In 2000, the publication of the Institute of Medicine report To Err Is Human: Building a Safer Health Care System was a pivotal event for the healthcare system in the United States. Prior to the publication of this report, many physicians and hospital administrators refused to acknowledge the frequent occurrence of preventable morbidity and the reality that our healthcare system was not adequately addressing the issue of patient safety. One estimate for annual error-induced mortality is greater than 250,000, making medical errors the third-leading cause of death in the United States. Healthcare errors do not usually occur because of ill-trained medical personnel but rather are due to imperfect systems that trap both the patient and the healthcare provider. Regardless of the exact number, we now know that tens of thousands of patients die each year because of medical errors. Unfortunately, the labor and delivery suite is not immune to this phenomenon.
In the past several decades, numerous changes to medical care have been advocated with the goal of improving patient safety, including mandating minimum nurse-to-patient ratios, reducing working hours of resident physicians, use of care bundles, and advancing the science of simulation training and teamwork. As Pratt eloquently stated, “Historically, medicine was simple, largely ineffective, and mostly safe (excluding perhaps trephination and bloodletting). Modern medicine is complex, highly effective, but dangerous.” The field of patient safety attempts to reduce that danger.
Sadly, maternal mortality in the United States has risen over the last several decades, despite improvements in patient safety and healthcare—many of the deaths are judged preventable. This is particularly troubling since this increase has occurred during a period (with the exception of COVID-19-related deaths) when global maternal death rates fell, thus making the United States an outlier for maternal mortality rates in the developed world. Improved communication and collaboration among all stakeholders involved in perinatal health has been proposed as necessary to reverse this trend. Although there have been significant developments to improve the safety of hospitalized patients, including scientific and policy approaches, human error continues to be a cause of morbidity and mortality. The numbers are staggering. A 2023 cross-sectional analysis of US-based observational data found that an estimated 795,000 Americans become permanently disabled or die annually across healthcare settings.
Obstetric anesthesia practice has continued to evolve, but a study evaluating the epidemiology of anesthesia-related complications in obstetric units in a single state reported that the incidence of anesthesia-related complications during labor and delivery “remains a cause of concern, particularly in women undergoing cesarean delivery, living in rural areas, or having preexisting medical conditions.”
A 2023 report evaluating healthcare in the UK National Health Service considered what needed to be done to “close the gap between ambitious patient safety objectives and the reality of frontline practice.” The report outlined themes that lead to avoidable errors. These include failure to make the right diagnosis, delay in providing appropriate treatment, inadequate handoffs, and failure to listen to the concerns of the patients or their families. Of note, the report found that a failure to be honest when errors occur, poor-quality investigations, and inadequate learning responses all compounded the original errors. Although these statements were made generally about medical care in the National Health Service, they likely are pertinent to the practice of obstetrics and obstetric anesthesia globally.
In the recent past, strategies to reduce errors in obstetric care often focused on teamwork and team training, and that strategy continues to be a key to improving safety. Improving interprofessional communication skills has been shown to reduce preventable adverse events. However, consensus care bundles, such as the ones for prevention of venous thromboembolism, obstetric hemorrhage, and hypertension are also vital for consistently preventing harm and improving parturient safety. Another imperative is to address racial disparities with a focus on patient safety (see Chapter 14 ). The Committee on Obstetric Anesthesia of the American Society of Anesthesiologists (ASA) has noted that significant disparities in maternal health exist in the peripartum period, most notably in maternal mortality, severe maternal morbidity, and in the use of neuraxial labor analgesia and general anesthesia for cesarean delivery.
Adverse outcomes in the obstetric patient often involve issues related to lack of standardization, especially as relates to fetal heart rate (FHR) tracing interpretation, massive transfusion protocols, proper and early identification of patients at high-risk for adverse outcomes (especially for hemorrhage or failed tracheal intubation), and suboptimal communication among caregivers. Although the advent of new techniques and equipment has decreased the risk of failed intubation in the obstetric patient, lifesaving airway devices are not always used or even immediately available in all obstetric units and difficult intubation remains a concern. A large multicenter observational cohort study of more than 14,000 women receiving general anesthesia for cesarean delivery, using data from 2004 to 2019, reported that the risk of difficult intubation remains a very real and ongoing problem (1 in 49). A 2017 UK review reported that anesthesiologists are not always prepared for a difficult airway and that videolaryngoscopy was less available in obstetric operating rooms than in other operating room suites. A report from Japan confirmed that general anesthesia compared with neuraxial anesthesia for scheduled cesarean delivery is associated with greater odds for severe maternal morbidity, despite the availability of advanced airway equipment. In addition, the increasing prevalence of chronic medical conditions in obstetric patients, such as heart disease, hypertension, morbid obesity, and diabetes, may be an important contributor to the high maternal morbidity and mortality rates in the United States.
