UPMC Hamot Nellann Nipper RNC NNP-BC. Use of a Standardized Tool for Bedside Report in L&D to Mother-Baby Unit Transfer

Transcription

1 UPMC Hamot Use of a Standardized Tool for Bedside Report in L&D to Mother-Baby Unit Transfer 1

2 Handoff Problem UPMC Hamot One of the most critical times for OB patient safety occurs in the communication of essential information from RN to RN in the transfer of mother and infant from the Labor and Delivery area to the Postpartum unit A dynamic bedside report has been the practice in our institution for several years, however the information relayed in report was variable. Accuracy and reliability was dependent on the skills, experience, and knowledge of the Labor and Delivery Nurse and the Mother Baby Nurse. There was no system in place to check whether the information given was complete. 2

3 Handoff Problem UPMC Hamot Information that had frequently been omitted in past transfer reports included maternal beta strep status and treatment, maternal medications received after delivery, the diagnosis of Maternal Gestational Diabetes, either insulin or diet controlled, and maternal medications received after delivery. Omission of this information can lead to errors in the plan of care for the mother and infant. 3

4 Approach UPMC Hamot UPMC Hamot Women s Hospital became part of the hospital pilot program for LifeWINGS. This patient safety program, using Crew Resource Management (CRM) techniques, is used by top medical institutions nationwide and brings together the best practices of other high reliability organizations including commercial aviation, and adapts those practices for use in healthcare. The LifeWINGS program focuses on reducing adverse events that are attributable to human error. 4

5 Approach UPMC Hamot CRM focuses on reducing adverse events attributable to human error. It emphasizes teamwork and communication methods and integrates hardwired tools and practices to create opportunities for improvement in the care environment. Communication skills utilized include call outs, cross-check and assertion, and standardized communications to ensure individual and team situational awareness and a shared mental model. 5

6 Approach UPMC Hamot Representatives from Labor and Delivery, Mother Baby and NICU created a Hard-wired Safety Tool Workgroup to review best practices and the decision was made to create and implement the L&D to Mother Baby Unit Transfer handoff form as one of our first tools. The task force looked at the areas where miscommunications or omission of vital information could have the greatest impact on patient safety. A standardized patient information tool was developed with a specific communication script and checklist. The team looked at the areas where miscommunications or omission of vital information could have the greatest impact on patient safety and included this information on the form. 6

7 Women s Hospital HST Team Nell Nipper MCH Educator NICU Janet Quinn NICU - RN Deena Lasher NICU - RN Danielle Dickson NICU U. S. Emily Hirsh NICU L&D Emma Mack L&D Cheryl Moore L&D - RN Sue Antonucci L&D - RN Jillian Weschler L&D RN Chris Tighe- L&D PCT MOTHER BABY Janice Moryc M/B - RN Michelle Carnegie M/B - RN Linda Mems M/B - PCT Dianna Lindsey M/B 7

8 Approach UPMC Hamot communications weekly to all staff introducing tool and target start dates. Information given to staff by the unit managers during monthly staff meetings. Face to face staff education showing the tool and review of how to use it. Education form presented to staff that detailed how to use the form, all information to be covered top to bottom and left to right with no areas left blank 8

9 Approach UPMC Hamot The attention of both nurses would be joint focused on the form during the bedside report. Studies have shown that handoffs involving incoming and outgoing healthcare providers are most effective when there is a joint focus of attention. This joint focus of attention on the handoff tool facilitates synchronicity of information transfer, and accuracy and understanding between the incoming and outgoing professional 9

