Purpose for the Program
In January 2010, the Joint Commission issued a Sentinel Event Alert addressing maternal death prevention. The Centers for Disease Control and Prevention states that current trends indicate maternal mortality rates may be increasing. The latest published statistics from 2006 cite 13.3 maternal deaths per 100,000 live births, far from the Healthy People 2010 target of no more than 3.3 deaths per 100,000 live births. Near misses (defined as maternal complications severe enough to endanger a woman's life) also have increased to approximately 34,000 per year. Analysis of negative outcomes calls for improvement in patient safety. Education utilizing evidence-based practice can be a key in providing quality patient care.
Recognizing the impact and great personal loss, The Memorial Hermann Healthcare System took the initiative in addressing maternal death prevention through an aggressive educational program. The initial goal was to develop evidence-based guidelines for nurses to follow when they identified changes in their patient's condition and to improve communication between the health care team.
Implementation, Outcomes, and Evaluation
A team of perinatal educators developed core content related to three leading causes of maternal death: postpartum hemorrhage, hypertensive disorders, and venous thrombotic events. Pharmacology was covered within each section as it pertained to the disease and treatment. After collaboration with obstetricians, the content was offered as a systemwide mandatory class presented by hospital perinatal educators. During May and June 2011, approximately 350 nurses from the labor and delivery and postpartum departments from four hospitals attended with a 95% compliance rate. The remaining hospitals in the system are currently implementing the program. Evaluations were overwhelmingly positive with many nurses expressing satisfaction with the content, guidelines, case studies, and use of Situation-Background-Assessment-Recommendation (SBAR) for communicating with physicians. Originally, it was thought the core content could be taught as three separate 1-hour offerings but the vast majority of hospitals chose to do one 3-hour session. This decision actually facilitated scheduling the classes and tracking attendees. Nursing contact hours were provided. Registration and completion of the course was entered on a system web site.
Implications for Nursing Practice
With education comes empowerment, and with evidence-based guidelines to support their assessment nurses can respond quickly to changes in their patient's condition. SBAR promotes clear communication between the nurse and the physician. As a result of this first educational program, physicians and nurses will soon be required to take additional self-study modules aimed at reducing negative maternal outcomes and improving patient safety.