Single-center task analysis and user-centered assessment of physical space impacts on emergency Cesarean delivery.

OBJECTIVE: This study aimed to begin to address this gap using validated techniques in human factors to perform a participatory user-centered analysis of physical space during emergency Cesarean. METHODS: This study employed a mixed-methods design. Focus group interviews and surveys were administered to a convenience sample (n = 34) of multidisciplinary obstetric teams. Data collected from focus group interviews were used to perform a task and equipment analysis. Survey data were coded and mapped by specialty to identify reported areas of congestion and time spent, and to identify themes related to physical space of the OR and labor and delivery unit. RESULTS: Task analysis revealed complex interdependencies between specialties. Thirty task groupings requiring over 20 pieces of equipment were identified. Perceived areas of congestion and areas of time spent in the OR varied by clinical specialty. The following categories emerged as main challenges encountered during an emergency Cesarean: 1) size of physical space and equipment, 2) layout and orientation, and 3) patient transport. CONCLUSION: User insights on physical space and workflow processes during emergency Cesarean section at the institution studied revealed challenges related to getting the patients into the OR expediently and having space to perform tasks without crowding or staff injury. By utilizing human factors techniques, other institutions may build upon our findings to improve safety during emergency situations on labor and delivery.

Point-of-Care Lung Ultrasound Pattern in Healthy Parturients: Prevalence of Pulmonary Interstitial Syndrome Following Vaginal Delivery, Elective and Unplanned Intrapartum Cesarean Delivery.

BACKGROUND: Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmonary edema, with the risk of fluid extravasating into the pulmonary interstitium being potentially at a maximum during the early postpartum period. Data on the impact of labor and peripartum hemodynamic strain on lung ultrasound (LUS) are limited, and the prevalence of subclinical pulmonary interstitial syndrome in peripartum women is poorly described. The primary aim of this exploratory study was to estimate the prevalence of pulmonary interstitial syndrome in healthy term parturients undergoing vaginal (VD), elective (eCD), and unplanned intrapartum cesarean deliveries (uCD). Secondary aims were to estimate the prevalence of positive lung regions (≥3 B-lines on LUS per region) and to assess the associations between positive lung regions and possible contributing factors. METHODS: In this prospective observational cohort study, healthy women at term undergoing VD, eCD, or uCD were enrolled. Following international consensus recommendations, a LUS examination was performed within 4 hours after delivery applying an 8-region technique. Pulmonary interstitial syndrome was defined by the presence of 2 or more positive lung regions per hemithorax. Ultrasound studies were reviewed by 2 blinded reviewers and assessed for interobserver reliability. RESULTS: Seventy-five women were assessed (n = 25 per group). No pulmonary interstitial syndrome was found in the VD and eCD groups (each 0 of 25; 0%, 95% confidence interval [CI], 0-13.7). Pulmonary interstitial syndrome was found in 2 of 25 (8%, 95% CI, 1-26) women undergoing an uCD (P = .490 for VD versus uCD and P = .490 for eCD versus uCD). In 1 woman, this correlated clinically with the development of pulmonary edema. One or more positive lung regions were present in 5 of 25 (20%), 6 of 25 (24%), and 11 of 25 (44%) parturients following VD, eCD, and uCD, respectively (P = .136). Positive lung regions were predominantly found in lateral lung regions. The number of positive lung regions showed a weak correlation with patient age (r = 0.25, 95% CI, 0.05-0.47; P = .033). No significant association was found between LUS pattern and parity, duration of labor, labor augmentation, labor induction, estimated total intravenous fluid intake, or net intravenous fluid intake. CONCLUSIONS: Although many focal areas of increased extravascular lung water (20%-44% prevalence) can be identified on LUS, the overall prevalence of pulmonary interstitial syndrome was 2.7% (2 of 75; 95% CI, 0.3-9.3) among healthy term parturients soon after delivery. Focal areas of positive lung water regions were weakly correlated with maternal age.

Operating Room In Situ Interprofessional Simulation for Improving Communication and Teamwork.

