1. FUTURE TMMC HOSPITAL 2015 Improving Perinatal Care Torrance Memorial Medical Center

2. TMMC  Community Hospital in South Bay  401 total beds  3200 annual deliveries  Private OB/GYN physicians  Perinatology consultants  Level 3 NICU, 25 beds  24 hour in house neonatologist  24 hour in house anesthesiologist

3. TMMC IHI/BETA Team Members Larisa Bargman, RN Colleen Champlin, RN Monika Chudoba, RN Debbie Ernst, RN Maria Hovsepian, RN Carol Kretsch, RN Tina Susatio, RN Donna Yukihiro, RN, CNS Maria Koegel, L&D Manager Diane Galati, Dir. MCHS Kenneth Chan, MD Albert Chen, MD Esther Schmuel, MD Ruth Idah, Clin.Qual.Analyst Heather Shay, Dir. of Quality Linda Dobie, VP Risk Manage.

4. Oxytocin Deep Dive References  JCAHO Standard MM.7.10 The organization develops processes for managing high- risk or high-alert medications  ISMP alert, August 9, 2007  Simpson, Kathleen Rice. Measuring Perinatal Patient Safety: Review of Current Methods. JOGNN.35, 432-442.2006

5. Oxytocin Deep Dive Chart audit occurred June 8, 9, & 10, 2010  124 charts pulled (deliveries occurring April 18 th -30 th )  64 charts audited (oxytocin used) Results – Positive  Careful Monitoring (98%) Results – Improvement needed  Documentation of oxytocin dose & pattern during handoff (2%)  Tachysystole with normal fetal heart rate identified/managed (3%)  Discontinued oxytocin if labor progressing (5%)  Oxytocin ↓ or discontinued due to tachysystole with significant fetal heart rate decelerations (6%)

6. Oxytocin Deep Dive Results – Surprises  Vaginal exam not done consistently prior to initial oxytocin administration  Order to discontinue oxytocin (12 AM) & to restart (6 AM) even with patients with ruptured membranes  Inconsistent notification of MD in change of oxytocin dose

7. Vaginal Exam (VE) & Oxytocin Audit Tool

8. VE & Oxytocin Results 25 charts audited (August) No vaginal exams prior to initiation of oxytocin (5) Vaginal exams done prior to initial oxytocin dose (20) VE done prior to initiation of oxytocin (80%) Goal: 100% Plan:Continue to audit chartsand review results Manager to follow up with staff

9. Tachysystole Algorithm

11. Tachysystole with normal fetal heart rate identified/ managed (3%) Goal  Nurses will identify, manage & document tachysystole Plan  Nurses & physicians will be inserviced  Tachysystole algorithm implemented  Chart audit