A 2022 ASA statement noted that anesthesiologists play a vital role in reducing maternal mortality and severe maternal morbidity. The statement recommended ways in which anesthesiologists can contribute to these efforts at the local, regional, and national levels. Recommendations included: (1) a physician anesthesiologist should be an active member of each state’s maternal mortality review committee, (2) antenatal anesthesiology consultations should be sought on high-risk patients, (3) physician anesthesiologists should be leaders in the implementation of the American College of Obstetricians and Gynecologists (ACOG) levels of maternal care, and (4) regular institutional multidisciplinary simulation for maternal emergencies should include teaching or planning by a physician anesthesiologist and should include all team members who work on the obstetric unit, including the anesthesia providers.
Because of the high intensity and rapid changes that are common on the obstetric unit, a collaborative and respectful work environment is essential, but too often is not clearly present. A group of individuals working in the same environment who are not communicating with one another does not constitute a team. This is especially true during crises such as maternal hemorrhage. A team is a group of individuals who achieve a mutual goal through interdependent and adaptive actions. Characteristics of effective teams are listed in Table 11.1 .
Table 11.1
Characteristics of Effective Teams
Modified from Salas E, Sims DE, Klein C. Cooperation and teamwork at work. In: Spielberger CD, ed. Encyclopedia of Applied Physiology . Academic Press; 2004:499–505.
| Knowledge/Skills/Attitudes | Characteristics of the Team |
|---|---|
| Leadership |
|
| Backup behavior |
|
| Mutual performance monitoring | Members understand each other’s roles. |
| Communication adaptability | Members communicate often and anticipate each other. |
| Mutual trust | Members trust each other and each other’s intentions. Members’ values are aligned. |
In addition, departmental silos can limit the ability to learn from our experiences. The reporting, trending, and sharing of suboptimal outcomes and near misses among all team members through a variety of approaches, including multidisciplinary rounds, are necessary to achieve a culture of safety. Joint efforts for review of suboptimal outcomes and near misses, including medical record reviews and joint meetings or morbidity and mortality presentations, should include the attendance and participation of anesthesia providers, obstetricians, neonatologists, midwives, and labor nurses. Discussions with patients and their families are also a part of optimal communication, shared decision-making, and necessary transparency (see Chapter 32 ).
Although there have been hundreds, if not thousands, of individual improvements that have contributed to safe anesthesia practices on the obstetric unit over the past half century, the ongoing occurrence of preventable harm suggests there is still much room for improvement.
PATIENT SAFETY AND MEDICAL ERRORS—BASICS AND DEFINITIONS
Medical error has been defined as a “failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.” Communication problems are consistently identified as a leading cause of medical errors in obstetrics, and perceptions are often misaligned. The Joint Commission has reported that lack of effective communication, along with leadership and human factors, are often the primary causes of sentinel events (defined as a patient safety event that results in death, permanent harm, or severe temporary harm).
Traditional assessments of medical error often blamed individuals and failed to address the broader issues that allowed the error to occur. New approaches are based on an understanding that humans, no matter how well trained and well meaning, will make errors and therefore the new approaches encourage creation of robust systems to minimize the likelihood of errors and their impact on patients when they occur. As James Reason said, “we can’t change the human condition, but we can change the conditions under which humans work.” This paradigm change has borrowed heavily from other high-risk areas such as the aviation and nuclear power industries.
In its simplest form, patient safety is freedom from accidental injury while receiving healthcare services. It includes the six dimensions of quality in healthcare, namely, safe, timely, effective, efficient, equitable, and patient centered. However, the US Healthcare Research and Quality has expanded the definition of patient safety as follows: “Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.” This definition acknowledges that patient safety is an emerging discipline of building systems that produce highly reliable results with as few errors as possible. The discipline involves the quality of the delivered care as well as patient safety (see later).
