strategies to facilitate earlier discharge times on postpartum service : professional issues
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Implications for Nursing Practice
Optimization of all obstetric patients due to the po-
tential of surgical intervention. Optimization of
nursing practices in the operating room setting
through education, policy revision, and observa-
tion. Increased awareness of pre-existing condi-
tions in the obstetric patient and the impact on
maternal and fetal outcomes. Our focus has chan-
ged to celebrating great catches instead of
reacting to near misses.
Lost Time Is Never Found Again: Ensuring
Predelivery AZT Infusion for HIV-Positive Mothers
Poster Presentation
Purpose for the Program
Women who are HIV positive may have a
planned Cesarean delivery in order to reduce
mother-to-child transmission (MTCT) of the HIV virus.
Current standards of care call for intravenous zidovu-
dine (AZT) 2mg/kg over the ¢rst hour, then 1mg/kg
for at least 2 more hours before delivery. This signi¢-
cantly reduces MTCT of HIV. However, even
admission for a scheduled Cesarean delivery does
not always go smoothly, and many of these women
were not receiving the full recommended dose.
Proposed Change
Our goal was to improve successful administration
of the recommended dosing for these mothers. We
had a motivated, multidisciplinary team: HIV nurses
and labor & delivery nurses, an obstetrician/gyne-
cologist in the HIV clinic, the perinatal education
team, nurse managers, and pharmacists.
Implementation, Outcomes, and Evaluation
Time was not on our side. Patients were told to arrive
4 hours before scheduled Cesarean delivery. This
gave us only an hour to get the mother admitted
and start AZT. Any of a number of issues could
delay quality patient care. Some women did not ar-
rive on time, and many of these women did not have
good veins. Time was lost trying to obtain orders
and the infusion from pharmacy. These resulted
in one unfortunate ending: the mother was in-
adequately treated, increasing the risk of HIV trans-
mission to her infant. Strategies implemented
included instructing the woman to arrive 6 hours
before scheduled delivery time and the HIV physi-
cian began placing orders on the unit the day
before admission. We could then send for the AZT
infusion the minute the patient arrived. The results
were immediately obvious. The results of the imple-
mentation were a signi¢cant improvement in patient
time of arrival, a reduction in delays obtaining or-
ders for the AZT infusion (mean of 45 minutes to 0),
and decreased time until start of the AZT infusion
(mean of 120 minutes down to 90 minutes).
Implications for Nursing Practice
There is still room for improvement, as obtaining
timely intravenous (IV) access continues to be a
challenge. Our next step will be to place a priority
on obtaining IV access, so if there is di⁄culty, it is
determined early and quickly. We continue to strive
for 100% quality outcomes and sustain these
changes.
Strategies to Facilitate Earlier Discharge Times on
Postpartum Service
Poster Presentation
Purpose for the Program
As of August 2009, 21% of mothers and 18% of
newborns were discharged by 2 p.m. With an
average occupancy of over 81% during August
2009, it became obvious that a dramatic change in
daily operations was necessary to improve patient
£ow through the obstetric service.
Proposed Change
To double the percentage of mothers and new-
borns discharged by 2 p.m. by building a frame-
work to support real-time demand capacity
Melanie Chichester, BSN,
RNC, Labor & Delivery,
Christiana Care Health
System, Newark, DE
Barbara A. Temple, RN, Labor
& Delivery, Christiana Care
Health Services, Newark, DE
KeywordsHIVperformance improvementmultidisciplinary teammother-to-child transmission
Professional
Issues
Patti Craig, MA, RN,
New York Presbyterian,
New York, NY
S48 JOGNN, 40, S2-S84; 2011. DOI: 10.1111/j.1552-6909.2011.01242.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 2011 AWHONN Convention
(RTDC) management and proactive discharge or-
chestration.