BACKGROUND: Effective teamwork and communication are correlated with improved patient care quality and outcomes. The belief that each team member contributes to excellent patient care in the operating room (OR) leads to a more productive work environment. However, poor teamwork and communication lead to poorer OR outcomes. We qualitatively and quantitatively explored perspectives of three OR professions (nursing, anesthesiology, and surgery) on teamwork and communication in the OR preinterprofessional and postinterprofessional in situ OR simulation. MATERIALS AND METHODS: One-on-one semi-structured interviews were conducted; 14 pre-in situ simulations during July-October 2017 (three surgery, four anesthesiology, and six nursing staff), and 10 post-in situ simulations during August-November 2017 (five surgery, four anesthesiology, and one nursing staff). Themes were identified inductively to create a codebook. The codebook was used to consensus code all interviews. This analysis informed the development of a quantitative survey distributed to all contactable interviewees (22). RESULTS: Presimulation and postsimulation interview participants concurred on teamwork and communication importance, believed communication to be key to effective teamwork, and identified barriers to communication: lack of cordiality, lack of engagement from other staff, distractions, role hierarchies, and lack of familiarity with other staff. The large majority of survey participants-all having participated in simulations-believed they could use effective communication in their workplace. CONCLUSIONS: Establishing methods for improving and maintaining the ability of OR professionals to communicate with each other is imperative for patient safety. Effective team communication leads to safe and successful outcomes, as well as a productive and supportive OR work environment.

Cognitive Aids in Obstetric Units: Design, Implementation, and Use.

Obstetrics has unique considerations for high stakes and dynamic clinical care of ≥2 patients. Obstetric crisis situations require efficient and coordinated responses from the entire multidisciplinary team. Actions that teams perform, or omit, can strongly impact peripartum and perinatal outcomes. Cognitive aids are tools that aim to improve patient safety, efficiency in health care management, and patient outcomes. However, they are intended to be combined with clinician judgment and training, not as absolute or exhaustive standards of care for patient management. There is simulation-based evidence showing efficacy of cognitive aids for enhancing appropriate team management during crises, especially with a reader role, with growing literature supporting use in obstetric and nonobstetric clinical settings when combined with local customization and implementation efforts. The purpose of this article is to summarize current understanding and available resources for cognitive aid design, implementation, and use in obstetrics and to highlight existing gaps that can stimulate further enhancement in this field.

Understanding the Heterogeneity of Labor and Delivery Units: Using Design Thinking Methodology to Assess Environmental Factors that Contribute to Safety in Childbirth.

OBJECTIVE: There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. We employed design thinking methodology to understand how the design of labor and delivery units impacts safety and identified spaces and systems where improvements are needed. STUDY DESIGN: Site visits were conducted at 10 labor and delivery units in California. A multidisciplinary team collected data through observations, measurements, and clinician interviews. In parallel, research was conducted regarding current standards and codes for building new hospitals. RESULTS: Designs of labor and delivery units are heterogeneous, lacking in consistency regarding environmental factors that may impact safety and outcomes. Building codes do not take into consideration workflow, human factors, and patient and clinician experience. Attitude of hospital staff may contribute to improving safety through design. Three areas in need of improvement and actionable through design emerged: (1) blood availability for hemorrhage management, (2) appropriate space for neonatal resuscitation, and (3) restocking and organization methods of equipment and supplies. CONCLUSION: Design thinking could be implemented at various stages of health care facility building projects and during retrofits of existing units. Through this approach, we may be able to improve hospital systems and environmental factors.

Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design.

This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000->5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.

Correlation of changes in hemodynamic response as measured by cerebral optical spectrometry with subjective pain ratings in volunteers and patients: a prospective cohort study.

