Hospital: Stanton Territorial Hospital
City: Yellowknife, Northwest Territories
Initiative: Innovations in Obstetrical Emergency Management North of 60

 

Overview:

 

Yellowknife's Stanton Territorial Hospital in the Northwest Territories an acute care referral hospital that serves the Northwest Territories and the Kitikmeot region of Nunavut. Women from across a vast region in the Northwest Territories and Nunavut come to Yellowknife for obstetrical confinement at around 36 weeks gestational age. The thirteen bed obstetrical unit includes two birthing rooms, two triage rooms and eight post-partum beds. A compliment of nineteen registered nurses, ten family doctors, three obstetricians and one nurse practitioner provide full service obstetrical care. The team on labour and delivery is also supplemented by frequent locum physicians and nurses. Our obstetrical unit averages 650 births per year. The Northern Women's Health Program (NWHP) is a nurse practitioner run program that coordinates the prenatal care for the women from the outlying communities as well as coordinates post-dates management,ultrasounds for position and fluid,etc. Healthy Pregnancy Group is a group prenatal class that is run by nurses and family physicians to provide an educational opportunity for women who are from the outlying communities who are in Yellowknife for confinement. Our dedicated team is focused on providing patient-centered, evidence-based obstetrical care to hundreds of women on an annual basis.

Our team is now in it's third year of the MORE<sup>OB</sup> program and our goal this year was to institute several improvements in patient safety through interprofessional collaboration, no harm event reviews and the elimination of hierarchy on our unit.All of the above is with the goal of improving patient safety and improving outcomes for mothers and babies.

 

Interprofessional Collaboration:

 

Our team recently completed our Workshop and ACE days during the month of November. The 2015-2016 cycle in our hospital was notable for two separate incidents of epidural emergencies. As a result of these events,our team was quite motivated to gain supplemental knowledge around this topic. One of our full time anesthesiologists, Dr. Sauve, kindly put together a comprehensive power point presentation reviewing anatomy of epidurals and spinals, the set up required,the procedure and the common and rare complications. The presentation reviewed hypotension, high epidural and spinals, epidural hematomas/abscesses, and post epidural headaches. The ninety minute presentation which was given four times over the course of the month (one core team day and three workshop days) and was a resounding success and much appreciated by all the staff that were in attendance. Our team is now more prepared for complications particularly as it relates to  the immediate emergency management of these complications, resuscitative measures and pharmacological management of these complications.

 

No Harm Events Reviews and Root Cause Analysis:

 

Using the MORE<sup>OB</sup> framework for no harm event reviews and root cause analysis, our MORE<sup>OB</sup> participants (both core team and non core team) were able to review several cases of post-partum hemorrhage. After these reviews, we found several root causes of the no harm events and were able to make some significant changes. One root cause that was a recurring challenge was that our lV's were becoming kinked where the IV was being taped down and this was preventing resuscitative fluid from getting to the patient. Therefore, we have introduced a J-loop attachment to our IV starts which is more rigid and prevents kinking at the tape down sites. Another innovation to come from our no harm event reviews and root cause analysis was the introduction of an obstetrical emergency crash cart that sits outside the two birthing rooms. In this new crash cart we have all of the preeclampsia meds, most of the post partum hemorrhage meds (with exception of meds kept in fridge), blood transfusion tubing,Bakri balloons, etc. This cart has already been useful in several cases on the unit. Finally a third innovation to come from our reviews was the motto "Benchmark the Uterus". This is a technique that we have all incorporated into our practice after a concealed post partum hemorrhage case with delayed delivery of the placenta."Benchmark the uterus" means to take note of where the uterus is located a few minutes after delivery and then continue to examine the fundus to ensure that a concealed post-partum hemorrhage is not occurring behind the placenta while waiting for delivery of the placenta.We disseminated this information to our team participants via weekly rounds, grand rounds and the workshop days.

 

Elimination of Hierarchy and Skills Development:

 

Our team continues to believe strongly in the elimination of hierarchy on our unit. Our team has decided that in the event of an obstetrical emergency with no obstetrical physicians in house, nurses should feel comfortable and competent in inserting fetal scalp electrodes to facilitate fetal monitoring.Weekly rounds have enabled our nursing team to practice the insertion of scalp electrodes and to review the contraindications to their insertion. In addition, our family physician colleagues have been trained in the insertion of intrauterine pressure catheters and amnioinfusion. We have created a Skills Drill station for IUPC insertion and amnioinfusion and continue to encourage our participants to practice these drills.

 

Summary:

 

The third year of our MORE<sup>OB</sup> program at Yellowknife's Stanton Territorial Hospital has been marked with wonderful changes and patient safety initiatives. Our core team and participants are highly motivated to make changes as we can see the benefits right before our eyes. Our obstetrical emergency crash cart was used within the first week of implementation and the team felt it had made a significant difference in the management of patient care!  We continue to strive to work collaboratively, improve patient safety and work on the improvement of our skills to better serve our patients and our communities.