Hospitals adopting a suite of perinatal best practices as part of the Premier Perinatal Safety Initiative (PDF)
reduced birth injuries by 5.4% to 25%, lowered costs and legal liability and prevented traumatic experiences that can haunt patients and staff.
Four million births occur at U.S. hospitals each year, with some type of adverse event occurring in about 9% of all deliveries
. Of these, it's estimated that 30% are avoidable. The leading cause for avoidable obstetric adverse events was poor communication.
The 14 hospitals in the Premier healthcare alliance, which launched the initiative in 2008
, sought to lower the number of serious injuries such as birth asphyxia, which can lead to permanent neurologic disability, better define preventable harm, identify practices that result in improved outcomes, and measure the financial value of improved outcomes.
The initiative's keys were the consistent use of care “bundles” during the appropriate situation, such as estimating fetal weight before administering oxytocin to speed labor, and enhanced communication—which included simulation drills using mannequins or actresses posing as patients.
One particular drill was credited with enhanced performance during an emergency at the University of Minnesota (Minneapolis) Medical Center, Fairview. The 33-weeks-pregnant nurse manager posed as a patient having a prolapsed cord, a potentially deadly situation where the umbilical chord comes out of the uterus ahead of the baby. The next day, the very same woman went into labor and experienced a prolapsed cord.
Nurse Becky Gams, advanced practice nurse leader at UMMC Fairview, said the previous day's simulation had the staff well-prepared for the real thing. “They had to do in real life what they practiced the day before,” Gams said. “If they had not done that the day before, they would not have been as sharp.”
Out of 12,000 births in 2008, the Fairview Health System reported that there were 498 maternal and 134 infant injuries. In 2009, they had 14 fewer infant injuries (a decline of 10.5%) and 74 fewer maternal injuries (a 15.1% decline), which together resulted in savings of $150,000. Figures on overall savings for the initiative were not yet available.
On average, the participating institutions reduced the cases of birth hypoxia and asphyxia, where a lack of oxygen can cause brain damage by 25%; reduced anesthesia-related complications by 15%; and reduced the cases of postpartum hemorrhage by 5.4%, according to a Premier news release.
Although the release acknowledged that malpractice claims are typically filed about two years after an injury, Premier noted that—across participating hospitals—liability claims filed per delivery fell by 39%. The 14 institutions totaled 10 obstetric liability claims in 2009, down from 18 in the baseline years of 2006 and 2007. For 2010, the hospitals are “trending” toward 8, Premier said.
A Premier white paper on the initiative cited a American Congress of Obstetricians and Gynecologists survey that found that 58% of ob-gyns changed the way they practiced because of the risk or fear of being sued. A similar obstetric safety effort by HCA hospitals
saw malpractice claims drop to four per 10,000 births in 2009, compared with 12 in 10,000 in 2000.
But Dr. Phillip Rauk, medical director for the UMMC Birthplace and lead physician for its Zero Birth Injury campaign
, said the fear of being sued was not part of his team's motivation.
“We don't ever use the term 'defensive medicine,' ” he said, adding that doctors and nurses want to “do the right thing,” and the evidence shows that the initiative's interventions—when consistently applied—have positive results.
“There's always been difficulty in getting buy-in from every provider—particularly providers who think their outcomes are good,” Rauk said. “When providers see these data, they're convinced that it's working and having an impact.”
He added also that when an injury does occur, it's his institution's policy to hold an immediate debriefing to go over what wrong and develop steps to prevent similar events in the future.
“When there is an adverse outcome, everyone is affected by it,” Rauk said. “Instead of letting the event smolder in people's minds, we review right away what was done.”
The other participating institutions were Aurora West Allis (Wis.) Medical Center; Baptist Hospital East, Louisville, Ky.; Baystate Medical Center, Springfield, Mass.; Bethesda North Hospital, Cincinnati; Fairview Ridges Hospital, Burnsville, Minn.; Good Samaritan Hospital, Cincinnati; Indian Path Medical Center, Mountain States Health Alliance, Kingsport, Tenn.; Methodist Medical Center of Illinois, Peoria; Presbyterian Hospital, Albuquerque, N.M.; St. Joseph Hospital, Bellingham, Wash.; Summa Akron City Hospital, Akron, Ohio; Texas Health Harris Methodist Hospital Fort Worth; and Texas Health Presbyterian Hospital Dallas.