Medicolegal Issues

National initiative cuts incidence of birth hypoxia by 25%

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By reducing harm to babies and mothers, 14 participating hospitals also lowered associated liability claims and payouts



Although it’s not a new trend, ObGyns are changing how they practice medicine as a direct result of the high cost or availability of liability insurance. From 2009 through 2011 about 18% of practicing obstetricians decreased the number of high-risk patients they were treating, 15% increased the number of cesarean deliveries they performed, 13.5% stopped offering vaginal birth after cesarean, and 5% stopped practicing obstetrics altogether, according to the American Congress of Obstetrics and Gynecology.1 Liability exposure, in part, also has resulted in fewer hospitals across the United States offering birthing services.2

The Premier Perinatal Safety Initiative (PPSI) is a national endeavor, involving 14 hospitals, designed to 1) lower the incidence of preventable adverse birth events, such as birth asphyxia and neonatal neurologic disability, 2) better define preventable perinatal harm, 3) identify measures to improve outcomes, and 4) evaluate the effect of harm reductions on liability claims and pay-outs.2

Reduced adverse events

In 2 years, PPSI hospitals reduced, on average2:

  • birth hypoxia and asphyxia by 25%
  • neonatal birth trauma by 22%
  • complications from administering anesthesia during labor and delivery by 15%
  • postpartum hemorrhage by 5.4%.

The adverse outcome index rate, which measures the number of patients with one or more of the identified adverse events as a proportion of total deliveries, was reduced by 7.5%, or 144 fewer adverse events from 2008 to 2010. All hospitals scored below the 2008 Agency for Healthcare Research and Quality (AHRQ) Provider Rate, a national comparative rate measuring perinatal harm.2

Reduced liability claims

In addition, liability claims and payouts decreased by 39% from 2006 to 2010, versus 10% at nonparticipating hospitals. All PPSI hospitals averaged 18 liability claims per year at baseline, but that number dropped to 10 in 2009 and is trending to 8 in 2010 (final claims losses are not yet available because it typically takes 2 years or longer for a claim to be filed).2

Strategies to achieve best outcomes

The best outcomes were achieved with two factors: An increased adherence to evidence-based care bundles in participating hospitals, and enhanced communication and teamwork among hospital staff.2

Increased adherence to evidence-based care bundles. Grouping essential processes together in care bundles helped clinical staff remember to take all of the necessary steps to provide optimal care. For a care bundle to be considered adhered to, staff were scored as “all or none,” meaning that all elements of the care bundle must have been observed for credit to have been given. For instance, the augmenting care bundle included four essential steps. If fetal weight was not calculated before oxytocin was administered, no credit was given for the care provided.2

PPSI hospitals significantly improved compliance with care bundles from 2008 to 2010. On average2:

  • Elective induction bundle compliance increased from 58% to 88%.
  • Augmentation bundle compliance increased from 33% to 72%.
  • Vacuum bundle compliance increased from 9% to 51%.

High-reliability teams. PPSI hospitals implemented proven strategies for certain high-risk protocols known to enhance communication and teamwork, including2:

  • TeamSTEPPS®. Developed by AHRQ, TeamSTEPPS produces highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.
  • Situation Background Assessment Recommendation (SBAR). An effective situational briefing strategy used by the US Navy helps people communicate relevant case facts in a respectful, focused, and effective manner.
  • Simulation drills. Practice exercises feature actresses and mannequins reacting as real patients during the birthing process.

Data regarding outcomes for these communication and teamwork strategies in the PPSI hospitals continues to be evaluated, and will be available in fall 2013.

Study information

Baseline data was completed in a retrospective study of harm outcome data from 2006 and 2007. During Phase 1, health-care teams implemented interventions and worked on improving performance and perinatal safety improvement across approximately 145,000 births. Phase 2 began in January 2011 and will be completed in December 2012.2

The 14 participating hospitals include 4 with small birth volume (1,000 to 2,499 births per year), 8 with medium birth volume (2,500 to 5,000 births per year), and 2 with large birth volume (5,000 or more births per year) in 10 states: Illinois, Kentucky, Massachusetts, Minnesota, New Mexico, Ohio, Tennessee, Texas, Washington, and Wisconsin. Six of 14 hospitals have academic teaching status.2

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