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Sunday, September 26, 2010
Title: Tackling Tachysystole! A Performance Improvement Process
Discipline: Childbearing (CB)
Learning Objectives:
Submission Description:- Define tachysystole and abnormal uterine activity patterns.
- Discuss interventions for tachysystole, taking into consideration fetal heart rate response.
- Verbalize methods for improving recognition and response to tachysytole
Background: Inappropriate use of oxytocin is one of the top five areas of obstetric harm. Cases almost always involve severely brain-damaged children, occasionally involves maternal death and consistently result in multi-million dollar jury verdicts. Historically there have been many issues: How many contractions are too many? What if baby ‘looks fine’? When do we intervene? Which of many terms for it do we use? The 2008 NICHD Update on Fetal Monitoring helped clarify this but putting the evidence into action and avoiding tendencies to ‘push the pit’ can be challenging.
Purpose: The purpose is to describe our level III perinatal center’s experience ‘tackling tachysystole” by standardizing its’ care, addressing multidisciplinary safety issues and monitoring progress to sustain improvement.
Method: In the summer of 2008, as part of the Premier Perinatal Safety Initiative, we created a team of nurses, doctors and administrators who reviewed existing Oxytocin administration policy and the current literature, benchmarked against other hospitals, and then developed an evidence based algorithm for uterine tachysystole and its management related to fetal response. The physician leader of the team took the algorithm to the major physician practice for support. The algorithm was also discussed and approved by physician departmental chairs and the operations committee.
Interrater reliability was established then every month since, staff nurses blindly audit 20 labor inductions and 20 pitocin augmentations. The audit involves reviewing the fetal monitor strip and determining if tachysystole was avoided, and if not was the algorithm followed. Nurses are identified for individualized follow-up or education. Cases of concern are also forwarded to a multidisciplinary team for physician peer review. Educational updates have been done in response to learning points identified in the audits. Nurses demonstrating excellence are recognized monthly to their peers and unit manager. Metric measures with a ‘take home message’ are emailed monthly to all nurses and providers, posted and discussed at staff meetings and monthly operations and departmental meetings.
Results: A monthly overall percentage of charts where uterine tachysystole is avoided or managed according to policy is calculated, and trended with related Premier Perinatal Safety Initiative bundle compliance. Current results have reached 98-100%.
Discussion: This project is part of a multifaceted patient safety initiative, so there have been other safety influences on staff but we feel this project has been a definate contributor to results. A physician-supported algorithm posted at the bedside, coupled with broadly disseminated measures of progress has helped counter resistance and normalization of deviance at our institution. Uterine tachysystole is more recognized now and acted upon. Instead of having the baby ‘declare itself,’ our nurses are more likely to turn the Oxytocin off for category II or III patterns or half the dose if category I. Also increasing acceptance of our algorithm, ACOG in the past qualified tachysystole to the presence of FHR decelerations but the 2009 ACOG Practice Bulletin on Induction amends itself to some interventions based on the various NICHD FHR Categories (I to III).
Conclusion: Clinicians need standardized definitions and guidelines with measures of progress to manage top safety concerns such as uterine tachysystole.
Purpose: The purpose is to describe our level III perinatal center’s experience ‘tackling tachysystole” by standardizing its’ care, addressing multidisciplinary safety issues and monitoring progress to sustain improvement.
Method: In the summer of 2008, as part of the Premier Perinatal Safety Initiative, we created a team of nurses, doctors and administrators who reviewed existing Oxytocin administration policy and the current literature, benchmarked against other hospitals, and then developed an evidence based algorithm for uterine tachysystole and its management related to fetal response. The physician leader of the team took the algorithm to the major physician practice for support. The algorithm was also discussed and approved by physician departmental chairs and the operations committee.
Interrater reliability was established then every month since, staff nurses blindly audit 20 labor inductions and 20 pitocin augmentations. The audit involves reviewing the fetal monitor strip and determining if tachysystole was avoided, and if not was the algorithm followed. Nurses are identified for individualized follow-up or education. Cases of concern are also forwarded to a multidisciplinary team for physician peer review. Educational updates have been done in response to learning points identified in the audits. Nurses demonstrating excellence are recognized monthly to their peers and unit manager. Metric measures with a ‘take home message’ are emailed monthly to all nurses and providers, posted and discussed at staff meetings and monthly operations and departmental meetings.
Results: A monthly overall percentage of charts where uterine tachysystole is avoided or managed according to policy is calculated, and trended with related Premier Perinatal Safety Initiative bundle compliance. Current results have reached 98-100%.
Discussion: This project is part of a multifaceted patient safety initiative, so there have been other safety influences on staff but we feel this project has been a definate contributor to results. A physician-supported algorithm posted at the bedside, coupled with broadly disseminated measures of progress has helped counter resistance and normalization of deviance at our institution. Uterine tachysystole is more recognized now and acted upon. Instead of having the baby ‘declare itself,’ our nurses are more likely to turn the Oxytocin off for category II or III patterns or half the dose if category I. Also increasing acceptance of our algorithm, ACOG in the past qualified tachysystole to the presence of FHR decelerations but the 2009 ACOG Practice Bulletin on Induction amends itself to some interventions based on the various NICHD FHR Categories (I to III).
Conclusion: Clinicians need standardized definitions and guidelines with measures of progress to manage top safety concerns such as uterine tachysystole.
