ObLS INTEGRATING OB AND NRP TRAINING. J. Arafeh MSN, RN M. Druzin MD A. Puck MSN, RN

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1 ObLS INTEGRATING OB AND NRP TRAINING J. Arafeh MSN, RN M. Druzin MD A. Puck MSN, RN

2 Disclosures Julie Arafeh, Maurice Druzin and Andrea Puck do not have disclosures or conflict of interest to report

3 Question 1 Your area of practice: A: Obstetrics B: Neonatology C: Both

4 Question 2 Current BLS/NRP training programs A: Completed separately B: Completed in an integrated program (both BLS and NRP cards received from same program)

5 Question 3 My goal in attending this session is: A: To find out more about integrating programs B: To develop a strategy for starting a program like this C: To compare or improve a similar integrated program

6 Question 4 Currently the staff I work with is required to maintain: A: NRP only B: NRP and BLS C: NRP, BLS and ACLS

7 WHY A LIFE SUPPORT PROGRAM FOR OB??

8 Definition: Maternal Mortality Rate Death from obstetric causes, 42 days postpartum, per 100,000 live births Numerator: The number of deaths with the underlying cause of death on the death certificate from the following ICD codes: ICD-10 codes A34, O00-O95, O98-O99 for 1999-present ICD-9 codes , , for Denominator: The number of live births in California, per year Same definition and method as U.S. rates calculated by National Center for Health Statistics and the World Health Organization Same definition and method used by Healthy People 2020 to create benchmark objective of 11.4 maternal deaths per 100,000 live births Used for reporting vital statistics and comparison of indicators and objectives Sometimes referred to as Maternal Mortality Ratio

9 Maternal Mortality Rate, California and United States; Maternal Deaths per 100,000 Live Births California Rate United States Rate HP 2020 Objective 11.4 Deaths per 100,000 Live Births Year SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, Maternal mortality for California (deaths 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). United States data and HP2020 Objective use the same codes. U.S. maternal mortality data is published by the National Center for Health Statistics (NCHS) through 2007 only. U.S. maternal mortality rates from 2008 through-2013 were calculated using CDC Wonder Online Database, accessed at March 11, Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

10 Maternal Deaths per 100,000 Live Births Maternal Mortality Rates by Race/Ethnicity, California Residents; White, Non-Hispanic Hispanic b a African-American, Non-Hispanic Asian, Non-Hispanic c Three-Year Moving Average c 4.9a b SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, Maternal mortality rates for California (deaths 42 days postpartum) were calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, May, 2015.

11 "No pregnant woman should die undelivered (yet one-third of these patients remain undelivered at the time of death) Sheila E. Cohen, MBChB, FRCA Professor of Anesthesia, Emerita Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Ref: Reidy Jr, Russell R, CMACE , Int J Obstet Anesth 2011;20:

12 Maternal Cardiac Arrest Not Immediately Reversed by BLS and ACLS Emergency Cesarean Section in Cardiac Arrest (5 minutes) When the gravid uterus is large enough to cause maternal hemodynamic changes due to aortocaval compression, emergency cesarean section should be considered, *regardless of fetal viability.* Resuscitation team leaders should activate the protocol for an emergency cesarean delivery as soon as cardiac arrest is identified in a pregnant women with an obviously gravid uterus. By the time the physician is ready to deliver the baby, standard ACLS should be underway and immediately reversible causes of cardiac arrest should be ruled out. (Stop Magnesium, think LAST) LAST Local Anesthesia Systemic Toxicity (administer Intralipid)

13 Question 5 Following maternal cardiac arrest, left uterine displacement should be utilized if the patient is 24 weeks or greater. A: True B: False

14 Why perform an emergency cesarean section in cardiac arrest? Several case reports of emergency cesarean section in maternal cardiac arrest indicate a return of spontaneous circulation (ROSC), or improvement in maternal hemodynamic status only *after the uterus has been emptied.* In a case series of 38 cases of perimortem cesarean section, 12 of 20 women (60%) for whom maternal outcome was recorded had return of spontaneous circulation immediately after delivery. No cases of worsened maternal status after cesarean section were reported. *The critical point to remember is that both mother and infant may die if the provider cannot restore blood flow to the mother s heart.* Ref: Circulation, Vanden Hoek et al, Part 12, 2010

15 Question 6 Emergency cesarean section following unsuccessful resuscitation of a pregnant patient PMCD (PeriMortem Cesarean Delivery) is indicated primarily for prevention of fetal hypoxia and acidosis. A: True B: False

16 Resuscitation of the Pregnant Patient in Cardiac Arrest There are no randomized controlled trials evaluating the effect of specialized obstetric resuscitation versus standard care in pregnant patients in cardiac arrest. There are reports in the literature of patients not in arrest that describe the science behind important physiological changes that occur in pregnancy that may influence treatment recommendations and guidelines for resuscitation from cardiac arrest in pregnancy.

17 Predicting Neurologic Outcome after Cardiac Resuscitation

18 Maternal Cardiac Arrest and Perimortem Caesarean Delivery: Evidence or expert-based? Einav S, et al. Resuscitation (2012) Results: 80 relevant papers, 94 included cases. Maternal Outcome: 54.3% (51/94) mothers survived to hospital discharge. 78.4% (40/51) with a CPC of 1-2 (c/w < 50% overall) PMCD was determined to have been beneficial to the mother in 31.7%of cases and was not harmful in any case.

