AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements that support rapid response systems. The key safety elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, anesthesiology providers, neonatal providers, and other labor and delivery (L&D) unit staff responsible for antepartum, intrapartum, and postpartum care.
How to use this tool: Review the key perinatal safety elements with L&D leadership and relevant unit staff to determine how the elements will be implemented at your hospital. Consider any existing hospital procedures, policies, or processes related to rapid response systems.
Key Perinatal Safety Elements
| Standardize When Possible (CUSP Science of Safety) | |
|---|---|
| Key Perinatal Safety Elements | Examples |
| Establish a unitwide approach for responding to a request for a rapid response for urgent maternity care issues. | A rapid response system includes four components:1-2
A unitwide approach means that there is a uniform way that primary staff (or patients or family) request a rapid response from other clinicians. When a request is made, staff individually and collectively know who is responsible for responding and expectations of the response, uniform expectations for documentation of the rapid response event exist, and a system for feedback exists to monitor and improve the approach. |
| Establish standard criteria for activation of a rapid obstetrical response. | Rapid response activation criteria can be general or specific. General activation criteria:
Note: Coordination with other hospital rapid response or emergency response (i.e., "code" teams) is critical. Patients on perinatal units can experience cardiopulmonary and metabolic events or deterioration that require a response from nonmaternity care rapid responders. Perinatal staff and maternity care rapid responders should have standard criteria for activating other rapid and emergency response teams. |
| Use standard rapid response kits or carts. | Rapid response kits or carts that are stocked with supplies, equipment, and cognitive aids that might be used for the more common situations that might activate a rapid response. |
| Create Independent Checks (CUSP Module) | |
| Have multidisciplinary rapid responders who can respond to requests for a rapid response to emergent or potentially emergent maternity care conditions. | Rapid responders offer a strategy for getting a second opinion, additional resources, and another set of "eyes" on the situation to prevent further deterioration and "failure to rescue." Rapid responders may include staff L&D nurses, nurse midwives, obstetricians, and anesthesiology providers. Rapid responders should—
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| Learn From Defects (CUSP Module) | |
| Debrief and analyze near misses and adverse events, regardless of whether a rapid response was activated. Debrief among clinical team after rapid response, regardless of outcome. |
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| Have a process in place to review severe maternal or neonatal morbidity and mortality events, regardless of whether rapid response was activated. |
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| Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning. | Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally. |
| Simulation (SPPC Program Pillar) | |
Sample Scenarios:
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| Teamwork Training (TeamSTEPPS®) | |
| Have situational awareness. | Situational awareness refers to all staff caring for the patient—
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| Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques. | Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of a rapid response, these techniques are particularly useful—
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| Communicate during transitions of care. | Use of transition communication techniques assures a shared mental model of plan of care and perceived risks between shifts, between units, and between care teams within a unit. This includes communication between primary team and rapid responders, or between rapid responders and other unit personnel (e.g., operating room team). |
Have high-reliability teams.
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| Patient and Family Engagement (CUSP Module) | |
| Use mechanism for patient activation of a rapid response. |
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| Communicate with patient and family during episode involving possible maternal or fetal deterioration. |
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| Disclose any unintended outcomes. | Unit-established process for disclosing unintended outcomes. This may include the following:
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References
- Devita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med 2006 Sep;34(9):2463-78. PMID: 16878033.
- Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011 Jul 14;365(2):139-46. PMID: 21751906.
Appendix
Every effort was made to ensure the accuracy and completeness of these resources. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
Sample: Obstetrical Rapid Response System Planning Worksheet
This worksheet is designed to provide guidance in establishing an obstetrical rapid response system at your facility.
- Afferent Components (Response Activation)
The afferent component of a rapid response system involves establishing activation criteria and an activation mechanism.
Activation Criteria
Activation criteria for an obstetrical rapid response should be clearly defined for all staff members, patients, family members, and those who support them during the birthing process (e.g., doulas). Some facilities may choose to use generalized activation criteria, while others may choose to use very specific conditions for activating a rapid response.
Some examples of general activation criteria include—
- An emergent or potentially emergent obstetric condition.
- An event that requires a team response.
- An acute situation that the provider or nurse or patient or family member believes needs immediate evaluation to avoid fetal or maternal harm.
