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Comprehensive Comprehensive Educational Model for Educational Model for
PIH TrainingPIH Training
Maricopa Medical Center, Phoenix, AZ
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Objectives
• Provide an educational model for PIH training, incorporating effective simulation for participants to integrate into your organizational practice
• Share CMQCC initiatives & toolkit• Identify predictors of PIH through nursing
assessment and incorporate appropriate interventions
• Recognize the value of simulation and debriefing components to overall improved patient outcomes
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U.S. Maternal Mortality
• CDC Review of 14 years of coded data 1979-1992• 4024 maternal deaths• 790 (19.6%) from preeclampsia
Obstetrics and Gynecology 2001;97:533
77.4%
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Maternal Hypertension in 1999-2005
Source: http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
All maternal hypertension identified at time of hospitalization for labor and delivery (includes pre-gestational and gestational hypertension)
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100x
Serious Morbidity: 800
Maternal Morbidity Based on Mortality
10x
Near Misses: 80
1x
Approx. 8 Preeclampsia Related Mortalities / Year in CA
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• Goal: Eliminate preventable maternal death & injury & promoting equitable maternal care
• Resources
• Tools
• Measures
• Quality improvement techniques
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What are the goals for Preeclampsia Collaborative?
– Early recognition of elevated BPs
(re-check, notify physician)– Early and aggressive treatment
(anti-hypertensives)– Staff education– Patient education and timely follow-Up – Patient Outcomes: Showing reduced rate of morbidities,
complications & extended LOS, improved patient education
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If Only We Knew -The Quest to Conquer Preeclampsia
If Only We Knew (video)
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Preeclampsia Collaborative Participants
• Alta Bates Summit
• Contra Costa Regional Med Ctr
• Doctor’s Hospital of Modesto
• John Muir Medical Center
• Kaiser Hayward
• Kaiser Oakland
• Kaiser Roseville
• Kaiser Santa Clara
• Mercy San Juan Med Center
• NorthBay Medical Center
• Salinas Valley Memorial
• Sonora Regional Med Center
• Sutter Medical Center
• Arrowhead Regional Med Ctr• Cedars Sinai Med Center• Citrus Valley Med Center• Henry Mayo Newhall Memorial• Kaiser San Diego• Kaiser West LA• Long Beach Miller• Riverside County Regional Med Ctr• St. Jude Medical Center• Saddleback Memorial• UCLA• St Bernardine Medical Center
• MIHS~Phoenix,AZMIHS~Phoenix,AZ
Northern CA Southern CA
25 California & ONE Arizona hospital representing ~ 82,000 births in 2011 (1:6)
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Why is MIHS participating in the Collaborative?
• The primary aim of the Preeclampsia Collaborative is to help reduce the rate of severe morbidities in women with any hypertension &/or severe preeclampsia/eclampsia & to reduce a significant portion of complications & extended hospital stays with the use of tools & guidelines developed to support early recognition, diagnosis, treatment & management of preeclampsia & triggers requiring immediate evaluation.
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MIHS Exceeds Target Rates
• California has a target of 8.8% for severe morbidity (complications) with hypertension.
• MMC/MIHS has consistently performed better than the target rate
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Severe Morbidity with Preeclampsia: Jul 2012-Jan 2013
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Timeline
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Timeline, continued
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NICE Guidelines
• Recommendation 7: Systolic hypertension requires treatment– 7.1 All pregnant women with pre-eclampsia and a systolic blood
pressure of 150-160 mmHg or more require urgent and effective anti-hypertensive treatment in line with the recent guidelines from the National Institute for Health & Clinical Excellence National Institute for Health & Clinical Excellence (NICE)3. Consideration should also be given to initiating treatment at lower pressures if the overall clinical picture suggests rapid deterioration and/or where the development of severe hypertension can be anticipated. The target systolic BP after treatment is 150 mmHg.
From CMACE 2011 report of maternal deaths from 2006-2008
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BP Treatment
Systolic ≥ 160
Diastolic ≥ 105
Treatment within 15-30 min
Gestational HTN = Preeclampsia =
Severe Preeclampsia =
ECLAMPSIA
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Key Points
• Detect elevated BP in perinatal period
• Take BP in a seated or semi-fowler’s position
• If elevated (>=160 systolic OR >=105 diastolic), repeat in 10 minutes
• If remains elevated, notify physician within 5 minutes
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Key Points continued
• Antihypertensive meds administered within 30 minutes
• Patients that are discharged having had elevated BP, follow up reevaluation w/n 7 days
• Discharge teaching instructions provided regarding signs & symptoms of preeclampsia
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Comprehensive Educational Model Developed
• Nursing Leadership Team– Clinical Educators– Nurse Managers– Clinical Resource
Leaders
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PIH Training Model Platform
• 10 offerings of class (3 hour each)• Pre-test• Didactic lecture • Demo/return demo: physical assessment & pump set-up • 4 Standardized patient simulation scenarios • Post-debriefing with all scenarios• Post-test• Evaluation
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Class Training Objectives
• Identify expected clinical findings during health assessment of patient presenting with PIH
• Recognize symptoms associated with Magnesium toxicity
• Assess various patient scenarios in real time simulation, by evaluating and implementing appropriate nursing interventions
• Demonstrate use of SBAR Communication with team members
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Didactic Lecture Content
• Normal Physiology, S/S Pre-eclampsia• Lab Testing / Values• Intrapartum & Postpartum Management• Pharmacologic Interventions• Eclampsia, HELLP• CMQCC • Practice Changes
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Practice Changes
• Magnesium Sulfate • Labeling Tubing
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Standardized Patients & Confederates
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Standardized Patients & Confederates
• Suspend disbelief > promotes realism
• Proper training > enhances emotional fidelity
• Guide scenario-specific tasks > meet objectives
• Bring to life the lesson intent > believability
• Experiential learning > risk free environment
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Show Time!