There is currently widespread interest in changing our healthcare culture to build safer systems, including ensuring an appropriate physical work environment, developing redundancies in safety procedures, and the use of safety care bundles, especially as it relates to hemorrhage. In addition, it is essential to allow healthcare workers to report their mistakes, even those that do not cause harm to a patient, without fear of punishment, and to provide mechanisms for learning from errors. None of these steps will ultimately achieve the goal of a safe environment without the broad support of physicians, other healthcare workers, hospital administrators, and other key stakeholders. The ACOG Committee on Patient Safety has highlighted objectives for the safe care of obstetric and gynecology patients ( Box 11.1 ).
Box 11.1
American College of Obstetricians and Gynecologists’ Objectives for Patient Safety
Summarized from American College of Obstetricians and Gynecologists’ Committee on Patient Safety and Quality Improvement. Committee Opinion Number 447: Patient safety in obstetrics and gynecology (reaffirmed 2019). Obstet Gynecol . 2009;114:1424–1427.
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Develop a commitment to encourage a culture of patient safety
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Implement recommended safe medication practices
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Reduce the likelihood of surgical errors
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Improve communication with healthcare providers
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Improve communication with patients
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Establish a partnership with patients to improve safety
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Make safety a priority in every aspect of practice
THE SWISS CHEESE MODEL
Patients are typically not injured by a single event resulting from the single act of a careless individual. More often, an underlying systems problem made the error possible, and numerous individual actions “fell through the cracks” of a system that allowed these actions to happen, ultimately resulting in harm to the patient. James Reason described the “Swiss cheese model” of error ( Fig. 11.1 ), in which he explained how numerous contributing factors are responsible for the ultimate harm. Reason developed this model to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple smaller failures that led up to the actual adverse event. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular hazard.
James Swiss Cheese Model of Organizational Accidents.
From Reason JT. Human Error . Cambridge University Press; 1990.
Fig. 11.2 illustrates the use of the Swiss cheese model to evaluate a near-miss event that occurred in a patient who almost underwent an unwanted surgical procedure. The events unfolded as follows:
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1.
A nulliparous woman in active labor at term arrived on the obstetric unit in severe pain. She did not speak English and was poorly understood by the unit’s staff. Despite a policy requiring the use of a translator, no translator was used because the husband, who had some fluency in English, was helping to translate.
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2.
Because the patient was in such severe pain, both she and the nurse rushed through the initial intake interview. Based on hospital policy, in perceived compliance with patient privacy regulations, the husband was asked to leave the room during this interview.
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3.
There was another parturient on the unit with the same last name and similar-sounding first name. This was not that unusual for this hospital and although a policy existed for such an event, it was not followed. The white board used for team rounding used only patient initials, which prevented some of the staff from realizing that there were two patients with the same last name.
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4.
Shortly after admission the patient developed a category 3 FHR tracing. She was remote from delivery and was transported to the operating room for emergency cesarean delivery. The obstetric trainee who had just come on duty (and was not informed of the patient’s name similarity at change-of-shift report) informed the labor nurse and anesthesiology trainee of the need for an emergency cesarean delivery. Mistaking the two patients, the procedure was booked for cesarean delivery plus bilateral tubal ligation. Unlike the other laboring patient with the same last name, this patient was nulliparous and did not wish to have a tubal ligation.
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The procedure was temporarily delayed because of nursing shift change and the attending obstetrician urged the nurses to hurry. The obstetrician was known to have a “hot temper” and this exchange caused friction and breakdown of communication and teamwork.
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The patient arrived in the operating room and was extremely anxious and crying. Her husband was outside getting dressed for the operating room and no one in the room was able to communicate with her.
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Because of the patient’s severe anxiety and high risk for a panic attack, the anesthesiologist opted to administer intravenous fentanyl 50 µg prior to initiation of spinal anesthesia. The calming effect was greater than expected and the patient became very sedated.
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8.
A time-out was performed but was not performed correctly by the team as there were at least two additional conversations occurring at the same time as the time-out and the attending obstetrician was not present. The patient was similarly not involved with the time-out and would not have been able to participate even if not sedated due to the language barrier.
