Purpose for the program:   Adverse outcomes in perinatal settings are a relatively rare occurrence but may have devastating consequences.  In order to mitigate adverse outcomes, key strategies generally include standardization of care, communication and teamwork, physician engagement on multidisciplinary teams and metrics.  Initiatives incorporating bundle science to standardize daily operations have been successful in reducing birth trauma.

Proposed change: Key nursing and medical leadership proposed a system-wide multidisciplinary strategy to change the culture of safety by incorporating the Perinatal Institute for Healthcare Improvement bundles at all six hospitals in the health care system.  Advanced Practice Nurse Leaders lead the process of standardizing evidence based practices related to induction and augmentation of labor and use of the vacuum extractor including order sets, policies, criteria for induction of labor, management of oxytocin and patient education. A sustainable infrastructure set the teams on a trajectory for further initiatives including the Management of Second Stage of Labor Guideline and the Management of Diabetes in Pregnancy and Postpartum Consensus Guideline. 

Implementation, outcomes and evaluation: Physician and nursing engagement is supported by leadership affirming the importance of partnerships in dialogue and decision-making, professional autonomy and accountability for improving outcomes and commitment to continued learning. 

Data is collected monthly to measure process compliance with all three IHI Perinatal Bundles.  Clinical outcomes are measured quarterly by the Perinatal Adverse Outcome Index (AOI).  Overall, all six hospitals are experiencing an annual decrease in the AOI since implementation of standardized practices in 2009.  The Zero Birth Injury multidisciplinary team engages in transparency by sharing learnings from in situ simulation training debriefs or adverse events. Data is shared with all disciplines and is posted on the hospital website. Action plans to address upward trending in particular adverse outcomes are developed and implemented.

Implications for nursing practice:   Birth injury, though infrequent, is traumatic for the family and the healthcare team. Nurses are often at the forefront of safety initiatives and are often the last defense to prevent harm to the patient.  However, changing organizational culture to focus on patient safety is difficult without a multidisciplinary team approach.  At any level, nurses incorporating evidence based care, standardized communication and teamwork concepts are integral to high reliability teams and reap the rewards of improved outcomes.

Keywords: Birth trauma, birth injury, perinatal bundle, team building, high reliability team, in situ simulation, perinatal safety, multidisciplinary team