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