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9.
The attending obstetrician arrived prior to incision and on reviewing the medical record asked why a tubal ligation was planned for a nulliparous patient.
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10.
Immediate investigation revealed that the patient was misidentified and a major error was narrowly averted.
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11.
Because no harm befell the patient (near-miss event), there was no follow-up and no systems were put in place to prevent a similar occurrence in the future. Thus, there was failure to learn from the event. Multiple different actions could have identified the near-miss event earlier.
“Swiss cheese” diagram of near-miss events illustrating how numerous layers/barriers to harm were breached and how these events almost resulted in permanent harm (permanent sterility) to the patient.
QUALITY ASSURANCE AND QUALITY IMPROVEMENT ON THE OBSTETRIC UNIT
Safety, and methods to improve safety, particularly by improving communication and developing a shared mental model, are critical to the care of the obstetric patient. However, quality of care, meaning not just avoiding error but achieving a set of desired health outcomes, is also essential. It is often stated that “if you can’t measure it, you can’t improve it.” This premise is the foundation for building a system that supports both quality and patient safety.
While quality assurance (QA) is defined as the maintenance of a desired level of quality and a way to ensure that agreed-upon standards are met, quality improvement (QI) is the continuous process of creating systems to make things better. Both QA and QI are essential to building a robust quality program—putting the right processes in place and making sure they are executed reliably are both important drivers of achieving the best possible outcomes.
Designing appropriate quality and safety activities is an important step towards achieving the goal of a safe obstetric unit and requires the identification of an area of unmet need. These areas of need may differ among hospitals. However, regardless of site, the area of need should ideally map to one of the six desirable outcomes of care systems—safe, timely, effective, efficient, equitable, and patient-centered care ( Table 11.2 ). Many opportunities exist for QI activities in every obstetric unit, no matter the type of hospital or unit. The key is to design the project so that there is agreement and acceptance from all stakeholders. One important method is soliciting feedback from key stakeholders, including patients, nurses, anesthesia providers, and obstetricians. QI projects are built on metrics, and these broadly fall into three categories— structural metrics , process measures , and outcome measures .
Table 11.2
Optimal Outcomes of Care Systems
Adapted from Fleisher LA. Quality anesthesia: medicine measures, patients decide. Anesthesiology . 2018;129:1063–1069.
| Domain | Description |
|---|---|
| Safe | Avoiding harm from care meant to help patients |
| Effective | Providing care based on scientific data and consensus statements |
| Patient centered | Providing care that is respectful of and responsive to the individual patient |
| Timely |
|
| Efficient | Avoiding waste |
| Equitable | Providing care that does not vary in quality because of personal characteristics |
In addition to consideration of the business case for the project (i.e., how much money will the project cost versus what benefits will be gained), an optimal place to begin is to consider three key questions.
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What do you (and your colleagues) want to improve? What need on the obstetric unit is strategically aligned with all stakeholders that is not currently being met?
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How can the identified issue be improved? This is not a simple question because one needs to consider not only the metrics but also the scope, finances, and scale of the proposed project. Few projects can be completed in isolation of other processes on the unit. If other participants are necessary, how will they be identified and remunerated? Goals that are specific, measurable, assignable, realistic, and time related will improve success.
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3.
How will you know if a project was successful? This involves clearly identifying the deliverables of the project and setting up objective criteria for the success of each deliverable. To determine whether these criteria ultimately are met, relevant data must be collected, interpreted, and reported to key participants in the project within an agreed-upon time frame.
There are many possible indicators that can be used to evaluate the quality of both the obstetric and anesthetic care on the obstetric unit. These are often a key to identifying various factors that may be responsible for variability in the level of care that is provided. Some of these indicators can best be measured by an outside entity; this removes concerns with bias and reticence on the part of the unit’s healthcare providers to participate in incident reporting. One example is the ASA Anesthesia Quality Institute, which has been a source of rich information for QI in the clinical practice of anesthesiology.
