Rapid Response for Perinatal Safety: Slide Presentation

Slide 1: AHRQ Safety Program for Perinatal Care

Rapid Response for Perinatal Safety

Slide 2: Learning Objectives

Image: Three ascending steps show the learning objectives:

• Define components of a rapid response system.
• Identify the key safety elements of a robust rapid response system.
• Identify tways to apply key safety elements to your unit procedures for rapid response to urgent maternity care.

Slide 3: Rapid Response

• Rapid response for maternal and fetal physiologic deterioration and urgent conditions is the focus of this bundle of the AHRQ Safety Program for Perinatal Care (SPPC).
• The training materials and tools in this bundle review the key elements of a rapid response system within the framework of the Comprehensive Unit-based Safety Program (CUSP).
• The key safety elements provide a comprehensive starting point for each unit to consider as it establishes its processes for ensuring rapid response capabilities.

Slide 4: Rapid Response System

A rapid response system (RRS) includes four components:^1,2

1. A mechanism for activating a clinical team response based on patient criteria.
2. A multidisciplinary clinical team that can rapidly respond to assess and intervene in order to prevent further deterioration.
3. A system for feedback, to help mitigate or improve response to similar situations in the future.
4. An administrative structure to implement, train, and monitor all related activities.

Slide 5: Obstetrical RRS

• Distinct from a medical RRS or emergency "code" team.
• Distinct from neonatal RRS.
• Although distinct, close coordination is critical.

Slide 6: Evidence for RRS

• Some evidence supports the use of RRS for improving patient safety and outcomes, mainly for improving cardiac care.^1,2
  • Most studies of RRS in the literature are from unblinded, nonrandomized studies conducted at single centers.
• Support for implementing RRS is based on the principle that early intervention can improve patient outcomes.³
• Numerous hospitals are implementing RRS, many through participation in the Institute for Healthcare Improvement’s 5 Million Lives Campaign.
• Studies and experience with the use of RRS for maternity patients are emerging.^4,5,6,7

Slide 7: RRS Tool

• Purpose.
• Who Should Use.
• How To Use.
• Key Safety Elements.
• Supporting Materials:
  • RRS Planning Worksheet.
  • Sample RRS call log.

Slide 8: SPPC Key Perinatal Safety Elements for RRS

• Standardize When Possible (CUSP Science of Safety).
• Create Independent Checks (CUSP Science of Safety).
• Learn From Defects (CUSP Module).
• Simulation (SPPC Pillar).
• Teamwork Training (TeamSTEPPS®).
• Patient and Family Engagement (CUSP).

Slide 9: Key Safety Elements: Standardize When Possible

• Establish a unitwide approach for a rapid response to urgent maternity care issues.
  • System is established as part of a hospital’s larger rapid response system, or is established as a separate entity.
  • Uniform mechanism for activating a rapid response.
  • Uniform approach to responding to an activation:
    • Staff and equipment.
    • Scope of response.
    • Documentation requirements.
    • System feedback.

Slide 10: Key Safety Elements: Standardize When Possible

• Develop standard criteria for activation of a rapid response:
  • General activation criteria.
  • Specific activation criteria.
• Coordination with hospital medical emergency or "code" teams:
  • Specific activation criteria for nonmaternity care urgencies or emergencies (e.g., cardiopulmonary issues or arrest).

Slide 11: Key Safety Elements: Standardize When Possible

• Establishment of a standard rapid response kit or cart for the most common situations for which a rapid response is likely to be activated:
  • Supplies.
  • Equipment.
  • Cognitive aids (e.g., checklists, protocols, algorithms, dosing guides, electronic fetal monitoring nomenclature).
• Standard location.
• Process for checking kit/cart and restocking.

Slide 12: Key Safety Elements: Create Independent Checks

• Use a team of multidisciplinary staff for responding to rapid response activations.
• Multidisciplinary responders offer built-in redundancy and another "set of eyes" on the situation.
• Rapid responders should—
  • Possess specialized maternity care clinical skills, knowledge, and equipment.
  • Be able to assess and manage a maternity patient who has deteriorated physiologically.
  • Be able to intervene to minimize risk of serious harm and further deterioration.

