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Review of outcomes among patients with invasive placentas after implementation of a standard operating protocol for patient and operating room preparation
Abstract Number: F4D-1
Abstract Type: Original Research
Introduction: Patients with invasive placentas are a growing, high-risk population. Ideally, cesarean delivery of these patients should occur in a planned setting; however, sometimes it must occur unexpectedly and off-hours. In the event of massive hemorrhage, the efficiency of anesthesia providers in carrying out appropriate interventions can directly impact outcomes. We recognized a role for process improvement to identify best practices and formalized a standard operating protocol (SOP) for preparation of the patient and operating room (OR). This SOP can only be fully implemented during planned cases, but may catalyze transfer of knowledge that is also applicable to unplanned cases. In this study, we assessed clinical outcomes comparing deliveries that occurred in planned vs. unplanned settings since implementation of the SOP.
Methods: The SOP was created through an iterative process of debriefings following real cases at our labor & delivery unit. It includes an equipment checklist with optimized spatial organization in the OR, a visual aid for tracking lab results and ongoing estimated blood loss (including lap pad weights), important phone numbers, and a summary of blood bank protocols. We also created standard assignments for OR personnel, including a nurse that communicates between the blood bank and the anesthesiologist (the “Blood Runner”). To evaluate the level of care we provide during planned vs unplanned deliveries, we compared outcomes of 18 planned and 13 unplanned cases that occurred between 2014-2017, by retrospective review of electronic medical records.
Results: No deaths occurred in either group. Median estimated blood loss for all cases was 3000 mL (range 1500 to 32000 mL). 3/18 (17%) of patients required ICU admission post-operatively in the planned group, compared with 3/13 (23%) of patients in the unplanned group. Indication for all ICU admissions was ongoing need for mechanical ventilation. Laboratory measures of resuscitation at the end of each case were not different among the planned vs. unplanned groups, including: Hct (29.9 ± 0.96 % vs. 28.2 ± 1.55%, p = 0.34), fibrinogen (272 ± 23 mg/dL vs. 264 ± 22 mg/dL, p = 0.80), pH (7.35 ± 0.01 vs. 7.35 ± 0.02, p = 0.92), and base excess (-4.1 ± 0.7 vs. -3.6 ± 0.8, p = 0.70).
Conclusions: Cesarean delivery of patients with invasive placentas can place high demands on the obstetric anesthesiologist, particularly when delivery occurs in an unplanned setting. Systems-level improvements are an important way to maximize efficiency and optimize workflow. While our SOP is easier to implement for planned cases that allow ample preparation time, its use also provides “institutional learning” that may translate to better outcomes for cases that must occur without preparation. This analysis suggests most outcomes of our unplanned cases are on par with those of our planned cases.