The Society for Obstetric Anesthesia and Perinatology (SOAP) in the United States, the Obstetric Anesthetists’ Association (OAA) in the United Kingdom, and similar professional societies in other countries issue position statements, consensus statements, and advisories that are helpful when reviewing the quality of delivered anesthesia care on a unit. The SOAP Center of Excellence (COE) designation recognizes excellent anesthesia care in individual obstetric units and sets a benchmark level of expected care with the goal of improving standards nationally. In the United Kingdom, the OAA undertook a collaborative Delphi project to identify key indicators to drive QI in obstetric anesthesia. They include (1) the percentage of unintentional dural punctures, (2) antenatal referral for anesthesia consultation in high-risk parturients, and (3) the percentage of neuraxial analgesia procedures that failed to provide adequate pain relief within 45 minutes of initiation. A follow-up survey of UK obstetric units found that most of the key indicator data are not routinely collected.
The following are some examples of quality initiatives that can be undertaken to improve culture and safety in the obstetric suite using implementation science. Implementation science , at its core, aims to accelerate the adoption and integration of evidence-based practices into healthcare. Implementation of these initiatives is an opportunity to put into practice the evidence-based approaches published in the scientific literature. It reduces the variability that comes from the “I do it that way because I’ve always done it that way—regardless of the literature” attitude of many clinicians. Lane-Fall et al. describe the goal of implementation science as making routine “the use of evidence-based practice, narrowing the gap between evidence and real-world practice.”
Maternal Early Warning System
The Maternal Early Warning System is a list of abnormal parameters of blood pressure, respiratory rate, oxygen saturation, urine output, and mental status that indicate the need for urgent bedside evaluation. Shields et al. implemented a Maternal Early Warning Trigger Tool in pilot hospitals based on this framework and found that it was particularly well suited for detecting evolving sepsis and hypertensive disorders, had a good predictive value for patients who were ultimately admitted to the intensive care unit, and resulted in a significant improvement in maternal morbidity.
Opioid Prescribing After Cesarean Delivery
The opioid epidemic in the United States is a nationwide public health crisis. Although opioid prescribing rates have declined in recent years, the increased availability and use of these highly addictive pain medications played an important role in the modern-day epidemic; this also includes the use of opioids in the postpartum patient (see Chapter 52 ). A population-based study using US data from 2003 to 2011 found that approximately 1 in 300 opioid-naive women become persistent opioid users following cesarean delivery. A 2017 follow-up study showed that the amount of opioid prescribed after cesarean delivery exceeded the amount actually used by a significant margin. Subsequently, an implementation study demonstrated that a shared decision-making approach to opioid prescribing after cesarean delivery was associated with a 50% decrease in the amount of opioids prescribed postoperatively.
Enhanced Recovery After Cesarean
Standardization is a way to reduce implicit bias in patient care, which has been identified as a contributor to disparities in maternal outcomes. An example of standardization includes enhanced recovery after cesarean (ERAC) protocols. The ERAC framework includes preoperative, intraoperative, and postoperative pathways (see Chapter 27 ). The intraoperative pathway recommendations focus on prevention of hypotension, maintenance of normothermia, optimal uterotonic administration, antibiotic prophylaxis, nausea/vomiting prophylaxis, multimodal analgesia, breastfeeding, fluid optimization, and delayed umbilical cord clamping.
Telemedicine
Implementing guidelines for improving maternal and fetal outcomes by leveraging telemedicine is an important opportunity. Potential benefits of telemedicine in obstetric anesthesia include cost savings, optimization of transfer decisions, improvement of resource allocation, better access, health provider education, greater patient satisfaction, increased range of care, and support of community-based care.
Maternal Mental Health
Obstetric anesthesia care may influence maternal mental health. Anesthetic complications have been associated with postpartum posttraumatic stress disorder. These complications include a negative delivery experience and pain during labor. Plaat et al. note that “a woman who experiences pain during caesarean section under neuraxial anesthesia is at risk of adverse psychological sequelae.” Close attention to the diagnosis and management of pain during cesarean delivery is an important component of quality of obstetric anesthesia care.
Clinical Care Team Well-Being
Shanafelt et al. have shown that healthcare provider burnout is associated with self-reported suboptimal patient care practices, including making medication errors, not discussing treatment options, and paying little attention to the personal impact of an illness on a patient. In 2009, Wallace et al. proposed that physician wellness be used as a quality indicator, given its impact on both physician and patient outcomes. There are many drivers of clinical care team well-being, and these drivers are important to address as part of a clinical quality and patient safety program. Training in high-performance teamwork is associated with significant improvement in supportive behavior among colleagues.