Implementation, Outcomes, and Evaluation
In the fall of 2009, we created a Census Alert
Scheme, with action items to address surges. In
early 2010, we began bed huddles at 8 a.m. and
8 p.m. to forecast admission and discharge activity
and create plans to match bed demand and capac-
ity. This was followed by the development of a
process for discharge prediction. At the unit level,
the nursing sta¡ focus is on round-the-clock dis-
charge orchestration.
Some of our key successes are the creation of a part-
nership with the medical sta¡, environmental services
and escorts, successful behavior changes through
one-to-one behavior modeling, the revision of a nurs-
ing shift hand-o¡ tool to include key elements of
discharge activity, shifting the execution of key dis-
charge tasks from day of to day before discharge, the
initiation of interdisciplinary rounds with focus on
milestones for discharge, the development of a medi-
cal care algorithm for routine postpartum and
Cesarean patients, the creation of care maps to man-
age patient/family expectations, and use of a
discharge checklist for mother and newborn.
Over the past 12 months we have seen dramatic im-
provements in the percent of mothers and
newborns discharged by 2 p.m. A by-product of our
work has been the improvement in scores on four of
our patient satisfaction questions.
Implications for Nursing Practice
Discharge orchestration requires a reframing of
nursing sta¡ focus and priorities. Once a frame-
work has been established to support success,
nursing practice can shift to be more of a working
partnership with the new family.
Postpartum Hemorrhage Simulation Project:
Outcomes, Successes and Lessons Learned
Poster Presentation
Purpose for the Program
Postpartum hemorrhage (PPH) is a signi¢cant
obstetric emergency, requiring an e¡ective
and timely multidisciplinary team response for pa-
tient safety and improved outcomes. Nation-wide
the incidence of PPH is 5% to 7% whereas the
incidence on two obstetric units at an academic
medical center was 14.3% during the baseline
year of 2008 to 2009. The incidence a¡ects
length of stay and blood product usage, thus in-
creasing the costs of hospitalization for the patient
and hospital. Recent literature has suggested
that team training via on-site simulation can have
a positive impact on outcomes from emergency
situations.
Proposed Change
Four goals of this educational and quality improve-
ment project were as follows: to implement team
training simulation scenarios on-site to improve
team response to PPH; to increase team awareness
of risk factors and strive for a quick and timely team
response to potential hemorrhage situations; to
decrease blood product usage by10% for this pop-
ulation; and to decrease length of stay for women
with PPH by 10%. Baseline data were obtained and
an application was made to the small grants com-
mittee at the hospital. Seed money was granted to
implement the simulation project for the year 2009
to 2010. Outcomes were then compared with the
baseline year.
Implementation, Outcomes, and Evaluation
Outcomes have indicated a positive trend. Evenwith
a high-risk population, the incidence of PPH, the
use of blood products, and the length of stay have
all decreased. Transference of skills from simulation
to real events has been documented with appropri-
ate use of medications and other initial interven-
tions. Response time has been measured. Journal
clubs for physicians and nurses have increased
evidence-based knowledge, providing a format for
practice changes.
There have been challenges and lessons learned.
The team composition changed with each ses-
sion requiring brie¢ng and debrie¢ng. Team
members often had to learn e¡ective use of
communication techniques such as closed loop.
Other gaps in practice were revealed with the
need to address and resolve. Extreme outliers
were identi¢ed with the impact on outcomes care-
fully analyzed.
Marisol Francisco, BSN, RN,
New York Presbyterian,
New York, NY
Keywordspatient flowdischarge planning
Professional
Issues
Deborah E. Davis, MS, RNC-
OB, CNS, University of Colo-
rado Hospital, Aurora, CO
Keywordsmultidisciplinary simulation
educationquality improvementpostpartum hemorrhage
Professional
Issues
JOGNN 2011; Vol. 40, Supplement 1 S49
Davis, D. E. I N N O V A T I V E P R O G R A M S
Proceedings of the 2011 AWHONN Convention
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