Safety, efficacy, and complexities in ART practice: physician commentary

There are few patient care processes for which a team approach is more important than for assisted reproduction. Close, continuous communication is required at many levels among physicians, nursing staff, therapists, the various laboratories, and patients. Quality of care is associated with the reduction of medical errors through processes of risk management, mechanisms to allow the safe evolution of assisted reproductive technology care within the clinic, and how clinics ethically communicate with team members and with patients through informed consent and direct and honest interaction.     

Teamwork in obstetric critical care

Whether seeing a patient in the ambulatory clinic environment, performing a delivery or managing a critically ill patient, obstetric care is a team activity. Failures in teamwork and communication are among the leading causes of adverse obstetric events, accounting for over 70% of sentinel events according to the Joint Commission. Effective, efficient and safe care requires good teamwork. Although nurses, doctors and healthcare staff who work in critical care environments are extremely well trained and competent medically, they have not traditionally been trained in how to work well as part of a team. Given the complexity and acuity of critical care medicine, which often relies on more than one medical team, teamwork skills are essential. This chapter discusses the history and importance of teamwork in high-reliability fields, reviews key concepts and skills in teamwork, and discusses approaches to training and working in teams.     

Collaborative Practice: Characteristics,Barriers, Benefits,and Implications for Midwifery

Most professional organizations agree that the collaborative model of care improves health care outcomes, is cost-effective, and increases patient satisfaction. This article discusses how collaboration is defined by various organizations and how midwifery has set its standard for collaborative practice.     

COLLABORATIVE PRACTICE: Characteristics,Barriers, Benefits,and Implications for Midwifery

Most professional organizations agree that the collaborative model of care improves health care outcomes, is cost-effective, and increases patient satisfaction. This article discusses how collaboration is defined by various organizations and how midwifery has set its standard for collaborative practice.     

Ethical and end of life considerations for neonates requiring ECMO support

ECMO has proven to be a life-saving intervention for a variety of disease entities with a high rate of survival in the neonatal population. However, ECMO requires clinical teams to engage in many ethical considerations. Even with ongoing improvements in technology and expertise, some patients will not survive a course of ECMO. An unsuccessful course of ECMO can be difficult to accept and cause a great deal of angst. These questions can result in real conflict both within the care team, and between the care team and the family. Herein we explore a range of ethical considerations that may be encountered when caring for a patient on ECMO, with a particular focus on those courses where it appears likely that the patient will not survive. We then consider how a palliative care approach may provide a tool set to help engage the team and family in confronting the difficult decision to discontinue ECMO.     

Postpartum Early Discharge: An Inner City Experience

Nurse-midwives collaborated with obstetricians, pediatricians, nurses and hospital administrators of a large tertiary care center to develop and establish a program for the discharge of low-risk mothers and babies, 12 hours postpartum. The idea was to establish a family-centered alternative to home delivery. Home visits were made each day for 2–3 days by a nurse-midwife/OB visiting nurse team. The baby is seen in a clinic 7–10 days later. At the end of the first year the program safety, acceptability, and cost containment factors were evaluated prior to expansion of the program. The results indicated that early discharge is providing great satisfaction for clients, reduces the cost of perinatal care while improving the quality of care for low-risk families and improves the utilization of available hospital beds.     

North Queensland midwives' experience with a team model of midwifery care

This qualitative study investigated midwives' perception of a team midwifery model of care implemented in North Queensland, Australia. A midwifery model of care is the use of primary health care principles to deliver care throughout the woman's entire pregnancy and postpartum period in partnership with other members of the health care team. Four focus groups were undertaken with 22 midwives to determine their perception of the team midwifery model of care. The study found the experience of the team midwifery model of care for midwives had been influenced by organisational characteristics, team structures, and accountability. Recommendations from this study include the need for an appropriate environmental scan and implementation of planning process and team building before the introduction of any new model of care, transportability of health care services to any new model of care, and a shared governance to allow midwives to meet both organisational and professional goals.     