CENTERS OF EXCELLENCE
The SOAP has developed a set of key recommendations for obtaining COE designation, with the aim of recognizing institutions and programs that demonstrate excellence in obstetric anesthesia care, setting a benchmark level of expected care to improve standards nationally, and providing a broad surrogate quality metric of institutions providing obstetric anesthesia care. By defining a standard, the COE designation provides institutions with key performance indicators that can be measured and tracked over time. The COE recommendations, which include implementing the ASA and SOAP guidelines for obstetric care, are listed in Box 11.2 .
Box 11.2
Society for Obstetric Anesthesia and Perinatology (SOAP) Centers of Excellence Recommendations
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1.
Personnel and Staffing
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Obstetric anesthesiologist leadership, specifically a board-certified physician anesthesiologist who has completed an Accreditation Council for Graduate Medical Education–accredited obstetric anesthesia fellowship and/or has equivalent expertise in obstetric anesthesia
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In-house (24/7) coverage of obstetric patients, by at least one board-certified (or equivalent) physician anesthesiologist who is dedicated to covering the obstetric service without additional responsibilities for nonobstetric patients
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Ability to mobilize (within a reasonable [30–60 min] time frame) additional anesthesia personnel in case of obstetric emergencies or high clinical volume beyond the capacity of in-house staff assigned to the obstetric service
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•
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2.
Equipment, protocols, and policies
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Availability of a massive transfusion protocol with O-negative blood and other blood products, and an emergency release system for available blood. Blood bank protocol needs to have been tested and be functional on the obstetric unit. Rapid-infuser device to assist with massive resuscitation readily available for use on the obstetric unit
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•
Difficult airway cart (with laryngoscopes, endotracheal tubes, rescue airway devices [e.g., supraglottic airway device], videolaryngoscope, surgical airway equipment) immediately available on the obstetric unit. Suction and a means to deliver positive pressure ventilation immediately available in readily accessible locations where neuraxial analgesia/anesthesia and/or general anesthesia are administered. Lipid emulsion, appropriate supplies, and protocols that will allow a timely response to local anesthetic systemic toxicity
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Multidisciplinary team–based approach with systems in place to ensure interprofessional communication and situational awareness on the obstetric unit. Daily multidisciplinary rounds or huddles to discuss management plans for women on the labor and delivery, antepartum, and postpartum units
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Obstetric emergency response team with a policy that includes obstetric conditions and/or vital sign parameters that warrant activation, and means of notifying all members of the response team
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An active multidisciplinary program with obstetric and anesthesia emergency simulation drills
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Additional operating room (with nursing/technical/obstetric and anesthesia personnel) available at all times for emergency obstetric procedures (i.e., if all obstetric unit operating rooms are occupied)
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•
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Cesarean delivery management
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A standardized clinical care pathway (e.g., enhanced recovery protocol) utilized by the institution and all obstetric anesthesia providers
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Routine utilization of a pencil-point needle, 25 gauge or smaller for the provision of spinal anesthesia
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Multimodal analgesia protocols and institutional efforts to minimize opioid use
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Strategies to prevent maternal and fetal intraoperative hypothermia
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Appropriate antibiotic prophylaxis to prevent surgical site infection
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Spinal anesthesia-induced hypotension, nausea, and vomiting prophylaxis and treatment
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•
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4.
Labor analgesia
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Use of low-concentration local anesthetic solutions with neuraxial opioids for neuraxial labor analgesia
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Combined spinal-epidural techniques available/offered in addition to standard labor epidural analgesia. Patient-controlled epidural analgesia and, ideally, programmed intermittent epidural boluses utilized for the provision of neuraxial labor analgesia
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Routine utilization of flexible (flex-tipped/wire-reinforced) epidural catheters for labor epidural analgesia
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Regular assessment of neuraxial labor analgesia effectiveness
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5.
Recommendations and guidelines implementation
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At a minimum, evidence of implementation of the Practice Guidelines for Obstetric Anesthesia by the ASA Task Force on Obstetric Anesthesia and Society of Obstetric Anesthesia and Perinatology
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•
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Quality assurance and patient follow-up
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7.
