Read 11_18 245pm CAPS-Behling-APS presentation_pptx text version

Administering Pitocin Safely

Policy, Procedure and the Elephant in The Room

Diana Behling has no relevant financial relationships to disclose, nor will there be any discussion of off label drug or device usage.

Diana J Behling MJ, BSN, RN Ob Right Program Manager Sentara Health Care Norfolk Virginia

Objectives

Describe the elements of event causation Discuss the two aspects of culture and their impact on the L&D team Identify the competing interests at play amongst the health care team in the safe administration of Pitocin Describe methods of shifting cultural beliefs regarding Pitocin administration

A discussion of how the various elements of culture play themselves out in the health care team in the L&D setting impacting patient care.

Induction of labor is one of the most common obstetrical interventions in the United States.

"Why are we discussing this.... we have a Pitocin policy that everyone knows."

The rate of labor induction: 9.5% in 1990 22.3% in 2005

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Kirmeyer S, et al. Births: final data for 2005. Natl Vital Stat Rep 2007;56:1-103.

Causes of Action... Many Ways to "Fail"

Failure to identify and respond to hyperstimulation Failure to identify and then react in a timely manner to non-reassuring FHR failure to discontinue oxytocin in light of a nonreassuring fetal heart rate Unnecessary induction due to lack of medical indication Failure to establish fetal well-being prior to initiating oxytocin Failure to adequately monitor fetal heart rate during oxytocin infusion Failure to adequately monitor uterine contractions Delays in identifying and responding to non-reassuring fetal heart rates Failure to notify provider of non-reassuring fetal heart rate Failure to respond to elevated resting tone Inappropriate titration of oxytocin ­ not based on accepted protocols Failure to follow a physician's order Failure to follow hospital policies And the list goes on....

Medication Errors

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)

"Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."

IOM July 2006

When Do Errors Occur?

Procuring the drug Prescribing it Dispensing it Administering it Monitoring its impact They occur most frequently during the prescribing and administering stages.

2007 National Academy of Science. Preventing Medication Errors: Quality Chasm Series

When all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day.

Most Common Causes of Medication Errors

Miscommunication of drug orders (messy handwriting, incorrect or unapproved abbreviations, salad, misuse of zeroes and decimal points, confusion of metric and other dosing units) Performance and knowledge deficits due to failures of training or education Unavailable drug information (such as lack of up-to-date warnings) Inappropriate or incorrect labeling as a drug is prepared and repackaged into smaller units

The Elephant in the Room...

An important and obvious topic, which everyone present is aware of, but which isn't discussed, as such discussion is considered to be uncomfortable.

Our Analysis Brief Case Summary

Science:

Pitocin Half-life: 3-10 minutes

Black & White & Grey: Science Meets Culture

Steady State: ~40 minutes after drug initiation or adjustment Infusion Rate Correlative to Organic Labor Level: 4-6 mU/min

Science: Pitocin and Fetal sPO2

Fetal sPO2 reaches its lowest level 90 seconds after the peak of the contraction. An additional 90 seconds is required for fetal sPO2 to return to normal levels.

Science: Tachysystole and Fetal sPO2

A pattern of 5 contractions in 10 minutes over 30 minutes= 20% reduction of fetal sPO2 A pattern of 6 or more contractions in 10 minutes over 30 minutes= 29% reduction of fetal sPO2

McNamara H, Johnson N. The effect of uterine contractions on fetal oxygen saturation. BrJ Obstet Gynaecol. 1995; 102:644-647.

Simpson KR, James D. Effects of oxytocin-induced uterine hyperstimulation on fetal oxygen status and fetal heart rate patterns during labor. Am J Obstet Gynecol. 2008; 199:34. e 1- 34.e5.

Science: How Much Pit is Enough?

Once active labor is established and the cervix is dilated to 5 centimeters, Pitocin may be decreased or turned off without adverse effect on the progress of labor

Culture of Pitocin Safety Survey

Anonymous Survey Residents, Nurses 5 Entities Internet Accessible

Ustunyurt E, Ugur M, Ustunyurt B, Iskender T, Ozkan 0, Mollamahmutoglu L. Prospective randomized study of oxytocin discontinuation after the active stage of labor is established.j Obstet GynaecolRes. 2007;33(6):799-803. Daniel-Spiegel E, Weiner Z, Ben-Shlomo I, Shalev E. For how long should oxytocin be continued during induction of labour? BrJ Obstet Gynaecol. 2004; 111:331-334.

