The Tetralogy: Hemorrhage, Hypertension, DVT, Infection. Implementation of a Perinatal Safety Net

Authors


Poster Presentation

Purpose for the Program

Pregnancy and childbirth may unexpectedly become obstetric emergencies. The Centers for Disease Control and Prevention, National Center for Health Statistics reported that the rate of perinatal mortality in the United States has increased since 2002. Hypertensive disorders or hypertensive emergencies are the most common medical complication of pregnancy and the second leading cause of maternal death in the United States. Pulmonary embolism remains a leading cause of death after hemorrhage in New York State. Advanced maternal age, obesity, cesarean delivery, and significant chronic disease contribute to postpartum infection.

Proposed Change

To initiate a realistic screening process to identify obstetric patients at risk of hemorrhage, hypertension, thromboembolic events, and infection after delivery; enhance nursing and medical staff education regarding evidence-based standards of care; establish specific triggers for responding to changes in maternal vital signs and condition, and triggers for the activation of emergency response teams; and furthermore, to conduct multidisciplinary obstetric emergency drills.

Implementation, Outcomes, and Evaluation

A Team STEPPS approach established a process to identify obstetric patients at risk of hemorrhage, hypertension, thromboembolic events, infection, and the tetralogy of Fallot. Individualized plan of care, medications, and home care referrals were driven by physician orders and nurse handoff communication. Multidisciplinary education included evidence-based standards of care, specific triggers for responding to changes in maternal vital signs and condition, and activation of emergency response teams. Preeclampsia, eclampsia, and magnesium sulfate education also was provided in the intensive care unit and emergency department.

Obstetric emergency drills that emphasized team goals, knowledge, mutual support, situation monitoring, and Situation-Background-Assessment-Recommendation communication were conducted using video playback to assist with debriefing.

The medical rapid response team (RRT) quickly recognized it was imperative to collaborate with the obstetrics department to meet the physiological needs of women who are pregnant and in the postpartum period. The code H team (Hemorrhage) and obstetric crisis team (OCT) were established.

Implications for Nursing Practice

For obstetric emergencies (i.e., hypertensive emergency, seizures, cardiac compromise, change in patient status) or when the nurse feels something is not right, the OCT and RRT respond via one phone call to the emergency operator. When the changing needs of the patient are identified quickly and a revised plan of care is implemented, a transfer to the intensive care area is frequently avoided and mother–infant bonding can continue.

A shared mental model is the foundation of this multidisciplinary perinatal safety initiative. Recognizing early deviations in the plan of care and escalation of patient care needs have fostered teamwork and provide an obstetric safety net.

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