ASA , American Society of Anesthesiologists.
Similar to the SOAP Centers of Excellence, reviews of quality have been embraced by other specialties. The ACOG has developed a voluntary review of quality of care program that offers a confidential and unbiased site visit that includes obstetricians, perinatologists, labor nurses, midwives, and when requested or deemed necessary, anesthesiologists. The program has been assisting departments for more than 30 years. The 4-day visit includes medical record reviews and interviews with key stakeholders. Clinical issues include lack of adherence to guidelines and poor management decisions. Systems issues include evaluation of leadership, nursing staffing, and quality assessment process. In addition, obstetric as well as anesthesia policies and procedures are reviewed.
According to the ACOG, potential benefits of the program include the following:
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Identifying issues underlying adverse events
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Improving teamwork and trust
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Enhancing the hospital’s position for value-based payments
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Reducing the risk of malpractice claims
A review of their program has been published ; some of the anesthesia-related quality measures (when the group was accompanied by an anesthesiologist) included the following:
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Preanesthetic airway examination is performed and documented.
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Blood pressure is documented after administration of epidural analgesia, and corrected if hypotension occurs.
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Unintentional dural puncture is clearly documented when it occurs.
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Wait times for providing epidural analgesia are noted, and if long, alternative analgesia is offered.
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Appropriate low-concentration local anesthetic solutions are used for epidural labor analgesia to minimize motor block.
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A difficult airway cart is immediately available.
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Procedure documentation is adequate.
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Preoperative and postoperative notes are completed.
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Appropriate medications are administered.
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Estimated blood loss or quantitative blood loss is documented during hemorrhage.
These quality measures can be easily assessed by individuals in their own departments as part of a QI project.
An assessment of quality and safety indicators in anesthesia was summarized in a systematic review. The authors identified 108 anesthetic clinical indicators; almost half were related to surgical or postoperative care. Most were process or outcome measures. They identified descriptive, prescriptive, and proscriptive indicators . Descriptive indicators were those that provided descriptive information. Prescriptive indicators were defined as those representing recommended or desired targets (e.g., preoperative antibiotic administration), and proscriptive indicators were defined as measures or actions that should not be performed (e.g., wrong medication).
LEVELS OF MATERNAL CARE
The ACOG and the Society for Maternal-Fetal Medicine proposed a system of regionalized levels of maternal care in 2015. The aim is to reduce maternal morbidity and mortality by establishing a structured system across geographic regions whereby risk-appropriate maternal care is provided by regional institutions with defined availability of personnel and resources. Collaborative relationships between hospitals with differing levels of care allow women to give birth safely in their communities but facilitate transfer of care to a higher level of care when appropriate. The levels of care range from an accredited birthing center and Level I (basic care) to Level IV (regional perinatal healthcare centers). The capability of each level includes the availability of specialized healthcare providers (obstetric providers, nursing services, and anesthesia providers ( Table 11.3 ), as well as the ability to perform special services, including advanced imaging and intensive care. All facilities need to have the capability to triage, stabilize, and provide initial care while arranging transfer to a higher level of care, if necessary.
Table 11.3
Anesthesia Resources for Levels of Maternal Care
Summarized from American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric Care Consensus Number 9: Levels of maternal care (reaffirmed 2021). Obstet Gynecol . 2019;134:e41–e55.
| Level | Definition | Anesthesia Providers |
|---|---|---|
| Accredited birth center | Care of low-risk women with uncomplicated pregnancy and anticipated uncomplicated birth | |
| Level I (basic care) | Care of low- to moderate-risk pregnancies | Anesthesia provider available for labor analgesia and surgical anesthesia at all times |
| Level II (specialty care) | Level I care plus care of appropriate moderate- to high-risk antepartum, intrapartum, and postpartum conditions | Anesthesiologist readily available at all times |
| Level III (subspecialty care) | Level II plus care of more complex maternal conditions, obstetric complications, and fetal conditions |
|
| Level IV (regional perinatal health care centers) | Level III plus on-site medical and surgical care of the most complex conditions for critically ill pregnant women and fetuses throughout antepartum, intrapartum, and postpartum care | Board-certified anesthesiologist with obstetric anesthesiology fellowship training or experience in obstetric anesthesia physically present at all times |
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