundation on the web at www.delmarvafoundation.org.