Safety Learning Laboratory for Neonatal and Maternal Care

Immediately after birth, the baby undergoes many transitions, including significant changes in pulmonary and systemic circulation corresponding to increased uptake of oxygen by the lungs during the baby’s first and subsequent breaths. Alterations in or failure to complete the usual physiology of birth transition may threaten a baby’s health and can result in life-long consequences. Thus, it is critical to improve our current methods of supporting and monitoring babies during this transition immediately after birth. Despite national recommendations regarding the monitoring of babies in the delivery room, there remains great variation in how providers execute this task.

We aim to improve neonatal care by developing an interactive data display, taking the opportunity to test innovative ideas in display design using a simulation-based approach. While we have labeled our device a data display, it will also have interactive features; it will receive input from providers and, ideally, the electronic medical record. Output will be not only visual; we are also exploring auditory and tactile feedback to enhance communication and allow for the quick dissemination of real-time data. We will also consider the use of clinical decision aids in the data display in order to guide providers through the neonatal resuscitation algorithm.

Labor and delivery units are acute care units where life’s most joyful moments transpire, but unfortunately it’s there too that adverse and sometimes tragic outcomes may occur. It can be challenging to assure that all providers caring for the mother and her baby during an emergency have all the necessary information. In fact, a 2004 Sentinel Event Alert published by the Joint Commission indicated that communication errors in the delivery room were the primary root cause of 72% of neonatal mortalities and long-term neurologic morbidities. Therefore, the goal of this project is to explore an improved method to allow efficient sharing of information with all providers during an obstetrical crisis.

We will develop an interactive data display for labor and delivery. The information needed on the screen will be decided upon after conducting multiple interviews with labor and delivery nurses, obstetricians and obstetrical anesthesiologists. We will also be reviewing videos of simulated medical crises involving mothers and babies to identify communication gaps. Similar to the neonatal data display, we envision the maternal data display to be both visually informative and dynamic. We are also planning to incorporate a clinical decision tool to promote the efficient and timely care and prevent adverse outcomes.

Maternal morbidity and mortality are emerging national health care priorities, as both have been rising over the past two decades despite the fact that at least 40% of maternal mortality is considered preventable. Provider factors such as under-treatment and inappropriate treatment are strongly associated with the progression of morbidity to near-miss mortality and even maternal death. Errors can have significant consequences for the health of the mother, the fetus/baby, or both.

This project focuses on developing robust systems for proactively identifying and mitigating maternal and maternal-fetal clinical deterioration. The project will use a design approach to conduct a rigorous problem analysis. The investigative team will then engage multiple stakeholders, including patients, in determining design objectives to develop technical solutions to improve clinical workflow processes. The final stage of the project will be to implement and evaluate the design solution(s) in a simulated environment and then in an actual labor and delivery unit.

There is increasing recognition that physical space and layout, including organization of equipment, can potentially impact the safety, efficiency, and quality of patient care. In an analysis of preventable maternal mortalities, it has been estimated that facility factors contributed significantly to the fatal outcome in 75% of cases. Moreover, our preliminary investigation of labor and delivery suites at several hospitals in the Bay Area shows there is a striking degree of variation in physical design, not only between hospitals but also within a single unit.

We propose to redesign the delivery suite in order to support seamless workflow, availability of equipment during emergencies, and integration of provider activities during emergencies in order to optimize safety for the mother and her baby, and streamline staff function. Our goal is to provide an environment in which we can both prevent complications before they occur and mitigate the effects of adverse outcomes, thereby reducing harm for the mother and her baby.

We are conducting observational studies and focus groups with providers and parents to explore what design features of current layouts are deficient and potentially hazardous. Then, we will test physical features of suites, including size, organization, and other aspects of physical design, in order to improve patient safety and promote standardization. These tests will be carried out in a simulated environment, and the final stage of the project will be to implement and evaluate the design solution(s) in a labor and delivery unit.

Sub Project: Electronic medical record use during Cesarean sections

As the central hub for patient information and a platform for interdisciplinary communication, the electronic medical record (EMR) has radically changed medical practice. To better understand the impact of the EMR on provider workflow and attention allocation, we have observed nurses in the operating room during Cesarean deliveries. We chose to observe Cesarean deliveries because they account for approximately one third of the 4 million births per year in the U.S. and are the most frequently performed surgery in U.S. hospitals. We measured the amount of time nurses spend on the EMR and used surveys to determine whether nurses felt they spent more or less time on the EMR as compared to the data collected.

We found that nurses actually spent ~40% of the intra-operative time during Cesarean delivery on the EMR, though they reported 55%. When asked what would be the optimal percentage of time spent on the EMR during Cesarean delivery, nurses indicated ~22%. We infer that nurses perceive the EMR to be onerous and time-intensive during Cesarean delivery at our institution. Future studies are needed to better understand the impacts of intra-operative EMR use on patient safety during Cesarean delivery.

Sub Project: Neonatal resuscitation at bedside and delayed umbilical cord clamping

Delaying umbilical cord clamping for 30-60 seconds after birth has been shown to have several benefits for babies; it may improve blood volume, reduce the incidence of intraventricular hemorrhage, and increase transfer of stem cells. In December 2012, the American College of Obstetricians and Gynecologists recommended delayed cord clamping for all preterm deliveries, and the American Academy of Pediatrics endorsed this statement. Babies requiring resuscitation may benefit from delayed umbilical cord clamping, but current practice in most institutions is to immediately clamp the umbilical cord so that the neonatal team can begin resuscitation. Reasons for this practice include short cord length, space constraints, concerns for equipment sterility and insufficiencies, and lack of communication between obstetric and neonatal teams. We are exploring options for performing neonatal resuscitation at the bedside in order to facilitate delayed cord clamping and reduce anxiety for the mother and family. Similar products designed to facilitate both neonatal resuscitation and delayed cord clamping are available; however, we are developing our own prototypes that will increase functionality and eliminate bed transfers from the delivery room to the NICU. Through simulation scenarios, we are learning about the feasibility of our prototypes.