Survey Questions 1-5

Do you know the standard Pitocin protocol for induction of labor? What is the standard protocol (fill-in) Is it ok to deviate from this protocol? If yes, under what circumstances? How is "adequate" labor defined?

Do you know the standard Pitocin protocol for induction of labor?

Yes No 100% 0%

What is the "Standing" Pitocin Order?

Increase pit by 2 milliunits/min q 20-30 mins Start pit @ 1 mu/min and increase every 15 min Baseve, 30 minutes of a reactive strip, q15 min bp Monitor x 20 min, increase by 1-2 mu q 20 min Starting dose 2 milliunits per minute Start at 2mu/mi and increase by 2mu/min q 30 Start at 2 milliunits and increase by 2 milliunits Begin at 2mu/min, increase q 30 min=adequate labor The rate of pit as in the md orders Start at 2.Omu min increase 15 -30 by 2 mu 2 units q 30, max of 20 units Start @ 2milliunits/hr and increase by 2 to max 20 Start pitocin at 2 milliunits/minute. Increase by Start at 2 and increase by 2 every 30 mins Start at 2 mu, inc by 2, to max of 20 Increase pit by 2 milliunits/min q 20-30 mins Start pit @ 1 mu/min and increase every 15 min Monitor x 20 min, increase by 1-2 mu q 20 min Start at 2mu/mi and increase by 2mu/min q 30 Start at 1-2mu/min q30 increase until adequate labor Start and advance by 2mu q____ min per md decision

Is it OK to deviate from this protocol?

Yes No

75% 25%

Survey Questions 6-9

Would you continue to increase the Pitocin of a patient who is making "adequate" cervical change? Y-N If yes, under what circumstances? Fill in Under what circumstances do you stop increasing the Pitocin? Fill in Are there conditions under which you would not start Pitocin? Y-N

Would you continue to increase the Pitocin on a patient who is making "adequate" cervical change?

Yes No

16% 84%

How Would You Define "Adequate" Labor"

Contractions 2-3 min apart, lasting 60-70 seconds, cervical change Contractions q 2-3 mins, lasting 60-120 mins & making cervical change Uterine ctx every 2-3 mins lasting 60 secs Contractions every 2-3 minutes, making cervical changes, mvu's greater than or equal to 180. Mvu at least 150. Contractions q. 2-3 mins with @ least 60 sec. Between. Contraction duration- 40-90 sec. Cervical change progresses, intensity of 40-90mm/hgusing intra-uterine pressure catheter Progressive cervical change Contractions lasting 60-90sec Contractions every 2-3min 180 mvus Contractions every 2-3 minutes, more than 60 seconds in between them and cervical change

Survey Questions 10-13

Under what circumstances do you turn off the Pitocin? Fill in Have you ever heard the term "Turbo Pit?" Y-N Has a provider ever asked you to run "Turbo Pit?" Y-N Have you ever felt pressured to "get things going" or speed along a patient's labor to get her delivered? Y-N

Under What Circumstances Do you Turn OFF the Pitocin Infusion?

Repetitive decels, hyperstimulation of uterus Fetal or maternal distress Late decels, fetal distress If there is repetitive decels with each contractions and iv bolus, fluids or position changes did not help. Or a md order. Fetal or maternal distress Non-reassuring fhr, decelerations of the fhr, hyperstimulation and no resting between contractions, fetal bradycardia, fetal tachycardia Non reassuring fhts; bradycardia; absent variability, etc. Uterine hyperstimulation; late decels, severe or recurring variables Hyperstimulation, decelerations, fetal bradycardia

Have you ever felt pressured to "get things going" or speed along a patient's labor to get her delivered?

Yes No

91% 9%

Survey Question 14-16

Can you name the potential complications or side effects of Pitocin? Y-N What are some of the potential complications or side effects of Pitocin? Fill in Where do you work in the corporation?

