CLiNiCAL PRACTiCE
Quality and Safety Unit
INSIDE
Code Greens
REVIEW NEWSLETTER May 2004
Pg
1
Editorial
2
Letters to the Editor
2
Response Code Blue
3
Is this death preventable?
4
ALSO course
5
Approach to the shocked patient in the ED
5
How well do we huff and puff
6
Teamwork in obstetric emergencies
7
Pharmacy news
8
Code Greens
What is a code green?
History and process
A code green is called when an immediate
caesarean section is required because of
impending fetal/maternal death, e.g. cord
prolapse, severe persistent bradycardia.
A caesarean section is a complex
multi-disciplinary procedure involving
obstetricians, midwives, anaesthetists,
paediatricians, theatre nurses, anaesthetic
nurses, as well as support services. How
do you get a woman requiring immediate
caesarean section, who may not even be
in a birthing suite, rapidly transported to
theatre and attended by all the required
staff?
By calling a code green, a process is
initiated that allows a rapid delivery to take
place. Prior to 2000, immediate caesarean
sections were classified as code blue –
immediate caesarean section. At that
time, there were many problems with
the management of these cases.
Primarily, these were due to difficulties
in communicating the urgency of the case
to appropriate staff, including obstetricians
and anaesthetists, a lack of clear understanding among staff as to the correct
process to follow when a code was
called, as well as the potential for
confusion with the adult and paediatric
code blue responses.
A new code green policy was developed
in May 2000. The code green name was
adopted to separate it from the adult and
paediatric code blue responses and also
to highlight the main difference in response.
Green means go! When a code green
is called all the team members attend
the operating theatre and the patient is
transported to theatre immediately.
This distinguishes it from the code blue
response where the team members go to
where the code blue was called. The code
green response team consists of a group
including obstetric, paediatric, anaesthetic,
midwifery and operating theatre staff
as well as other essential personnel. To
minimise delays team members carry an
emergency page that is set off as a group
page by switchboard when they are
notified of a code green.
Typically a member of the obstetric or
midwifery staff calls a code green.
The patient is immediately transported
to theatre and met in theatre by the team
necessary to perform the caesarean
section. In the OR, a theatre is always
designated for these emergencies with
the necessary equipment, drugs etc
readily available to minimise delays.
What is the rationale for an
urgent caesarean delivery?
It has been known for a long time that even
with maternal death, it is still possible to
deliver a neurologically intact infant if the
delivery interval is short enough. Large
series have demonstrated that even with
intervals up to 15 minutes post maternal
cardiac arrest, up to 83% of surviving
infants were neurologically intact. Beyond
15 minutes, only 18% of surviving infants
had no neurological sequelae.
These are extreme cases but we can
extrapolate to other situations where fetal
well being is compromised, such as a cord
prolapse or abruption. Often we can see
no direct cause of fetal compromise but
see severe bradycardia or other major CTG
abnormality. In these situations, we hope
that by expediting delivery we can improve
the outcome for the baby and the mother.
What are the outcomes?
Code greens are becoming more frequent.
Over a 7 month period to October 2003,
101 code greens were called compared
to 63 for the same period in 2002.
The process is working well. In the six
months to December 2003, the meantime
from calling a code green to patient arrival
in theatre was four minutes.
EDITORIAL
Responding to emergencies is both a
test of, and an opportunity for, improving
care. Any opportunity for error, disorganisation or lack of team work is
amplified in the context of the reduced
time frames found in an emergency
response. The RWH has been a leader
in this area but as suggested above,
opportunities for improvement always
exist. This issue of the Clinical Practice
Review Newsletter addresses the theme
of responding to emergencies. There
is good evidence that when a clinical
situation begins to deteriorate to an
emergency, a standardised, rehearsed
and well understood team response
improves all outcomes including survival,
and reduced adverse events. Bellomo
et al 1 at the Austin Hospital in Heidelberg
reported last month on the results of a
Rapid Response Team on a population
of more than 1,000 post-surgery patients,
the team found a 37 percent relative
reduction in mortality and a 79 – 88%
reduction in a variety of complications.