10 Approach UPMC Hamot Side 1 Side 2 10

11 TOOL NAME: Women s Hospital RN to RN, L&D to MBU Patient Transfer Report Tool TOOL USE: To give a standardized, consistently uniform hand off report from RN to RN when transferring a mother and baby from L&D to the Mother Baby Unit. It is the UPMC Hamot Women s Hospital Policy/ Process to use the Unit to Unit RN to RN shift hand off report tool for report when transferring a mother and baby to the MBU or transferring a baby from transition nursery to the MBU. HOW TO USE THE TOOL: A phone call prior to transfer, to the MBU will alert them that the patient is ready for transfer and the admitting nurse will be notified. The admitting MBU RN will meet the L&D or NICU RN in the patient s room. All information will be covered in report using the tool going from top to bottom, left to right in the mother s information section then top to bottom, left to right in the infant information section. The LifeWings tool is to be viewed by both RN s during the entire hand off report. This is a joint focused report. Bedside report is the policy at UPMC Hamot. Report should not be given without a completely filled out tool being in hand for both RN s to review. In the case of an infant from transition nursery being transferred to the MBU, RN to RN handoff report will take place at the infant s bedside on the MBU. Report must be verbal. The tool is never to be handed to the MBU RN in place of the verbal report to be given as described above. All information must be completed from top to bottom and all lines or check boxes must be filled in with the requested information. Any maternal or newborn red flags that are noted in the history should be circled on the back of the tool and the yes box for red flags should be checked on the front of the tool. These red flags must be noted in the hand off report. In certain instances, any red flag that is not discussed in front of the patient should be pointed to on the tool by the RN giving report and further information given RN to RN outside of the patient s room. The tool will be initiated upon admission of the patient to the Labor and Delivery floor by the RN assigned to the patient. By the time the patient is ready for transfer to the MBU all maternal information and infant information should be filled in. After bedside report has been given, the original tool goes inside the front of the mothers chart and a copy goes on the inside front of the baby chart. In the case of an infant going to transition nursery and then up to the MBU, all infant transition nursery information is to be completed by the NICU nurse in both the infant section and in the transition nursery section on the back of the tool. RN to RN face to face handoff report will take place at the infant s bedside on the MBU. EDUCATION: The rollout of this tool will begin at 7am on Wednesday 8/29/2012. All RN s will be responsible for utilizing this form and held accountable for filling out the tool and using it for unit to unit RN to RN handoff report. The blank report tools will be kept on the main desk in the L&D nurses station in an envelope marked Unit to Unit report HST s. The used tools will be taken off of the patients charts at discharge and placed in the envelope marked used Unit to Unit HST s in the north east nurses station on MBU. They will be collected weekly to monitor for 100% compliance and evaluation for any necessary changes or improvements. Please communicate any suggestion or concerns to unit director or Nell Nipper. Tool owner: Sue Antonucci, Cheryl Moore Nell Nipper

12 Mother Patient Label Cesarean Spontaneous Cytotec PDI IUFD Indication Allergies: Gravida Para Gestational Age Blood Type PPH Risk: High Med. Low Medical History: OB History: (Seee Back) Rubella: Hep.B RPR/Anti Trep HSV Pos Rx No Rx Social History: (See Back) Marital Status: M S O Support People Drug Screen: Yes No Beta Strep Status: Negative Unknown Positive Treated: Membranes: A S Clear Mec NICU notified Delivery History: Date Time Vaginal - Lacerations Fundal Height Lochia Anesthesia: Epidural Spinal Duramorph Local OB Assessment Meds IV Fluids Site Elimination: Void Foley Doc. Meds by HX Antenatal Lab Form Delivery Documentation Newborn Data Red Flags: Yes - Seee Back No Result Copy Reporting RN Receiving RN IPOC Resolved I & O totals in Cernerr (Including Bolus Oxytocin) Baby Photo Baby Patient Label Weight Critical Values Addressed Power Plans D/C Task List Complete Finalize & Disassociate APGARS Weight BG Time Symptomatic Asymptomatic Admission Meds Given in: DR Yes No / Transition nursery Yes No Parent Refused ID Photo Taken ID Bands on: Mother Infant ID band # Infant security tag on Hugs tag # Skin-to-Skin Elimination: Stool Void Breast Bottle: Last Feeding: WIC Breast Feeding Obstacles PCP Notified Yes No Time Newborn Assessment Form completed Yes No Red Flags: Yes - Seee Back No Reporting RN Receiving RN

13 CIRCLE ALL EXISTING RED FLAGS FOR MOTHER AND NEWBORN OB Red Flags Newborn Red Flags Abnormal Labs Medical History: Seizures IDDM Chronic Hypertension Drug Abuse Screened? Other OB History: Gestational Diabetes/Diet/Insulin/ Meds Infections Magnesium Sulfate Previous Delivery Complications Pre-Eclampsiaa Pre-term Labor Steroids? PPD Other Delivery History Meconium Post-Partum Hemorrhage Vacuum Delivery Placenta Abnormalities Prolonged Second Stage Shoulder Dystocia Other Social History N/ /A Adoption or Surrogate Incarcerated Language No Prenatal Care OCY Involvement Violence Abnormal Sonogram Congenital Abnormalities Late Pre-Term Delivery Room Intervention PPV O O 2 Mechanical Suction Abnormal Newborn Assessments Transition Nursery Other Transition Nursery Treatments Labs: O 2 : % Time: On Off Feeding Chest X-ray PCP Notified Yes No Date Time Drug Screen Initiated ID photo taken Time Into Transition Time Transferred from Transition Newborn Assessment Form completed: Yes No Reporting RN Revision J Receiving RN