Can you Identify the Complications of Pitocin Infusion?

uterine rupture, water intoxication uterine rupture, fetal death hyperstim, fetal distress, uterine rupture uterine rupture uterine rupture, fetal distress, placental abruption. uterine rupture, hyperstimulation, decreased b/p, cardiac arrhythmias, headache uterine rupture; fetal distress; uterine hypertonus postpartum hemorrhage (when used on long inductions) uterine rupture, decelerations, hyperstimulation

Under What Circumstances Do you Turn OFF the Pitocin Infusion?

repetitive decels, hyperstimulation of uterus fetal or maternal distress late decels, fetal distress if there is repetitive decels with each contractions and iv bolus, fluids or position changes did not help. or a md order. fetal or maternal distress non-reassuring fhr, decelerations of the fhr, hyperstimulation and no resting between contractions, fetal bradycardia, fetal tachycardia non reassuring fhts; bradycardia; absent variability, etc. uterine hyperstimulation; late decels, severe or recurring variables hyperstimulation, decelerations, fetal bradycardia

Lessons Learned From the Survey

The Road is Fraught With Peril!

Confusing Communication Multiple and Various Ways of Doing the Same Thing Provider Specific Practice

A Survey of Sentinel Events Reveals the Root Causes of Adverse Events in L&D:

Staff competency ­ 47 % Orientation & training ­ 40 % Inadequate fetal monitoring ­ 34 % Unavailable equipment or drugs ­ 30 % Credentialing issues for MDs - 30 % Communication issues ­ 72 %

Model of Event Causation

Layers of Culture

Physical Things

Words, Language, Images

Observable Characteristics

Patterns of Behavior

Ideas & Knowledge Guiding Principles

Not Directly Visible

Underlying Assumptions

Guiding Principles... Knowledge

Policy & Procedure Technical Bulletin Guidelines For Perinatal Care Williams, Gabbe etc... AWHONN, ACOG, AAP, ASA Everyone knows what they are supposed to do!

Guiding Principles...Team

Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal; have specific roles or functions; and have a time-limited membership.

Barriers to Team Performance

· · · · · · · · Hierarchy Defensiveness Conventional thinking Varying communication styles Fatigue Workload Misinterpretation of cues Lack of role clarity

Words, Language, Images

· Inconsistency in team membership · Lack of time · Lack of information sharing · Conflict · Lack of coordination and follow-up · Distractions

Let's get the patient delivered Push the Pit Let's get things going Up the Pit

Guiding Principles...Underlying Assumptions

MD ­RN: Communication Styles

What the Physician is thinking What the Nurse is thinking What the Nurse thinks the Physician is thinking What the Physician thinks the Nurse thinks he is thinking

Nurses are trained to be narrative and descriptive Physicians are trained to be problem solvers " what do you want me to do" ­ " just give me the headlines" Complicating factors: gender, national culture, the pecking order, prior relationship Perceptions of teamwork depend on your point of view

Barriers to Safety in L&D

Catastrophic events are rare "It won't happen to me" Errors are associated with poor performance Focus on individuals, not complex systems

Human Error is Inevitable Because:

Inherent human limitations Complex, unsafe systems Safety is often assumed, not assured Culture of the expert individual

Where do Things Fall Through the Cracks ?

Systems ­ information, tests, diagnoses Communication - Hand-offs Failure to plan Failure of recognition Failure to rescue

Our Basic Road Map For Safe Clinical Practice

Use applicable evidence and/or published standards and guidelines When a clinical choice is presented, chose patient safety rather than production

OB Right

Provide Appropriate Training Avoid Reliance on Memory Introduce Simplifications Introduce Standardization Reduce Workloads

The OB Right Program

To minimize the risk of iatrogenic injury to the mother and infant To reduce adverse patient safety events in the Labor and Delivery To decrease professional liability exposure To increase collaboration, teamwork and communication to effect optimum maternalfetal clinical outcomes

Shifting Culture

· It is difficult to break with tradition. · We are trained and familiar with our experiences and practices. · Even with authentic commitment to new approaches it is very easy to default back to what is "safe"

Team... Crew Resource Management

Best Practice Alert

Pitocin Pre-Flight Checklist

·

Critical Thinking

Critical thinking is the metaphorical bridge between information and action. The disciplined, intellectual process of applying skilful reasoning as a guide to belief or action (Paul, Ennis & Norris)

Critical Thinking

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care (Heaslip). The action must be appropriate for the condition or problem presented at that time and place.

Layers of Culture

Nurses (and other providers) must develop critical thinking skills for managing situations where the routine use of oxytocin is not producing routine results.

Physical Things

Words, Language, Images

Observable Characteristics

Patterns of Behavior

Ideas & Knowledge Guiding Principles

Not Directly Visible

Underlying Assumptions

The Elephant in the Room...

An important and obvious topic, which everyone present is aware of, but which isn't discussed, as such discussion is considered to be uncomfortable.

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