Some examples of specific activation criteria include—
- Category III fetal heart rate tracing.
- Bright red vaginal bleeding.
- Severe abdominal pain.
- Uterine tachysystole.
- Inability to complete delivery (e.g., shoulder dystocia).
- Cord prolapse.
- Hypotension.
- Consistently rising blood pressure (BP) or systolic BP > 180 mm Hg or diastolic BP > 120 mm Hg.
- Severe headache.
- Inability to control pain.
- Seizure.
- Mother unresponsive (may also require activation of medical rapid response or emergency response team).
| ACTION: Determine criteria for activating a rapid response at your facility. |
Activation Mechanism
A mechanism for an individual to activate a rapid response must be established, and all staff must know this mechanism and communicate it to patients and family members at admission. Activation mechanism may differ for staff as compared with patients and family members. Examples of activation mechanism include—
- Calling a specific pager number.
- Calling the charge nurse.
- Pressing a call button.
- Calling the hospital operator.
In addition, coordination with other hospital rapid response teams is essential. For example, some situations may require the activation of both an obstetrical rapid response and a neonatal rapid response. Other situations may require anesthesiology support, or a medical emergency (i.e., “code”) team response.
| ACTION: Determine activation mechanism, and coordination with other hospital rapid response and emergency response teams. |
- Efferent Components (Response Deployment)
The efferent component of a rapid response system includes the timeliness of response, scope, staff types for response, and supplies and equipment.
Timeliness of Response
Service-level expectations for response time should be established. A goal or unstated expectation may be for rapid responders to arrive as quickly as possible, but written service-level expectations help foster a shared mental model of how quickly staff need to respond once a response is activated.
| ACTION: Determine service level expectations for timeliness of responding to a rapid response activation. |
Scope
Defining the scope and limits of the staff responding to a request for a rapid response is essential. Different models exist. Rapid responders can simply provide role backup and task assistance to the primary maternity care provider and L&D or postpartum nurse, or rapid responders may assume responsibility for directing patient care. The scope and role may vary depending on the unit to which the rapid responders deploy (e.g., antepartum, postpartum, ED, etc.). Limits to the situations rapid responders are qualified to address and interventions they are able to execute should also be articulated as part of the scope of a rapid response. Defining responsible parties for documentation is also part of defining the scope and limits for rapid response staff.
| ACTION: Determine the scope and limits for rapid response staff. |
Staff Types Responding
The specific types and numbers of rapid responders may vary depending on your facility’s size, in-house staff availability, and existing rapid response systems. Use the table below to discuss options with your unit leadership and staff.
| Title | Role During a Rapid Response | Method of Contact for Rapid Response |
|---|---|---|
| Physician(s) | ||
| Nurse midwife(s) | ||
| L&D staff nurse(s) | ||
| Anesthesiology | ||
| Charge nurse | ||
| L&D technician | ||
| Lab/Blood bank | ||
| Pharmacy | ||
| Other |
Supplies and Equipment
Rapid responses are facilitated by readily available supplies and equipment. Depending on the scope determined and staff types identified for response, identify any supplies and equipment that can be made readily accessible for rapid responders. Identify a standardized location for this equipment, and ensure a process for checking functionality and restocking after use. Determine a process for transporting equipment for when rapid responses are activated outside of L&D.
| ACTION: Determine plan for supplies and equipment for use during rapid response. |
- Patient Safety/Process Improvement Component
This component involves education and training for deployment, along with debriefing, monitoring, and feedback that can be used for process improvement.
Education and Training
Prior to going "live" with a rapid response system, staff will need to receive education and training. Training and education should be tailored depending on whether staff are rapid responders, or “users” of the rapid response system. In addition to training current staff, a plan for training new staff and providing refresher training at periodic intervals is also necessary. Lastly, a routine approach for communicating the process for patient/family member rapid response activation should be included as part of the admission process.
| ACTION: Develop a rapid response training and education plan for current staff, new staff, and patients/family members. |
Debriefing
Debriefing is a crucial part of all rapid responses. Debriefing provides an opportunity for all individuals involved in the incident to reflect, assess, get questions answered, evaluate the process, and make changes to the process if appropriate. It also helps everyone understand why the event occurred and how it could be prevented in the future.
| ACTION: Determine the approach rapid responders will use to debrief following a rapid response call, including any documentation requirements, such as completing a rapid response call log. |
Monitoring
Monitoring use of a rapid response system with respect to both process and outcome can help with process improvement. Examples of items to monitor:
- Number of rapid response activations.