19 Maternal Cardiac Arrest and Perimortem Caesarean Delivery: Evidence or expert-based? Einav S, et al. Resuscitation (2012) Results: 80 relevant papers, 94 included cases Maternal Outcome: 54.3% (51/94) mothers survived to hospital discharge. 78.4% (40/51) with a CPC of 1-2 (c/w < 50% overall) PMCD was determined to have been beneficial to the mother in 31.7% of cases and was not harmful in any case.

20 Einav S, et al. Resuscitation (2012) continued In-hospital arrest and PMCD within *10 min of arrest were associated with better maternal outcomes. Neonatal Outcome: Survivors: * min. Non-survivors: * min. In-hospital arrest to delivery Conclusion: Treatment recommendations should include good overall performance of resuscitation and delivery within *10 minutes of arrest. Cognitive dissonance may delay both situation recognition and the response to maternal collapse.

21 Ref: Cases Anesthesia Analgesia. Org, 2015

22 HOW IS ObLS DIFFERENT?

23 Traditional life support training BLS, NRP and ACLS training arranged by individual staff to maintain current card status Training occurred with a hospital wide group of providers or at any center licensed to give a card for that program

24 Deficits of traditional training Staff from different units and disciplines randomly placed in programs Not unit specific/with unit colleagues For OB providers: OB specific content not covered Not all ACLS content applicable to practice BLS pediatric resuscitation different from NRP

25 No opportunity to practice what staff would be expected to do on their unit during resuscitation

26 No opportunity to practice with unit colleagues as a team

27 CHANGING PRACTICE

28 Genesis of ObLS: Performance During Maternal Arrest Am J Obstet Gynecol 2010;203:179.e interdisciplinary OB provider teams in an unannounced, unrehearsed maternal arrest Findings: Proper compressions 56% of time Proper ventilations 50% Uterine displacement and use of backboard frequently neglected Majority did not call for peds until after patient completely unresponsive

29 Genesis of ObLS: Where to Deliver? Anesth Analg 2013;116: teams of two providers Effectiveness of chest compressions measured in transport vs when stationary transport negatively affects the overall quality of resuscitation on a mannequin during simulated maternal arrest

30 Genesis of ObLS: Data Analysis Why doesn t current performance meet standards? Rare event Practice every two years Maternal arrest requires additional actions Obstetric specific information rarely covered in existing life support programs (BLS, ACLS and NRP) Life support training does not occur with providers from the same unit

31 Genesis of ObLS: Solutions Develop a program specific for OB providers Address performance issues Algorithm for maternal arrest Review of information specific to OB Practice in teams that parallel those that would respond on the OB unit

32 Obstetric Life Support (ObLS) Recognition of the decompensating patient Basic Life Support accomplished per AHA standards with inclusion of actions specific for pregnancy Delivery within 5 minutes if no ROSC Collaboration with the adult code team Diagnosis of underlying problem Management of patient

33 Goals of OBLS Recognition of the decompensating obstetric patient Covered in two recorded sessions One hour of case studies that demonstrate signs and symptoms of decompensation One hour of review of the H s and T s of pregnancy (the reasons for arrest per AHA)

34 Goals of OBLS Basic Life Support Importance of early effective Compressions Ventilation Use of automated external defibrillator (AED) Alterations for pregnancy Uterine displacement

35 Goals of OBLS Delivery of fetus within five minutes of arrest Review key issues Location of scalpel Differences between cesarean and perimortem delivery Preparation for neonatal resuscitation Review of procedure for peri-mortem delivery for MDs, how to support procedure for RNs

36 Goals of OBLS Coordination of care with code team, ICU intensivists Role of OB/Anes MD and OB RN input in patient management

37 ObLS Program Combines NRP and BLS in one training session NRP, BLS and ACLS testing can be completed on line Three days off unit training condensed to one full day of interdisciplinary team training J Perinat Neonat Nurs Volume 26 Number 2,

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39 ObLS Agenda Welcome and Introductions BLS and NRP skills review Briefing/Trigger video Sim room familiarization Deliberate practice: maternal/neo Walk through practice, stop to correct errors Maternal/neo scenarios recorded video debriefing Evaluation

40 Simulation Based Training Scenario based Designed to practice BLS/ACLS skills with alterations for obstetric patients We DO NOT expect a perfect performance Individual and team performance is confidential but any system issues uncovered are reported to unit manager

41 Trigger Video CAPE neonatal resuscitation video, clip from optimal resuscitation Trigger video discussion points What makes this code optimal? What behaviors supported team performance? What could have been done better?

42 FINANCIAL AND LOGISTICAL STRATEGIES

43 Financial Strategy Initial pilot of ObLS partially funded by a grant Purchase of task trainer Purchase of licenses for ACLS and BLS online training Life support budget for staff used to send staff to ObLS

44 Logistics Location: Simulation center near unit Not affected by unit census Faculty: RNs from L&D and maternity units, OB CNS, neonatal MD/NNP and simulation specialist Scheduling: Every two year training schedule maintained Staff initially divided into two groups based on card expiration Currently staff register internally through CNS

45 Logistics AHA/AAP cards ACLS no longer required based on AWHONN position statement Current program does not include ACLS BLS and NRP cards issued through local AHA training center

46 Reference Circulation. 2015;132: DOI: /CIR

47 Additional References The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Management of Cardiac Arrest in Pregnancy Anesth Analg 2014;118: AWHONN Position Statement: Advanced Cardiac Life Support in Obstetric Settings JOGNN, 39, ; 2010.DOI: /j x

48 Questions?

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