In this issue of the CPR newsletter we
look first at what an emergency response
should be. The audit of neonatal
resuscitation undertaken by Colm
O’Donnell and the NICU team presented
at the last Grand Round (page 6) looks
at what we do, what evidence there is
and addresses gaps and deficiencies
in our knowledge base of neonatal
resuscitation. Sheila Bryan writes on
the response in the emergency dept to a
shocked patient (page 5). Ruth Bergman,
Andrew Beuttner and others report on
how we respond; the Code Blue and
Code Green experience at the RWH,
(pages 1 & 3) the latter being a unique
home grown response with impressive
benefits for patient outcomes. Glenys
Jansen reports on the ALSO course she
attended, a multi-disciplinary education
program responding to obstetric
emergencies (page 5). It is clear that
teamwork is the glue that sticks the
differing disciplines together when
responding to an emergency (page 7).
Mary Draper looks at improvements and
outcome that could be achieved by a
medical emergency team on (page 5).
Finally on (page 3) Sharyn Donovan
summarises the CPGs and our policies
on reponses to emergencies
Not-so-trivial fact for the day: If you go to
Advanced Google and type in the phrase
– obstetrics emergency, limited to .au, it
finds 8,230 hits. Number one hit? RWH
emergency dept. Well done guys!
Leslie Reti
Editor
[email protected]
Reference
1. Bellomo R. et al Prospective
controlled trial of effect of medical
emergency team on postoperative
morbidity and mortality rates.
Crit Care Med. 2004 Apr; 32(4):916-21.
23% of patients took more than five minutes to
arrive in theatre but only three patients took more
than ten minutes to arrive. During a similar time
period in 2002 the mean time to patient arrival in
theatre was 5 minutes. 27% of patients took more
than five minutes and five patients took more than
ten minutes.
These results compare well with other centres.
Tuffnell et al 1 reported a large series from a
district general hospital in the UK performing
a similar number of deliveries to RWH. 69% of
patients in the series from 1997 onwards arrived
in theatre within a target time of ten minutes.
These figures suggest that the process of code
greens is working. They do not tell us if they are
resulting in better outcomes. The increase in the
code green rate implies that the incidence of fetal
distress is increasing. This may not be the case
and indicates that the diagnosis of fetal distress
is imprecise. The rationale for performing a code
green is to improve fetal and maternal safety.
In the vast majority of instances, however, the
code is called for a fetal indication. It may be
that the code green process increases the risk
for women undergoing the caesarean section.
In 2002/3 the general anaesthetic rate for elective
caesarean sections at RWH was 6%.
For code green caesareans the general
anaesthetic rate was 54%. We know that
general anaesthetics for caesarean sections
are a hazardous procedure but the urgency of
a code green means that a general anaesthetic
will be required far more often.
We need to ensure that the code green
process continues to work well, is refined where
necessary and that fetal and maternal outcomes
are monitored to guarantee that the goal of
improved fetal and maternal safety is realised.
Dr Andrew Buettner
Deputy Director Anaesthesia RWH
Reference
1.Tuffnell DJ, Wilkinson K, Beresford N. Interval
between decision and delivery by caesarean section
– are current standards achievable? Observational
case series. [see comment]. Bmj. 2001; 322:1330-3.
LETTERS TO THE EDITOR
Dear Les,
It is a minor point, but just for the record,
I wanted to correct a statement in the most
recent (April 2004) Clinical Practice Review
Newsletter. On the second page, Tony Smith’s
Grand Round on 25 March 2004 was described as
the second Grand Round for 2004. In fact, it was
the third. The first was on Thursday 29 January
2004 on ‘Obesity and Pregnancy Complications’ –
Data from the Danish Birth Cohort" given by Ellen
Nohr. The second was given on Thursday 26
February 2004 by Babill Stray-Pedersen on
‘Reproductive Health of Immigrant Women’.