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Pregnancy Induced Hypertension
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Props and Costumes
• Bridge the gap
• Cue cards
• Helping cues adapted to match learner’s path
• Assigned actual learners roles
• Minimize uncertainty: Orient learner to learning environment, props, characters, boundaries and maximize real-time
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Eclampsia
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Simulation is the Perfect Stage!
• Real-time learning
• Experiential, safe, supportive environment
• Practice, observation
• Commit errors without risk to patients
• Feedback, reflection
• Interpret and integrate knowledge, skills & attitudes
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Magnesium Sulfate Toxicity
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Scenes and Scripts
• Based on specific learning objectives of the simulation sessions
• Improvising is essential
• Connection between all participants
• Flexibility for rapidly changing circumstances
• Teamwork is key!
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Course Evaluations
• 52 nurses participated
• 51 of 52 passed post-test with scores of 90% or greater
• Summary evaluations = 4.9/5.0
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Severe Morbidity (excluding Hemorrhage) with Preeclampsia: Feb 2013-Jan 2014
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Timely Treatment of Severe Hypertension Jul 2012-Jan 2013
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Timely Treatment of Severe Hypertension within 60 Minutes Follow Up 2/13-1/14
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Preeclampsia CollaborativeMaricopa Medical Center
2014 and Future•Working on implementing new ACOG recommendations
• Providers developing protocol to ensure patients are seen for BP check within 3 days postpartum
• Low-dose aspirin with history preeclampsia•Plan to present case studies to ED providers to stress importance of timely treatment and consultation for preeclamptic patients
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Current Simulation Drills with Standardized Patient
• OB Alert Training (online learning)
• Ongoing OB Alert Drills (un-announced)– Emergency Department (more)– On Postpartum Unit (May 2014)– Cafeteria (June 2014)
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OB ALERT DRILL: ED
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Debriefing Points
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Debriefing Points, continued
• What went well
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Debriefing Points, continued
• Teachable Moments…
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Debriefing Points, continued
• Room For Improvement!– Management of OB patient in ED– Familiarization with equipment– Assign learning module to Physicians,
including Anesthesiologist and CRNAs– System issues - correct overhead paging – More un-announced drills!!!
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Preeclampsia Toolkit Wins ACOG Award
• https://www.cmqcc.org/preeclampsia_toolkit https://www.cmqcc.org/preeclampsia_toolkit
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Share This Link!
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CMQCC Tool Kit
• Executive Summary• Clinical Pearls• Patient and Treatment Recommendations• Compendium of Best Practices• Algorithms• Appendices• Simulations/Drills• Slide set for Professional Education• Patient Education Materials• Multiple References
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Sample from the kit
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Final Act!
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Differential Diagnosis with History of Methamphetamine Use
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Remember…
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References
• American College of Obstetricians and Gynecologists’ Report (2013) Task force on hypertension in pregnancy, Vol 122, No. 5
• Baile, W., Blatner, A. (2014) Teaching communication skills using action methods to enhance role-play in problem-based learning. Soiciety for Simulation in Healthcare, Vol.00, No.00
• Fanning, R., Gaba, D., (2007) The role of debriefing in simulation-based learning. Society for Simulation in Healthcare, Vol.2, No.2
• Gilbert, E.S. (2007). Manual of high-risk pregnancy and delivery. Fourth Ed. Mosby: Missouri.
• http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
• CMQCC http://www.cmqcc.org/preeclampsia_toolkit Improving health care response to preeclampsia: a california quality improvement toolkit CMQCC
• Mandeville, L.K. & Troiano, N.H. (1999). AWHONN High-Risk and Critical Care Intrapartum Nursing, 2nd Edition. Lippincott: Philadelphia.
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References, continued
• Mattson, S. & Smith, J. (2004) Core curriculum for maternal-newborn nursing, third edition, Elsevier Saunders, St. Louis MO.
• Preeclampsia Foundation http://www.preeclampsia.org/the-news/videos/video/if-we-only-knew-the-quest-to-conquer-preeclampsia
• Sanko, J., Shekhter, I., et. al. (2013) Establishing a convention for acting in healthcare simulation merging art and science. Society for Simulation in Healthcare, Vol.8, No.4
• Shield, L. (2013) California maternal quality care collaborative and preeclampsia expert panel