Slide 13: Key Safety Elements: Create Independent Checks

• Different models for the multidisciplinary team of responders exist and can vary by the following:
  • Volume and complexity of maternity patients cared for.
  • Availability of in-house obstetric hospitalists (also called laborists) and dedicated anesthesiology support of labor and delivery (L&D).
  • Presence of graduate medical education or nurse midwifery programs with in-house residents or students.
  • Other available hospital rapid response teams.
• Core rapid response staff typically includes a maternity care provider (obstetrician or midwife) and a staff L&D nurse.
  • Other responders may include an anesthesiology provider, an L&D or operating room technician, additional L&D staff nurses, or surgeon.
• Units establish the scope and limits of rapid responders.

Slide 14: Key Safety Elements: Learn From Defects

• Debrief and analyze near misses and adverse events, regardless of whether a rapid response was activated.
• Debrief among clinical team after rapid response, regardless of outcome.
• Have informal debriefs among clinical team.
  • Rapid Response Call Log can facilitate a debrief.
• Have a process in place to review serious maternal or neonatal adverse outcomes.
• Share outcomes or process improvements from informal and formal analysis with staff to achieve transparency and organizational learning.

Slide 15: Key Safety Elements: Simulation

• Use of simulation to practice and train teams on rapid response processes.
• Simulation can reinforce teamwork and communication related to—
  • Situational awareness.
  • Ability to get additional help quickly and activate a rapid response based on unit-established criteria and processes for activation.
  • Communication between primary care team and rapid responders.
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.

Slide 16: Key Safety Elements: Teamwork Training

• Have situational awareness during rapid response events.
• Use SBAR, callouts, huddles, and closed-loop communication techniques during a rapid response.
• Communicate during transitions of care.
• Have high-reliability teams.

Slide 17: Key Safety Elements: Teamwork Training

• Characteristics of high-reliability teams:
  • Anyone can sound an alarm, request help, or challenge the status quo.
  • Hierarchy is minimized.
  • Communication is continuous, valued and expected.

Slide 18: Key Safety Elements: Patient and Family Engagement

• Unit approach incorporates—
  • Mechanisms for patient activation of a rapid response.
  • Communication with patient/family during rapid response.
  • Disclosure of any unintended outcomes.

Slide 19: Unit Next Steps

• Decide whether to select the rapid response system bundle for implementation locally. Consider these factors:
  • Unit data suggesting adverse events or near misses that may have been minimized or averted as a result of a rapid response system.
  • Synergy with related or similar initiatives, or existing hospital rapid response systems.
  • Interest and enthusiasm of unit staff and administration for implementing.

Slide 20: Unit Next Steps

• Review the Key Safety Elements of the Rapid Response Tool, including the Planning Worksheet and Sample Call Log available as an appendix to the tool.
• Support implementation of unit rapid response system through:
  • Staff training/communication.
  • Simulation.
• Monitor implementation progress, collect data for quality improvement.

Slide 21: Tips for Implementation Success

• Use CUSP principles for implementing teamwork and communication (e.g., incorporating diverse perspectives) to develop consensus on activation criteria and response expectations.
• Provide education and training to staff on the use of the RRS and make routine education for patients and family on the rapid response activation a part of the admission process.
• Debrief regularly after rapid response events, and solicit ongoing feedback from staff and patients to continually refine RRS processes.

Slide 22: References

1. Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006 Sep;34(9):2463-78. PMID: 16878033.
2. Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011 Jul 14;365(2):139-46. PMID: 21751906.
3. Preparing for clinical emergencies in obstetrics and gynecology. Committee Opinion No. 590. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:722–5.
4. Skupski DW, Lowenwirt IP, Weinbaum FI, et al. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006 May;107(5):977-83. PMID: 16648399.
5. Gosman GG, Baldisseri MR, Stein KL, et al. Introduction of an obstetric-specific medical emergency team for obstetric crises: implementation and experience. Am J Obstet Gynecol 2008 Apr;198(4):367.e1-7. Epub 2007 Nov 5. PMID: 17981251.
6. Srinivas SK, Lorch SA. The laborist model of obstetric care: we need more evidence. Am J Obstet Gynecol 2012 Jul;207(1):30-5. doi: 10.1016/j.ajog.2011.10.009. Epub 2011 Oct 15. PMID: 22138138.
7. Catanzarite V, Almyryde K, Bombard A. Ob team stat: developing a better L&D rapid response team. Contemp Ob/Gyn 2007;52(9):52-65.

Slide 23: Disclaimer

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