Hospital Maternity Ward Significantly Decreases NICU Admissions With Shamaym

Challenge

Research shows that 70% of accidental injuries in hospitalized patients are caused by medical error or failure to follow accepted practices. Additionally, half of all surgical complications are thought to be avoidable, and most result from communication failures.

The delivery ward at Emek Hospital, considered to be one of Israel’s top delivery wards, strives continuously to improve its outcomes. The ward is a complex, multifaceted setting where effective communication and coordination between team members is vital for patient safety and positive outcomes.

The medical staff sought to upsurge patient outcomes and processes, specifically related to two medical procedures conducted during a number of deliveries: vacuum deliveries and genital tract examinations performed in cases of postpartum hemorrhage or retained placental products.

The ward’s director, Prof. Raed Salim, turned to Shamaym to implement aviation-based debriefing practices in an effort to achieve superior outcomes. “The simplicity of the method enabled us to use it in our crazy lack of time environment,” said Prof. Salim.

Process

With an innovative spirit and a desire to engender true change, Emek’s delivery ward joined forces with Shamaym to implement simple and effective individual and team-based learning, improve communication between team members, and ultimately reduce medical error in order to reach superior outcomes for mothers and newborns.
Over the course of 18 months delivery ward physicians, led by Prof. Salim, regularly debriefed using the Shamaym Platform’s mobile application. The mobile application offered the team an easily accessible space to quickly record and share lessons and best practices.<br>
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After each procedure, regardless of outcome, physicians were prompted to answer a series of three questions about their experience and performance: What happened? Why did it happen? How can I improve? A similar form was completed regarding equipment used.Once every three to four months, forms were presented anonymously to members of the delivery ward team, to examine outcomes as a group.

Simultaneously, the staff participated in workshops at the team, managerial, and executive levels, where they had an opportunity to learn hands-on, share experiences in person, and hold each other accountable for their mutual improvement. Among other outputs, these workshops led to the creation of a birth checklist to keep all staff members on track.
The team debriefed 308 vacuum deliveries and 219 general tract examinations that were studied to assess the debriefing method’s impact on health outcomes for mothers and newborns.

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Results:

Regular debriefing by delivery ward physicians led to concrete outcome improvements in the health of mothers and newborns in the department, according to a 2019 study published in the European Journal of Obstetrics and Gynecology and Reproductive Biology.

“The simplicity of the method enabled us to use it in our crazy lack of time environment."

Prof. Raed Salim,
Head of Delivery Ward, Emek Hospital

Neonatal intensive care unit (NICU) admission (P = 0.048)
 Hemoglobin drop (an indicator of bleeding, P = 0.042)
Maternal length of stay at the hospital (P = 0.003)
Blood transfusions  (P < 0.001) Need for phototherapy (P < 0.001)

In addition to improved patient outcomes, Shamaym’s solution helped the delivery ward team put in place more effective procedures that reduce inefficiencies and promote teamwork. The team saw a reduction in equipment use errors (as shown below). A number of issues were identified and addressed promptly, including the prevention of equipment shortages, and rearranging of equipment and medications in the delivery and operating suites for easier access.

Source: Garmi et. al, European Journal of Obstetrics and Gynecology and Reproductive Biology, 2019

“This process empowered the team to focus on various events and processes. It opened their eyes to the importance of examining events that went perfectly, in order to recreate them, and built a more committed atmosphere”, said Prof. Salim.

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