Practice the rare

Tuesday, July 01, 2014 12:32 PM

Preparing for the once-in-a-career emergency

by Kate Alfano, CMS contributing writer

How can a medical team prepare for emergencies? The answer, said Gerald Zarlengo, MD, and Jennifer Roller, MD, is to practice and to learn from that practice. Zarlengo is a board-certified OB/GYN at Midtown Obstetrics and Gynecology and serves as the medical director of Women’s and Children’s Services at St. Joseph Hospital. Roller is a family physician in Grand Junction and on the faculty of the family medicine residency program at St. Mary’s Hospital and Regional Medical Center.

Zarlengo spoke about his experience at St. Joseph with amniotic embolism – a rare pregnancy complication that occurs in between 1 and 12 patients per 100,000 deliveries. Before the hospital implemented Critical Events Team Training, they experienced one maternal death from the condition. Since then they have had four occasions of amniotic embolism with four survivals.

In Critical Events Team Training, every member of the obstetric medical team – physicians, residents, nurses, scrub techs and unit secretaries – goes through a halfday training covering two of a dozen potential scenarios, not knowing in advance what they will be. “You want to practice the rare but, more important, you want to practice the common to constantly improve,” Zarlengo said.

The concept of the training is to level the playing field and create a safe environment. “The take-home message from our process is to get nurses, physicians, everyone to realize that when we’re in the middle of a situation, we’re a team,” he said. “I’m not better than the nurse because I have an ‘MD’ after my name. The most important person on the obstetric unit when all three ORs are dirty and we need to do an emergency C-section is housekeeping. Realize that having everyone on your team is how you’ll have a safe outcome.”

Two other best practices he’s learned from the program are the importance of daily and real-time debriefs. For the daily debrief every member of the medical team jams into a labor-and-delivery room to hear about the day’s patients. “You might have 12 people on the board and you might not be taking care of those people but later in the day when a disaster happens, you’ve already put together what you might do to care for them.”

More important are the real-time debriefs, Zarlengo said. It’s easy to forget the details during a root-cause analysis – where the medical team and the risk management staff go over the details of an adverse event two to three weeks after it occurs. With a real-time debrief, the providers involved gather the day of the event to talk and record the details. “We started a process where anyone in labor and delivery can call for a real-time debrief at the end of the shift. It doesn’t have to be a seminal event.”

Roller helps coordinate the pediatrics curriculum at St. Mary’s residency program, and as she got more involved she realized they had an issue. St. Mary’s is not a critical care children’s hospital but critically ill children are often referred to them for care, particularly when poor weather prevents transport to Denver. Roller and the other program faculty identified their many resources for caring for these young patients: They have pediatric anesthesiology, a pediatric surgeon, and many pediatricians and family physicians trained in neonatal resuscitation and pediatric life support.

Even with these resources the team identified areas where they could improve pediatric resuscitation. The biggest factor was to help providers overcome the fear of treating critically ill children. They also wanted to reduce response time, establish a leader in emergency situations and delegate tasks, create protocols for equipment location and use, remember or access PALS protocols, and avoid drug dosing errors.

By studying how people learn most effectively, the faculty knew the best way to improve care would be through hands-on learning in St. Mary’s simulation lab. “One of the barriers we had was that a lot of the doctors said, ‘I don’t need this. This is for medical students or residents but this isn’t for me who has been in practice for 15 or 30 years,’” she said. “The interesting thing was that when we finally did the sims, the experienced faculty didn’t do so well. We all thought we could do these simulations and that we knew how to resuscitate a child and we really didn’t. That was eye-opening.”

Their team practices numerous scenarios – from respiratory events to cardiac emergencies to trauma – and afterward conducts a post-simulation debrief, which Roller said is more important than the actual simulation. Participants give each other feedback, ask questions about a person’s thought and decision processes, and then go back to the simulator to practice again.

The lesson, Roller said, is that it’s possible to have success stories, even in rare situations, if you practice and actively strive to improve care. “There’s nothing special with what either of us has done in our systems, it’s just about looking at your own system, identifying the problems and finding solutions.”