Planning a developmentally appropriate neonatal intensive care unit

Neonatal intensive care units (NICUs) are now being redesigned in the wake of growing evidence that the physical environment of the NICU has a profound impact on all who live and work there.These new units reflect the universal trend of bringing families directly into the center of the medical care team. More than ever,such projects are bound to change how staff care for babies, how families interact with babies, how staff and families interact with one another, and how staff interact among themselves. When a NICU decides that a more developmentally appropriate environment should be initiated, the question of funding and obtaining other resources inevitably arises. This chapter identifies the essential components that should be included when planning to seek investments in NICU facilities.     

Trends in prenatal diagnosis of critical cardiac defects in an integrated obstetric and pediatric cardiac imaging center.

OBJECTIVE: Prenatal diagnosis of critical (requiring neonatal intervention) cardiac defects (critical congenital heart diseases (CCHD)) improves survival, yet detection of such malformations is poor. Our institution changed its practice and integrated a pediatric cardiologist into the perinatal team. The purpose of this study was to evaluate how this change affected the rate of detected congenital heart disease (CHD) and the diagnostic accuracy. STUDY DESIGN: Obstetrical ultrasounds of mothers at high and normal risk for fetal CCHD at a single center between 1991 and 2001 were reviewed. Rate of detected CCHD, positive predictive values and false positives were compared before and after pediatric cardiology integration. RESULTS: Between the first and second time periods, the rate of detected CCHD increased from 6.8/1000 ultrasounds to 12.9/1000 ultrasounds (p=0.007), and positive predictive value increased from 75 to 96%. CONCLUSION: Collaboration with pediatric cardiology can significantly improve the rate of detected CCHD. These findings have significant implications for sonographer education and patient care.     

Recognizing psychosis

Women with severe mental illness inevitably will be part of the practice of ob/gyns. It is important therefore to learn to recognize psychosis and to know how this chronic illness and its treatments affect gynecologic care and obstetrics. The ob/gyn will often need to coordinate treatment with the psychiatrist as a team. It is important to appreciate how treatable mental illness can be, and it is gratifying to work with this special population.     

Teamwork and quality during neonatal care in the delivery room.

OBJECTIVE: Experts believe good teamwork among health care providers may improve quality. We sought to measure the frequency of team behaviors during delivery room care and to explore how these behaviors relate to the quality of care. STUDY DESIGN: We video recorded neonatal resuscitation teams then used independent observers to measure teamwork behaviors and compliance with Neonatal Resuscitation Program (NRP) guidelines (a measure of quality of care). RESULTS: Observer agreement was either fair or good for all teamwork behaviors except workload management, vigilance, and leadership, for which agreement was slight. All teams (n=132) exhibited the behaviors information sharing and inquiry, and all but one team exhibited vigilance and workload management. Other behaviors were present less often: assertion in 19.9% of teams, teaching 16.7%, leadership 19.7%, evaluation of plans 12.9%, and intentions stated 9.1%. Factor analysis identified three fundamental components of teamwork: communication (comprised of information sharing and inquiry); management (workload management and vigilance); and leadership (assertion, intentions shared, evaluation of plans, and leadership). All three components were weakly but significantly correlated with independent assessments of NRP compliance and an overall rating of the quality of care. CONCLUSION: Most team behaviors can be reliably observed during delivery room care by neonatal resuscitation teams, and some are infrequently used. We found weak but significant and consistent correlations among these behaviors with independent assessments of NRP compliance and an overall rating of the quality of care. These findings support additional efforts to study team training for delivery room care and other areas of healthcare.     