Cheers, Shaun
Reply: Absolutely right, as usual – ed.
Dear Editors,
Well done on producing a newsletter that is
interesting, refreshing and widely read, but
please take care with your headings. Last
month’s edition had a heading ‘… hots up’.
I almost wrote back then to complain that hot
is a noun and heat is the verb but thought I’d
let such an indiscretion pass! This month though
another suspect heading ‘Does Albumin Kill?’
The SAFE study was, as Ruth Bergman correctly
states, set out to compare mortality and morbidity
for intensive care patients receiving either
albumin or saline. To suggest the study cleared
Albumin from ‘killing’ is a tabloid approach not
befitting a ‘quality’ newsletter. I look forward to
a quality improvement in next month’s headlines.
Cheers, Geoff Steele
Reply: Actually, ‘hot’ is an adjective, certainly not
a verb, we agree. It is only a noun in the plural as
in ‘has the hots for!’ With regard to our tabloid
tendencies, the original title of the presentation
by Simon Finfer, was ‘Does Albumin Kill? Results
of a Randomised Control Trial of 7,000 Patients.’
Now there’s a sentence that’s too long for a
newsletter! The shorter version does grab
the attention – ed.
Respond Code Blue
A code blue is called in the event of an
unexpected medical emergency. This
includes a respiratory arrest, cardiac
arrest, epileptic seizure or another
condition where it is deemed that urgent
medical attention is required. (RWH Policy
and Procedure manual 9W-04-2-124).
An audit of Code Blue responses
conducted for quality assurance purposes
has shown 2 arrests have occurred in the
past 12 months and in 2003 there were a
total of 31 ‘Respond Code Blue’ and of
these, 18 were faints.
Consequently, at the RWH, when a code
is called it is less likely that the patient has
had a cardiac arrest, but rather medical
staff are required urgently. It is less likely
that a Code Blue is called for a ward and
more likely that it is called for outpatient
and visitor areas.
A variety of settings over the past 12
months have included Frances Perry
House, ground floor admissions, the
RWH Emergency Department car park,
Physiotherapy, Health Information Services,
Grattan Street Café, Outpatient clinics
and Women’s Social Support Services.
The various locations have highlighted the
issue of easy access for the resuscitation
trolley and numbers in attendance.
Policies, Procedures and Guidelines
Policies and Procedures
Clinical Practice Guidelines
Located in RWH Policy and Procedure
Manual on the Intranet.
Located on the RWH CPG website
on both the Intranet and Internet.
• Guidelines for Management of
Intrapartum Fetal Distress 9W-04-2-117
• Code Green – Immediate Caesarean
Section 9W-02-2-001
• Fetal Distress requiring Caesarean
Section 9W-02-2-035
• Resuscitation: Neonatal Cardiopulmonary
– Delivery Suite 9W-04-2-020
• Resuscitation: Neonatal –
Cardiopulmonary, Intensive and Special
Care Nurseries, Postnatal Ward and
Community Setting 9W-04-2-028
• Respond Code Blue 9W-04-2-124
•
•
•
•
•
Cardiopulmonary Resuscitation (adult)
Ectopic Pregnancy
Pre Eclampsia: Management
Shoulder Dystocia
Primary Post Partum Haemorrhage:
Management – this guideline includes
links to other CPGs;
- Advanced management of PPH
- Anaesthetic management of PPH.
