QI Project: Slade Bigelow, DO, Meagan Gold MD, MPH and Nathan Lamborn MD, MBA

23 yr old F with G1P0 otherwise healthy laboring on floor with epidural. CA2 called at 3am by RN.  RN: “We have a patient we are taking for a C/S”  CA2: “Is this an EMERGENT C/S”  RN: “Yes I think so.”  CA2: “What is the indication?”  RN: “The OB’s think there is something in the vagina.”  CA2: “Something like the cord?”  RN: “Yeah I think so.”  CA2: “ Which OR?”  RN: “Main, we are on our way.” Arrive in OR, pt arrives 3 min later. OB intern with hand in vagina. Baby with reassuring tones. Nonetheless, massive panic. Mom is terrified. Dad is terrified. Move pt to OR bed, drapes up. Anesthesia attending arrives. Induce general anesthesia. Mom and baby to great. Time out not performed.

 Current communication for urgent/emergent cases : OB-to-RN RN-to-Anesthesia OB Anesthesia-to-Attending OB  RN may be: Unclear about indication May not know everything about the pt. Has to prepare the patient for transport to the OR. Has to call the scrub tech. Has to call NICU. Key safety points are missed given the lack of provider-to-provider communication.  Problems: Key details miss Delays in care leading to potentially serious morbidity and mortality. Nursing feels stressed, unclear of role, stick in the middle Anesthesia may not respond appropriately either from a timing standpoint or from a care standpoint (GA vs neuraxial) OB with delays in care, poor outcomes both physically and psychologically.

 Who: The entire OB team, specifically: OB residents, OB anesthesia residents/CRNA’s and RN’s.   When: Before urgent and emergent cesarean section case starts.   Where: University of Colorado Hospital Women’s Care Center and Birth Center.

 Team Huddle – Pilot Study (6mo-12 mo)  Education on new communication format  Laminated Cards for all OB staff with Structured Communication Format: S – Situation: Urgent case for X reason A – Active Drips/Conditions:Pit, Mag, RAD, Pre-E F - Fetal Status E – Expected time in OR: time to bolus epidural? (or something like this….)

PATIENT/NEONATESTAFF SATISFACTION  Decision-to-Incision time. Decision-2-OR Decision-2-Cut  To account for change of plans, acuity, pt/fetal status.  Non-anesthesia related time issues.  Urgent/Emergent Cases Pre/Post Implementation: GA Regional APGAR Patient Satisfaction Scores  Likert Scale Questionnaire.  Pre and Post Satisfaction Surveys: OB RN’s OB Charge RNs OB/GYN Team Anesthesia Team