A dedicated ectopic pregnancy team leads to an improvement in patients’ management

Introduction The aim of the study is to determine whether a dedicated ectopic pregnancy team improves the management of haemodynamically stable patients with suspected ectopic pregnancy who do not require immediate life-saving surgery. Methods A non-randomized population based study involving 210 patients admitted with a suspected ectopic pregnancy over a 2-year period in a university teaching hospital in the UK, was carried out to compare the management of those women before and after the introduction of the ectopic pregnancy team. Results Following the introduction of an ectopic pregnancy team, there were fewer laparotomies performed, fewer negative diagnostic laparoscopies, a reduced overall surgical intervention rate, and a reduced duration of hospital stay. Although, it was difficult to quantify the extent of improvement of training, yet there were fewer operations performed out-of-hours, more continuity of care, more learning opportunities and acquisition of laparoscopic skills of junior staff. Conclusions The introduction of an ectopic pregnancy team led to an improvement in the management of patients with suspected ectopic pregnancies. Efforts aiming at setting up such a specialized team and its implementation in day-to-day clinical practice should be considered in hospitals where the mainstay of treatment remains laparotomy. Oral presentation at the British Fertility Society Annual Meeting (2003), Aberdeen, UK. The study describes for the first time the significant improvement in management of patients with suspected ectopic pregnancies with the introduction of an ectopic pregnancy team.     

Team midwife care: maternal and infant outcomes

The aim of this study was to add additional information on intervention rates and maternal and infant outcomes of team midwife care to previous reports which have suggested this model of care can be associated with a reduction in medical interventions during labour and birth with no statistically significant influence on maternal and infant outcomes. The study was designed as a randomised controlled trial, with 495 women randomised to team midwife care being compared to 505 women randomsed to standard care. The study revealed no statistical differences between team midwife care and standard care in medical interventions, maternal health and infant health. These findings suggest that team midwifery as it is practised in this study is a safe alternative for women.     

The treatment experiences of Australian women with gynaecological cancers and how they can be improved: a qualitative study

Gynaecological cancers are the fourth most common form of cancer and the fifth most common cause of cancer mortality for women in Australia. Definitive treatment is available in tertiary hospitals in major capital cities. This study aimed to understand how care is received by women in order to improve both their experience and outcomes. We interviewed 25 women treated for ovarian, cervical and uterine cancers in public or private hospitals in four states, including urban, rural and Indigenous women. Referral pathways were efficient and effective; the women were diagnosed and referred for definitive management through well-established systems. They appreciated the quality of treatment and the care they received during the inpatient and acute phases of their care. Three main problems were identified – serious post-operative morbidity that caused additional pain and suffering, lack of coordination between the surgical team and general practitioners, and poor pain management. The lack of continuity between the acute and primary care settings and inadequate management of pain are acknowledged problems in health care. The extent of post-operative morbidity was not anticipated. Establishing links between the surgical team and primary care in the immediate post-operative period is crucial for the improvement of care for women with gynaecological cancer in Australia.     

Projets de naissance en soins palliatifs : un domaine de la périnatalité à construire

Some couples may choose to continue the pregnancy unable to decide for termination of pregnancy. Such situations recently occurred in neonatology units and may lead to neonatal palliative care. Faced with all uncertainties inherent to medicine and the future of the baby, medical teams must inform parents of different possible outcome step by step. Consistency in the reflection and intentionality of the care is essential among all different stakeholders within the same health team to facilitate support of parents up to a possible fatal outcome. This issue in perinatal medicine seems to be to explore how caregivers can contribute in the construction of parenthood in a context of a palliative care birth plan.     

Women with pre-existing diabetes and their experiences of maternity care services

Aims and objectives

the aims of the study were to explore the experience of maternity care services used by women whose pregnancy is complicated by pre-existing diabetes, to gain a deeper understanding of service use and to identify aspects of services that women with pre-existing diabetes would like improved.

Background

for women with pre-existing diabetes; pregnancy, birth and the transition to motherhood can be complex and even chaotic. The aim of specialist diabetes care given during pregnancy and delivered by a specialist team of health-care professionals is to optimise pregnancy outcome. However, how health-care professionals within maternity services provide care and support women with pre-existing diabetes during pregnancy and early motherhood has received limited attention.