- Reasons for activations.
- Timeliness of rapid response.
- Nature of assistance provided during response.
- Whether a debriefing with primary team occurred.
- Action items from debriefings.
- Maternal and fetal outcomes in cases where response was activated.
| ACTION: Determine items and measures to monitor the rapid response system. Determine how these items and measures will be collected, such as with a rapid response call log. |
Feedback From Staff and Patients
Solicit feedback from unit staff who are “users” of the rapid response system and unit staff who function in rapid responder roles. It is also important to obtain feedback from patients and families and doulas to give them a chance to offer their opinions about either the availability of a rapid response system to them, or their direct experience with activating it in order to provide recommendations from the patient perspective.
| ACTION: Determine how to collect staff and patient feedback about the rapid response system process in place within your facility. |
Sample Rapid Response Call Log
| Unit activating: | |
| Call date: | |
| Call time: | |
| Arrival time: |
Charge nurse notified: ___ Yes ___ No
Nurse manager notified: ___ Yes ___ No
Attending M.D. or midwife notified: ___ Yes ___ No
| Rapid Response Activator Information Name: Check one of the following: ___ R.N. ___ Resident physician ___ Attending physician ___ Midwife ___ Student ___ Patient/Family ___ Doula ___ Other ____________ |
Rapid response R.N.:_______________________________________________________
Rapid response provider (midwife or physician):__________________________________
| Maternal Information Age: G ___ P ___ EGA: Relevant obstetric history:
|
(Check all that apply)
| Reason for Call | Diagnostics / Interventions | Outcomes |
|---|---|---|
| ___ Category II FHR tracing _____________________ _____________________ ___ Category III FHR tracing _____________________ _____________________ ___ Cord prolapse ___ Shoulder dystocia ___ Vaginal hemorrhage ___ BP > 180 mm Hg systolic ___ BP > 120 mm Hg diastolic ___ Consistently rising blood pressure ___ Sudden low blood pressure ___ SaO2 < 90% ___ Uterine tachysystole ___ Severe abdominal pain ___ Seizure ___ Severe headache ___ Difficult to control pain/agitation ___ Mother unresponsive ___ Other (specify): _____________________ _____________________ |
___ Labs drawn (specify ___ Diagnostic tests (specify): Interventions: ___ Repositioned ___ Suctioned ___ Oral/nasal airway ___ Oxygen (NC/FM/NRB) ___ Bag mask ventilation ___ Nebulized med (specify): ___ IV access ___ IV fluid bolus ___ Blood product ___ Tocolytic ___ Methergine ___ Other medications (specify): ___ Assisted vaginal delivery (specify): ___ Expedited c-section delivery ___ Other intervention (specify): |
___ Vaginal delivery ___ C-section delivery ___ No delivery Maternal status: ___ No transfer ___ Transfer to L&D PACU ___ Transfer to antepartum unit ___ Transfer to L&D ___ Transfer to ICU ___ Other___________________ Neonatal status: ___ Infant to NICU ___ Infant to newborn nursery ___ Infant in room with mother ___ Infant deceased ___ Mother deceased Other comments: _____________________ _____________________ _____________________ _____________________ |
BP = blood pressure; c-section = cesarean section; FHR = fetal heart rate; FM = face mask; ICU = intensive care unit; IV = intravenous; L&D = labor and delivery; NC = nasal canula; NICU = neonatal intensive care unit; NRB = non-rebreather PACU = post-anesthesia care unit; SaO2 = oxygen saturation
Rapid response team debriefing (day/time):_________________________________________
Participants in debriefing:________________________________________________________
_______________________________________________________________________________
Rapid response team concerns: __________________________________________________
______________________________________________________________________________
Action items from debriefing (if applicable): _______________________________________
______________________________________________________________________________
Submit form to [Insert name of Safety Data Coordinator or Quality Manager here].
DO NOT PLACE IN PATIENT CHART.
