The design of "TeamBirth": A care process to improve communication and teamwork during labor

BACKGROUND

Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients.

METHODS

We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication.

RESULTS

We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated.

DISCUSSION

We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.

Rapid Cycle Implementation and Retrospective Evaluation of a SARS-CoV-2 Checklist in Labor and Delivery

Background

Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient.

Methods

Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR).

Results

Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time.

Conclusion

We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06787-5.

Language Preference and Risk of Primary Cesarean Delivery: A Retrospective Cohort Study

OBJECTIVES

While some medical indications for cesarean delivery are clear, subjective provider and patient factors contribute to the rising cesarean delivery rates and marked disparities between racial/ethnic groups. We aimed to determine the association between language preference and risk of primary cesarean delivery.

METHODS

We conducted a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) deliveries of patients over 18 years old from 2011-2016 at an academic medical center, supplemented with data from the Massachusetts Department of Public Health. We used modified Poisson regression with robust error variance to calculate risk ratios for cesarean delivery between patients with English language preference and other language preference, with secondary outcomes of Apgar score, maternal readmission, blood transfusion, and NICU admission.

RESULTS

Of the 11,298 patients included, 10.3% reported a preferred language other than English, including Mandarin and Cantonese (61.7%), Portuguese (9.7%), and Spanish (7.5%). The adjusted risk ratio for cesarean delivery among patients with a language preference other than English was 0.85 (95% CI 0.72-0.997; p = 0.046) compared to patients with English language preference. No significant differences in risk of secondary outcomes between English and other language preference were found.

DISCUSSION

After adjusting for confounders, this analysis demonstrates a decreased risk of cesarean delivery among women who do not have an English language preference at one institution. This disparity in cesarean delivery rates in an NTSV population warrants future research, raising the question of what clinical and social factors may be contributing to these lower cesarean delivery rates.

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools

Supplemental Digital Content is available in the text.

Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training.

Lymphopenia and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection Among Hospitalized Obstetric Patients

Lymphopenia does not identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among asymptomatic patients admitted to an obstetrics unit or among obstetric patients under investigation for coronavirus disease 2019 (COVID-19).

Meeting Milestones: Results of a Quality-Improvement Curriculum to Achieve Cost-Conscious Care

There is a lack of residency education in cost-conscious care. We implemented a costing and quality improvement (QI) curriculum to Obstetrics and Gynaecology trainees using “Time-Driven Activity-Based Costing (TDABC),” and assessed its educational impact.

The curriculum included didactic and practical portions. Pre-and post-knowledge surveys were obtained from 24 residents on self-perceived knowledge of key QI principles. Self-perceived knowledge, before and after the curriculum, was scored on a Likert scale from 0 to 5 points (0 is the least knowledge and 5 is the most knowledge). The mean scores reported an increase in knowledge of clinical guideline development (pre = 1.19 vs. post = 3.07, p = 0.0052); confidence in participating in QI work (pre = 1.75 vs. post = 3.42 points, p < 0.0001); and knowledge in communicating QI principles (pre = 1.89, post = 3.17, p < 0.0003). Our educational programme uses the TDABC method and the residents’ clinical experience effectively to teach residents cost-conscious care.

Human-Machine Collaborative Optimization via Apprenticeship Scheduling

Coordinating agents to complete a set of tasks with intercoupled temporal and resource constraints is computationally challenging, yet human domain experts can solve these difficult scheduling problems using paradigms learned through years of apprenticeship. A process for manually codifying this domain knowledge within a computational framework is necessary to scale beyond the "single-expert, single-trainee" apprenticeship model. However, human domain experts often have difficulty describing their decision-making processes. We propose a new approach for capturing this decision-making process through counterfactual reasoning in pairwise comparisons. Our approach is model-free and does not require iterating through the state space. We demonstrate that this approach accurately learns multifaceted heuristics on a synthetic and real world data sets. We also demonstrate that policies learned from human scheduling demonstration via apprenticeship learning can substantially improve the efficiency of schedule optimization. We employ this human-machine collaborative optimization technique on a variant of the weapon-to-target assignment problem. We demonstrate that this technique generates optimal solutions up to 9.5 times faster than a state-of-the-art optimization algorithm.

Robotic assistance in the coordination of patient care

We conducted a study to investigate trust in and dependence upon robotic decision support among nurses and doctors on a labor and delivery floor. There is evidence that suggestions provided by embodied agents engender inappropriate degrees of trust and reliance among humans. This concern represents a critical barrier that must be addressed before fielding intelligent hospital service robots that take initiative to coordinate patient care. We conducted our experiment with nurses and physicians, and evaluated the subjects’ levels of trust in and dependence upon high- and low-quality recommendations issued by robotic versus computer-based decision support. The decision support, generated through action-driven learning from expert demonstration, produced high-quality recommendations that were accepted by nurses and physicians at a compliance rate of 90%. Rates of Type I and Type II errors were comparable between robotic and computer-based decision support. Furthermore, embodiment appeared to benefit performance, as indicated by a higher degree of appropriate dependence after the quality of recommendations changed over the course of the experiment. These results support the notion that a robotic assistant may be able to safely and effectively assist with patient care. Finally, we conducted a pilot demonstration in which a robot-assisted resource nurses on a labor and delivery floor at a tertiary care center.

Improvement in Perinatal HIV Status Documentation in a Massachusetts Birth Hospital, 2009-2013

BACKGROUND AND OBJECTIVES

Despite recommendations for universal HIV testing during routine prenatal care, maternal HIV status is not always available at the time of delivery, which may lead to missed opportunities for antiretroviral prophylaxis. We completed a quality improvement project focused on increasing the availability of maternal HIV status documentation at our perinatal facility. Our primary aim was to improve documentation rates from 50% to 100% between 2009 and 2013. Our secondary aim was to identify predictors of documentation.

METHODS

After an initial needs assessment, we performed a multidisciplinary quality improvement effort to address lack of HIV documentation in perinatal charts. The interventions included a switch to a verbal-only consent process, a rapid HIV testing protocol, and a simplified newborn admission document. To assess the impact of our intervention, we audited 100 charts per month and formally analyzed a second random sample of 200 charts in the postimplementation phase.

RESULTS

Rates of HIV status documentation improved between 2009 and 2013, from 55.5% to 96.5%. Multivariable models revealed that before our interventions, mothers receiving care at freestanding offices (versus community-based outreach clinics) and those privately insured (versus publicly) were less likely to have HIV status documented. In 2013, neither ambulatory site nor insurance type predicted documentation.

CONCLUSIONS

We demonstrated improvement in maternal HIV status documentation on admission to labor and delivery after implementation of a 3-pronged intervention. Next steps include investigating persistent barriers to achieving universal screening and documentation.