Malpractice Claims Drop 39% Under Perinatal Safety Initiative

Obstetric units have dramatically decreased adverse events that harm women in labor and their newborns—and the costly malpractice claims that sometimes follow—by consistently using three sets of process bundles, a 14-hospital collaboration has found after studying outcomes in 145,000 births.

"The hospitals that decided to do this work together realized that perinatal harm drives up 50% of the liability expense for many hospitals," said Susan DeVore, President and CEO of Premier, a 2,700-hospital healthcare alliance that set up the collaboration in 2008 based in part on its previous work with the Institute for Healthcare Improvement and Ascension Health.

"What we see from the data is that there has been a 25% reduction in birth hypoxia and asphyxia, which can cause infant brain damage, a 22% reduction in neonatal birth trauma, and for just these 14 hospitals over just this short period of time, (2008—2010 compared with the project's first phase, from 2008 to 2010) there have been 30 fewer babies that have experienced these harms," she said during a news briefing Wednesday.

For maternal harm, there also was a reduction of up to 15% in cardiac arrests, cardiac complications and postpartum hemorrhage, "even in an environment where the Centers for Disease Control and Prevention is reporting that postpartum hemorrhage rates have doubled among U.S women between 1998 and 2009."

Newborn deliveries that develop complications cost about twice as much as stays without complications, especially when they require admission to the hospital. Nationally, DeVore said, they account for approximately $17.4 billion in hospital costs each year in the U.S. and involve hospital stays that average about one day more.

The project, called the Premier Perinatal Safety Initiative or PPSI, also reduced annual liability claims by 39% in these 14 hospitals, compared to a 10% reduction in hospitals in the same healthcare systems as the participants, but which did not participate in the PPSI. Premier officials believe that the recession and other economic factors may have led to a reduction in pregnancies in women who would have been at higher risk, and that may explain the decrease in non-participating hospitals claims.

Premier officials said they could not give the actual dollar amounts of claim reductions because a few claims are pending, but will publish final loss data next summer. 

The claims information was available to Premier through a company that provides malpractice insurance to some of its hospital members, American Excess Insurance Exchange. AEIX is a Premier affiliate.

But, DeVore said, "that's a significant difference and a higher reduction in liability claims with these participants."

"This evidence suggests we have prevented approximately 110 additional harms to mothers and babies, and 106,000 mothers and their babies have gotten all the evidence-based quality measures," DeVore said.

Each of the three bundles used an "all or nothing" scoring system, in which failure to adhere to one part of the bundle resulted in a failure to adhere to any of it. For example, one of the bundles focuses on reducing labor augmentation which involves the use of oxytocin, a drug intended to slow labor.

That bundle requires that caregivers document that they estimated the fetal weight, assessed fetal heart rate, performed a pelvic exam before administering oxytocin and recognized and managed excessively frequent contractions, called tachysystole.

But if the caregivers failed to do one of those things, the team received no credit for doing any of them.

The PPSI found that there was significant improvement in observing the bundles. For example, adherence to the augmentation bundle improved from 33% to 72%; the elective induction bundle from 58% to 88% and the vacuum bundle from 9% to 51%.

A most important strategy is that obstetrical units resist pressure from pregnant women and their obstetricians to have their babies electively induced prior to 39 weeks gestation, a period that is becoming increasingly acknowledged as one that may result in newborn developmental or behavioral issues due to insufficient brain or other organ gestation.

On this point, DeVore expressed a personal concern involving her daughter-in-law, "who told me that her physician wanted to do her C-section at 38 weeks. It (prompted) this conversation about why you would do it at 38 weeks, and why would the physician want to do it?  I think we just have to know the questions to ask and have the data that would indicate there are some best practices here that we want to replicate nationally."

Some of the participant hospitals talked about "hard stop" policies, which prohibit obstetricians from performing C-sections or inductions in women prior to 39 weeks of gestation in the absence of medical necessity.

Premier's PPSI experts gave some credit for the observed improvements to enhanced communication and teamwork through three tools:

• TeamSTEPPS, developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality
• Situation Background Assessment Recommendation (SBAR), developed by the U.S. Navy as a system to communicate relevant case facts in a respectful, focused and effective way and
• Simulation drills, which use actresses and mannequins to simulate various events that could go wrong during the birth process to either mother or baby or both.

The hospitals that agreed to employ the three bundles are: Methodist Medical Center of Illinois in Peoria, IL; Baptist Hospital East in Louisville, KY; Baystate Medical Center in Springfield, MA; Fairview Ridges Hospital in Burnsville, MN; University of Minnesota Medical Center, Fairview, MN; Presbyterian Hospital in Albuquerque, NM; Bethesda North Hospital, Cincinnati; Good Samaritan Hospital, Cincinnati; Summa Akron City hospital in Akron; Indian Path Medical Center in Kingsport, TN; Texas Health Harris Methodist, Fort Worth, TX; Texas Health Presbyterian Hospital, Dallas; St. Joseph Hospital, Bellingham, WA; and Aurora West Allis Medical Center in West Allis, WI.