Design

an exploratory study utilising a grounded theory approach was conducted. Data were collected via in-depth interviews with 20 respondents; one-to-one, dyad and group interviews were undertaken to fully explore issues. Analysis was undertaken by sub-groups of the research team with at least two members working on each of them.

Findings

three themes were identified from interviews: empathic care with care more focused on diabetes not pregnancy; feeling judged by health-care professionals (with nearly all respondents reporting negative encounters of consultation with the specialist team); and the notion of expertise (with respondents reporting feeling frustrated when it seemed health-care professionals did not value their expertise).

Conclusions

the study emphasised the importance of the health-care relationship for pregnant women with pre-existing diabetes. For outcomes to be optimised women need to be able to form open and trusting relationships with the health-care team.

Relevance to clinical practice

this study highlights the need for the health-care team not only to provide physical care to optimise outcome but also supportive care to assist women with pregnancies complicated by diabetes to achieve the best possible physical and emotional health and well-being.     

注：王晓怡、孙雯为本文并列第一作者多学科团队参与对胎盘植入患者母婴结局的影响

目的 探讨多学科团队参与对胎盘植入患者母婴结局的影响。方法 选择2005年1月1日至2014年1月1日在广州医科大学附属第三医院分娩的临床资料完整的81例胎盘植入患者。根据多学科团队（多团队）参与的情况,分为全程（妊娠期及分娩期）多团队参与组,分娩期多团队参与组,和分娩期无多团队参与（仅有产科与新生儿科）组。回顾性分析三组胎盘植入患者的母儿结局。 结果 在植入性胎盘中全程多团队参与组和分娩期多团队参与组出血量[（1453.2±991.2）mL和(1536.4±1001.3）mL]、术中输血量[（592.1±301.2）mL和(632.4±279.8）mL]以及早期并发症的比例[26.5%（9/34）和31.8%（7/22）]均低于分娩期无多团队参与组[(1889.3±1403.4)mL、(721.4±298.1)mL和60.0%（15/25）]（P<0.05）。结论 多学科团队参与治疗植入性胎盘可改善产妇妊娠结局,但对新生儿结局则无影响。     

Risk management in obstetrics

Risk management is an integral part of clinical care in the UK in 2011. It is vital that all clinicians, managers and commissioners understand the underlying principles and how it works in practice. It is a useful tool in driving forward the quality of patient care combining as it does evidence based medicine (pro-active risk management) and response to incidence and complaints (re-active risk management).The risk management team will be responsible for ensuring that guidelines are up to date, national reports are responded to, training of all staff is in line with national recommendations and there is a good system for responding to, investigating and learning from all incidents, complaints and claims.This review will describe some of the principles of risk management, the current standards and assessments of the clinical negligence scheme for trusts (CNST) and includes two case reports to illustrate how risk management works in practice.     

The Team Approach to Adolescent Pregnancy

One form of the team approach is concerned with the interdependent functioning of members of various disciplines who work together, not just cooperatively, to improve patient care. This model is particularly applicable to the care of pregnant adolescents. The composition of the team varies with each situation, but there is always a core of workers who share an approach to the patient-based on knowledge of pregnancy, adolescent development, and group process. There are some basic requirements which include responsibility to the team and the ability to communicate clearly and to relate well to others. The advantages of a team committed to high-quality patient care outweigh the dort needed to work out difficulties in working together closely. The team approach is relatively new, and there are some steps that nurses can take to further its effectiveness.     

Risk management in obstetrics

Risk management is an integral part of clinical care in the UK. It is vital that all clinicians, mangers and commissioners understand the underlying principles and how it works in practice. It is a useful tool in driving forward the quality of patient care combining as it does evidence based medicine (pro-active risk management) and response to incidence and complaints (re-active risk management).The risk management team will be responsible for ensuring that guidelines are up to date, national reports are responded to, training of all staff is in line with national recommendations and there is a good system for responding to, investigating and learning from all incidents, complaints and claims.This review will describe some of the principles of risk management and the role of the National Health Service Litigation Authority (NHSLA). We have also outlined two case reports to illustrate how risk management works in practice.