2
documentation of this program. Finally, long-term goals involve promoting depression screening in all obstetrician o⁄ces associated with this hospital and supporting a collaborative network within the community dedicated to improving the mental health of perinatal women. Packed and Wearing Pink: Damage Control Surgery in the Obstetric Operating Room Poster Presentation E valuation of hospital practice standards to im- prove practice and patient outcomes must occur on a routine schedule. During a review of our hospitals Sponge, Sharp and Instrument Count Policy, it was identi¢ed that a communication sys- tem needed to be developed for the severely injured, unstable, surgical patient who required ab- dominal packing and required immediate transfer to a surgical trauma intensive unit for stabilization. Damage control surgery has had a major impact on the survival rate in the severely injured trauma patient, especially one who has sustained a life- threatening injury such as liver rupture. Although damage control surgery continues to be a mainstay in trauma surgery, its use in the obstetric (OB) pop- ulation within our institution has become a standard of care when the unexpected occurs in the OB operating room. Damage control surgery has had a direct impact on the survival of patients who experienced a liver rupture and unstable, sur- gical, amniotic emboli patients. Evidence suggests that abdominal packing and a staged repair of hepatic and retroperitoneal injury are more e¡ective if instituted early as part of the resuscitative e¡orts in the management and pre- vention of the lethal triad of hypothermia, acidosis, and coagulopathy. Because the time to reoperation varies between 8 hours and 10 days, a team of op- erating room nurses, intensive care nurses, and obstetric nurses developed a patient safety process to prevent retained sponge(s) following damage control surgery. Communication between the OB unit, Surgical Intensive Care Unit, and Operating Unit is a critical safety factor that needs to be initi- ated with the packing procedure and continues through the ¢nal operative procedure and removal of packing. The team decided that when a patient has damage control surgery, a pink bracelet would be applied to alert the Intensive Care Unit bedside nurse that the patient has abdominal packing, and a packing log is included in her chart to be used when packing is removed or when packing is added. The presenta- tion discusses the development the packing log process to prevent retained sponges following dam- age control surgery in the OB patient. Included in the presentation are three OB patient scenarios where favorable outcomes depended on damage control surgery and communication between disciplines. Scheduled Cesarean Delivery: Start-Time Performance Improvement Initiative Poster Presentation S ervice e⁄ciency and e¡ectiveness are impor- tant concerns for many hospitals today. This is particularly true in the operating room (OR), which is one of a hospital’s largest revenue-producing cost centers.The Scheduled Cesarean Section (C/S) pro- ject began in 2005 with the perception that cases were delayed and the Obstetric OR was run in a man- ner that did not meet the surgeon, anesthesia, or the patient needs. These perceptions often led to frustration and hostility among team members, which greatly a¡ected employee, physician, and pa- tient satisfaction. This performance improvement (PI) Nancy Skinner, MSN, RNC, Women’s & Children’s Ser- vices, Christiana Care Health Services, Newark, DE Childbearing JOGNN 2010; Vol. 39, Supplement 1 S39 Skinner, N. I NNOVATIVE P ROGRAMS Proceedings of the 2010 AWHONN Annual Convention

Scheduled Cesarean Delivery: Start-Time Performance Improvement Initiative : Childbearing

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documentation of this program. Finally, long-term

goals involve promoting depression screening in

all obstetrician o⁄ces associated with this hospital

and supporting a collaborative network within the

community dedicated to improving the mental

health of perinatal women.

Packed and Wearing Pink: Damage Control

Surgery in the Obstetric Operating Room

Poster Presentation

Evaluation of hospital practice standards to im-

prove practice and patient outcomes must

occur on a routine schedule. During a review of our

hospitals Sponge, Sharp and Instrument Count

Policy, it was identi¢ed that a communication sys-

tem needed to be developed for the severely

injured, unstable, surgical patient who required ab-

dominal packing and required immediate transfer to

a surgical trauma intensive unit for stabilization.

Damage control surgery has had a major impact

on the survival rate in the severely injured trauma

patient, especially one who has sustained a life-

threatening injury such as liver rupture. Although

damage control surgery continues to be a mainstay

in trauma surgery, its use in the obstetric (OB) pop-

ulation within our institution has become a

standard of care when the unexpected occurs in

the OB operating room. Damage control surgery

has had a direct impact on the survival of patients

who experienced a liver rupture and unstable, sur-

gical, amniotic emboli patients.

Evidence suggests that abdominal packing and a

staged repair of hepatic and retroperitoneal injury

are more e¡ective if instituted early as part of the

resuscitative e¡orts in the management and pre-

vention of the lethal triad of hypothermia, acidosis,

and coagulopathy. Because the time to reoperation

varies between 8 hours and 10 days, a team of op-

erating room nurses, intensive care nurses, and

obstetric nurses developed a patient safety process

to prevent retained sponge(s) following damage

control surgery. Communication between the OB

unit, Surgical Intensive Care Unit, and Operating

Unit is a critical safety factor that needs to be initi-

ated with the packing procedure and continues

through the ¢nal operative procedure and removal

of packing.

The team decided that when a patient has damage

control surgery, a pink bracelet would be applied to

alert the Intensive Care Unit bedside nurse that the

patient has abdominal packing, and a packing log

is included in her chart to be used when packing is

removed or when packing is added. The presenta-

tion discusses the development the packing log

process to prevent retained sponges following dam-

age control surgery in the OB patient. Included in

the presentation are three OB patient scenarios

where favorable outcomes depended on damage

control surgery and communication between

disciplines.