PURPOSE: Noninvasive cerebral optical spectrometry is a promising candidate technology for the objective assessment physiological changes during pain perception. This study's primary objective was to test if there was a significant correlation between the changes in physiological parameters as measured by a cerebral optical spectrometry-based algorithm (real-time objective pain assessment [ROPA]) and subjective pain ratings obtained from volunteers and laboring women. Secondary aims were performance assessment using linear regression and receiver operating curve (ROC) analysis. PATIENTS AND METHODS: Prospective cohort study performed in Human Pain Laboratory and Labor and Delivery Unit. After institutional review board approval, we evaluated ROPA in volunteers undergoing the cold pressor test and in laboring women before and after epidural or combined spinal epidural placement. Linear regression was performed to measure correlations. ROCs and corresponding areas under the ROCs (AUC), as well as Youden's indices, as a measure of diagnostic effectiveness, were calculated. RESULTS: Correlations between numeric rating scale or visual analog scale and ROPA were significant for both volunteers and laboring women. AUCs for both volunteers and laboring women with numeric rating scale and visual analog scale subjective pain ratings as ground truth revealed at least good (AUC: 70%-79%) to excellent (AUC >90%) distinction between clinically meaningful pain severity differentiations (no/mild-moderate-severe). CONCLUSION: Cerebral Optical Spectrometry-based ROPA significantly correlated with subjectively reported pain in volunteers and laboring women, and could be a useful monitor for clinical circumstances where direct assessment is not available, or to complement patient-reported pain scores.

National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review.

In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies. However, it is unclear whether national and international obstetric societies' PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland, an international multidisciplinary consensus group, and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies' recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.

Building Comprehensive Strategies for Obstetric Safety: Simulation Drills and Communication.

As pioneers in the field of patient safety, anesthesiologists are uniquely suited to help develop and implement safety strategies to minimize preventable harm on the labor and delivery unit. Most existing obstetric safety strategies are not comprehensive, lack input from anesthesiologists, are designed with a relatively narrow focus, or lack implementation details to allow customization for different units. This article attempts to address these gaps and build more comprehensive strategies by discussing the available evidence and multidisciplinary authors' local experience with obstetric simulation drills and optimization of team communication.

Airway management in cervical spine injury.

To minimize risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo). To provide safe and efficient care in these patients, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know how airway maneuvers, neck stabilization, and positioning affect the cervical spine. This review discusses the risks and benefits of various airway management strategies as well as specific concerns that affect patients with known or suspected cervical spine injury.

A high-throughput method for generating uniform microislands for autaptic neuronal cultures.

Generating microislands of culture substrate on coverslips by spray application of poly-d lysine is a commonly used method for culturing isolated neurons that form self (autaptic) synapses. This preparation has multiple advantages for studying synaptic transmission in isolation; however, generating microislands by spraying produces islands of non-uniform size and thus cultures vary widely in the number of islands containing single neurons. To address these problems, we developed a high-throughput method for reliably generating uniformly shaped microislands of culture substrate. Stamp molds formed of poly(dimethylsiloxane) (PDMS) were fabricated with arrays of circles and used to generate stamps made of 9.2% agarose. The agarose stamps were capable of loading sufficient poly D-lysine and collagen dissolved in acetic acid to rapidly generate coverslips containing at least 64 microislands per coverslip. When hippocampal neurons were cultured on these coverslips, there were significantly more single-neuron islands per coverslip. We noted that single neurons tended to form one of three distinct neurite-arbor morphologies, which varied with island size and the location of the cell body on the island. To our surprise, the number of synapses per autaptic neuron did not correlate with arbor shape or island size, suggesting that other factors regulate the number of synapses formed by isolated neurons. The stamping method we report can be used to increase the number of single-neuron islands per culture and aid in the rapid visualization of microislands.

Synaptic vesicle protein 2 enhances release probability at quiescent synapses.

We report a thorough analysis of neurotransmission in cultured hippocampal neurons lacking synaptic vesicle protein 2 (SV2), a membrane glycoprotein present in all vesicles that undergo regulated secretion. We found that SV2 selectively enhances low-frequency neurotransmission by priming morphologically docked vesicles. Loss of SV2 reduced initial release probability during a train of action potentials but had no effect on steady-state responses. The amount and decay rate of asynchronous release, two measures sensitive to presynaptic calcium concentrations, are not altered in SV2 knock-outs, suggesting that SV2 does not act by modulating presynaptic calcium. Normal neurotransmission could be temporarily recovered by delivering an exhaustive stimulus train. Our results indicate that SV2 primes vesicles in quiescent neurons and that SV2 function can be bypassed by an activity-dependent priming mechanism. We propose that SV2 action modulates synaptic networks by ensuring that low-frequency neurotransmission is faithfully conveyed.