Clinical Focus on Quality
How Intermountain's Labor and Delivery Safety Project changed minds, improved processes, and increased safety.
The Labor and Delivery Safety Project began as the Women and Newborns Clinical Program leaders discussed ways to increase reliability in program services. During those discussions, Labor and Delivery quickly became the focus. Labor and Delivery is the "emergency department" for obstetric care, and the unit manages a wide range of scheduled and unscheduled patients, ranging from routine obstetric care to very high-risk situations, such as pre-term twins that deliver quickly and need resuscitation/stabilization.
A pilot to bring rural and urban care to the same standard
In 2009, Intermountain launched a pilot project addressing an important safety and quality issue: how to provide consistent, high quality care to moms and their babies-whether patients receive care at facilities that serve many patients or those that see fewer. This is important, since it is generally true that in healthcare, "practice makes perfect" (or, put another way, the more experience the better).
The 2009 pilot project paired Heber Valley Medical Center with Utah Valley Regional Medical Center, which does significantly more L&D procedures. As part of the project, a nurse at Utah Valley served as a kind of "second set of eyes" for both facilities, monitoring important patient data called "maternal-fetal tracings" (which include the mother's contractions, fetal heart rate, etc.), consulting with on-site nurses when there were concerns, and keeping regular record of patient data.
Goals help establish a safety net
By establishing redundant processes, Intermountain created a kind of safety net, allowing nurses to consult and advise and create a more reliable process for accurately assessing and quickly intervening in situations where there are problematic maternal-fetal heart rate tracings.
This was done by:
- Offering a collaborative educational program on new maternal-fetal monitoring terminology to providers and L&D nurses in the system. Special attention was paid to the importance of concise and thorough patient reports.
- Defining an algorithm for reviewing and acting on problematic tracings, and consulting with a maternal-fetal medicine expert at a higher-level facility whenever any questionable tracings emerged.
- Defining a clear chain of command in each facility and posting this in Labor and Delivery.
- Establishing clear criteria for providers about when to come to the bedside to assess and/or intervene or call for a subspecialty opinion.
- Improving nursing confidence in small facilities that have far fewer nurses on hand by having an experienced Labor and Delivery nurse in a tertiary site to verify concerns. The goal was to have three experts concur on a concerning tracing and agree on interventions needed.
The project was expanded in 2010 to include all of Intermountain's rural sites, as well as Alta View and Valley View Medical Center.
Outcomes are positive and lasting
Initially, some facility staff members felt apprehensive about having off-site personnel involved in patient care decisions at a remote site. However, over time, those concerns about the redundant review changed, and all but one participating hospital asked that the project be continued indefinitely.
System changes have resulted from this project as well, including documentation alerts/reminders in the charting system to improve safety processes. All tertiary facility L&D Charge Nurses are being trained to support their referral sites based on the outcomes of this project, and a recommendation has been made to have nurses at rural facilities work a few shifts annually in their tertiary site in order to sustain the improved communication processes needed for referrals.