A M U L T I D I S C I P L I N A R Y A P P R O A C HK E N D R A F O L H R N , B S N

Peripartum Cardiomyopathy

Admission assessment to MICU

30 year old multiparous female at 38 weeks gestation, without significant medical history, presented to a suburban Emergency Room with complaints of sudden onset dyspnea, cough and lower extremity edema. After evaluation including a chest x-ray revealing pulmonary edema and cardiomegaly, the patient was transferred to a tertiary care center to the intensive care unit.

• Heart Rate 121 beats per minute• Respirations 36 breaths per minute• Blood Pressure 130s-140s/80s• SpO2 95% on 2l NC• EKG Sinus tachycardia• Unremarkable labs• +3 pitting edema to lower extremities• Diaphoretic• Course bilateral crackles

Patient was diagnosed

Obstetric consultation occurred in the ICU and the patient was diagnosed with pre-eclampsia and transferred to the Labor and Delivery unit for induction of labor and Magnesium Sulfate administration for seizure prophylaxis. During admission to the Labor and Delivery Unit, the nursing assessment included:• Course crackles bilaterally• Patient complained of shortness of breath• Heart Rate 135 BPM• SpO2 89% on 4l O2increased to 10l O2 for SpO2 96%• +3 lower extremity pitting edema• Patient denies headache, right upper quadrant pain or visual

disturbances• Diaphoretic• Orthopnea• PIH panel negative

Plan of care

• Lasix was administered • Pitocin was initiated for induction.• Oxygen saturation continued to decrease to 89% despite Lasix and 10l

O2.• Respiratory rate and heart rate continued to steadily increase• The patient became increasingly anxious and agitated, had a “sense of

impending doom”

Despite request for bedside evaluation by the nurse and SBAR report given with recommendations for cardiology and echocardiogram to chief resident and attending physician, no change in plan of care occurred for the patient.

Concerns and recommendations

The Charge Nurse was notified of nurse’s assessment, concerns and recommendations.

The Case was brought to multidisciplinary unit Safety Rounds by bedside nurse and the charge nurse.

Multidisciplinary Safety Rounds

With multidisciplinary rounds, disciplines come together, informed by their clinical expertise, to coordinate patient care, determine care priorities, establish daily goals, and plan for potential transfer or discharge. This patient-centered model of care has proven to be a valuable tool in improving the quality, safety, and patient experience of care.

The team

This unit includes the entire perinatal team and reviews and discusses assessment, plan of care and management of all obstetric patients on the Women's Services Unit. It is Charge nurse led and creates an opportunity for communication regarding specific cases, concerns and/or patient flow issues. The team huddles together and discusses the board.

Team members include:• Maternal Fetal Medicine Physician and Resident• Generalist Attending and Chief resident• Anesthesia Attending and Chief resident• Charge Nurse/Nursing Director/ Managers• Clinical Nurse Specialist• Neotransport RN• Case Management

SBAR

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and a culture of safety.

SBAR

Situation: What is the problem?• Patient in room 32 is 30 year old G3P2002 at 38 weeks gestation being

induced for Pre-eclampsia who is rapidly de-saturating despite 80mg Lasix administration and aggressive oxygen support

Background: Pertinent background information related to the situation

• Patient was MFT to MICU for cardiomegaly and pulmonary edema, then transferred to L&D with diagnosis of pre-eclampsia

• BP range 130s/80s• HR 115-135, O2 saturation 89% on 10l O2• Respiratory rate 40bpm, chest pain and shortness of breath• Inability to remain flat or in semi-fowler’s position• Negative Pre-eclampsia panel, denies signs and symptoms of

Pre-eclampsia

SBAR

Assessment: What is the Nursing assessment of the situation?• The patient is exhibiting signs and

symptoms of cardiac failure

Recommendation: What does the nurse want to happen?• Immediate bedside evaluation by

MFM, Cardiology including an Echocardiogram

Bedside evaluation

Immediate bedside evaluation occurred by MFM, Attending, and Anesthesia

• Cardiology consult occurred at bedside• Echocardiography revealed left systolic dilated dysfunction and an EF

25-30%. • The patient was diagnosed with peripartum cardiomyopathy,

magnesium discontinued, and additional Lasix administered and supplemental oxygen increased to 15l via fm.

• Multidisciplinary plan to transfer patient to CVICU• Cardiology team and MFM team remained at bedside until delivery• Patient precipitously delivered vaginally a female infant APGARS 8,9• Within 30 minutes of delivery patient rapidly decompensated due to

fluid shifts

Patient was discharged home on Day 5 and followed by outpatient Cardiology

Outcome

• HeartRate 150,SpO2 85% on 15L O2, respirations 46 breaths per minute.

• Patient was immediately transferred to CVICU and placed on BiPAP, diuretics, nitrates, beta adrenergic blockers, and ace inhibitors.

Nurses are empowered

Nurses have an essential role on the healthcare team for successful collaboration!

Assessment, Assessment, Assessment!

Patient Advocate

Communicator

Care Coordinator

Leadership has an imperative role in creating an environment of safety in which nurses are empowered to speak up and advocate for patients without fear of repercussions .

It is the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have

prevailed. – Charles Darwin

What we need to do is learn to work in the system, by which I mean that everybody, every team, every platform, every division, every component is there not for individual competitive profit or

recognition, but for contribution to the system as a whole on a win-win basis.

– W. Edwards Deming

Work in the system

F O R Q U E S T I O N S :kendra . fo lh@memor ia lhe rmann.o rg

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