Scheduled Cesarean Delivery: Start-Time

Performance Improvement Initiative

Poster Presentation

Service e⁄ciency and e¡ectiveness are impor-

tant concerns for many hospitals today. This is

particularly true in the operating room (OR), which is

one of a hospital’s largest revenue-producing cost

centers.The Scheduled Cesarean Section (C/S) pro-

ject began in 2005 with the perception that cases

were delayed and the Obstetric OR was run in aman-

ner that did not meet the surgeon, anesthesia,

or the patient needs. These perceptions often led to

frustration and hostility among team members,

which greatly a¡ected employee, physician, and pa-

tient satisfaction. This performance improvement (PI)

Nancy Skinner, MSN, RNC,

Women’s & Children’s Ser-

vices, Christiana Care Health

Services, Newark, DE

Childbearing

JOGNN 2010; Vol. 39, Supplement 1 S39

Skinner, N. I N N O V A T I V E P R O G R A M S

Proceedings of the 2010 AWHONN Annual Convention

Page 2: Scheduled Cesarean Delivery: Start-Time Performance Improvement Initiative : Childbearing

project was developed to identify barriers and put

into place recommended system changes to improve

obstetric OR e⁄ciency and e¡ectiveness, increase

teamwork and pride, and improve overall satisfaction

among caregivers.

To accomplish the PI project, a task force consisting

of physicians, labor and delivery room (LDR) sta¡

nurses, LDR leadership, and anesthesia was

formed to enhance productivity and e⁄ciency in

the OR that would balance patient safety and sta¡

satisfaction.

It was then decided that baseline data were needed

to validate the physician’s perceptions and evaluate

any improvements that may occur. Review and

analysis of the retrospective data by the task force

identi¢ed three major reasons for delay. Behaviors

of physicians, nurses, and anesthesiologists were

identi¢ed as the top three barriers to starting

scheduled cases on time. The task force discussed

actions and strategies that would e¡ectively

change the behaviors of the groups involved. The

¢rst strategy was to have all parties involved use

the same de¢nition of start time of the procedure.

Start time was de¢ned for all disciplines involved.

Next the task force considered what actions would

best help the OR sta¡ to reach the goal set at 90%

of all scheduled C/S cases starting on time.

After reaching and consistently maintaining the

goal of 90% on time starts, the unit and the organi-

zation continue to reap the bene¢ts gained from the

Scheduled C/S on-time PI project for the past 5

years. From a quality perspective, the project results

have improved throughput in the OR, increased

professionalism and collaboration between disci-

plines, and created a positive work environment for

the clinicians and sta¡ members.

Decision to Incision Time for Unscheduled

Cesarean Deliveries: Can We Meet the

Standard?

Poster Presentation

The national standard for performing unsched-

uled Cesarean delivery is 30 minutes from the

time of decision for Cesarean delivery to the time of

the incision.There is little evidence supporting a re-

lationship between the decision-to-incision interval

and maternal or neonatal outcomes. Despite the

lack of evidence, the 30-minute standard is the

benchmark in medical-legal proceedings where

the timeliness of Cesarean delivery is questioned.

Published studies indicate that the 30-minute stan-

dard is met in only 50% to 75% of cases of

emergency Cesarean delivery.

Observations in our facility suggested that we were

not meeting the standard. Review of 36 cases of un-

scheduled Cesarean delivery performed for

nonreassuring fetal status demonstrated that the

average time from decision to incision was 39 min-

utes, with a range of 10 to 90 minutes. The 30-

minute standard was met in 25% of cases. This

prompted a full review of the process and resources

for performing unscheduled Cesarean deliveries.

In 2008, 5,988 mothers delivered in our facility,1,226

by unscheduled Cesarean delivery. In 1998, 615 la-

boring women, from a total of 4,728 deliveries,

required unscheduled Cesarean delivery. Despite

the near doubling of unscheduled Cesarean deliv-

eries, the process had changed minimally and the

resources (personnel and physical) had not in-

creased, making it di⁄cult to meet the standard.

Data were shared with medical and nursing sta¡,

and a concerted e¡ort was started to improve per-

formance. An audit form was completed for each

unscheduled Cesarean delivery allowing measure-

ment of the following:

� Average time from decision to incision for un-

scheduled Cesarean deliveries

� Frequency of meeting 30-minute standard by

indication for Cesarean

� Reasons for delay when standard not met

With increased awareness, the frequency of

meeting the 30-minute standard for cases of

nonreassuring fetal status quickly increased to

44% and remained 43% to 47% over the next

year. An interdisciplinary team under the direction

Donna Smith, MSN, RNC-OB,

Women’s and Children’s Ser-

vices, Christiana Care Health

System, Newark, DE

Barbara A. Temple, RN,

Christiana Care Health

System, Newark, DE

Childbearing

Beverly VanderWal, MN,

RNC, MemorialCare Center

for Women, Miller Children’s

Hospital, Long Beach Memo-

rial Medical Center, Long

Beach, CA

Childbearing

S40 JOGNN, 39, S19-S41; 2010. DOI: 10.1111/j.1552-6909.2010.01119.x http://jognn.awhonn.org

I N N O V A T I V E P R O G R A M S

Proceedings of the 2010 AWHONN Annual Convention