Websites
Department of Reproductive Health and Research – World Health Organisation
http://www.who.int/reproductive-health/impac/Clinical_Principles/ Emergencies_C15_C16.html
Managing complications in pregnancy & childbirth – A guide for midwives and doctors
CREST Clinical Resource Efficiency Support Team – Northern Ireland
Management of Pre Eclampsia and Eclampsia
http://www.crestni.org.uk/publications/severe_eclampsia.pdf
In addition, it is important to tell
switchboard the floor and exact location,
for example ‘Level 1 Special Clinics’, so the
code blue response group (anaesthetic
registrar and consultant, obstetric resident
and registrar, perioperative nurse, after
hours co-ordinator and porter) know
exactly where to go.
‘Cervical cancer not
yet beaten – and at
what cost?’
Clinical symposium on cervical cancer
Women’s health practitioners, trainees
and non-medical staff are invited to
the The Royal Women’s Hospital on
Ruth Bergman, Sharyn Donovan,
Kate McLean and Andrew Buettner
Saturday July 17th 2004
8.30am – 5.00pm
Teamwork at its best!
The Royal Women’s Hospital Sailing
Team, Glenys second from the left.
See (page 5) for the full story.
Contact Renae Paul
(03) 9344 2439 or
[email protected]
Is this death preventable?
It became apparent, when clinicians
looked more closely at patients who died
of a cardiac arrest in hospital, that signs of
clinical instability had been apparent from
one to six hours beforehand. During that
time, there were nurses and medical
officers who were concerned about the
patient, but the chain of communication
went up the traditional clinical hierarchy.
There were often significant delays
because of other commitments, for
example, a registrar completing an
outpatient clinic. There were then further
delays when a registrar needed to call a
more senior clinician or other specialist
via their registrar. These delays were
multiplied throughout this complex
communication hierarchy. By this time, the
patient had often gone on to a full cardiac
arrest. Then a Code Blue would be called.
The survival rate for patients who have an
in hospital cardiac arrest is poor (about
60%). A view emerged that a number of
these deaths were preventable.
Two Victorian hospitals, the ARMC and
Dandenong hospital, received funding from
DHS to audit their current practice and trial
the concept of the medical emergency
team (MET). The MET was an innovation
introduced at the Liverpool hospital in
Sydney. The typical team comprises a
medical registrar, an intensive care
registrar, and a senior intensive care nurse
and is equipped with resuscitation drugs,
fluids, and equipment. Any member of the
hospital staff can activate the MET.
The criteria for calling the MET were
available on a small card similar to the
one for codes and well publicised in wards.
The two Victorian projects were very
successful. The incidence of in-house
cardiac arrests was reduced by 65% in
the ARMC project and by 50% in the
Dandenong project . At both hospitals,
unexpected cardiac arrest deaths were
reduced by about half. In simple terms, the
ARMC project saved 80 lives in four months
and was associated with a 26% reduction
in overall hospital mortality. Not only did
these projects save lives, an unexpected
side effect was a significant boost to
morale, especially for nurses and junior
medical staff. Following a Coroner’s report
into a child’s death, the RCH introduced a
paediatric MET. There is now an Australian
wide trial where hospitals have been
randomised to trial the MET concept further
– just to make sure it really works.
Like the RWH Code Green, the MET is a
simple organisational innovation. These
MET projects contested some taken-for
granted aspects of hospital life –
preventable deaths and hierarchical
communication and referral. What does this
mean for RWH? We are not confronted with
the same risks of cardiac arrests, but we do
have a number of patients where there is
a story that sounds a bit like this, where a
patient deteriorates, say from post partum
haemorrhage, and it seems as if the
hospital responds all too slowly and
suddenly there is an emergency. Does the
RWH need a Rapid Response Team and
what would it look like? What do you think?
Emergency response training website
The SIMULATION CENTRE supports education and research
activities using realistic, ‘hands-on’ simulation. The facility has
been designed in such a way as to maximise the benefit from
the experience of a high-fidelity simulation session, in that it
replicates the full complexity of a wide variety of clinical areas
– including Operating Theatre, Intensive Care Unit, Emergency
Department Bay, Delivery suite, and general ward areas.
Criteria for calling the
medical emergency team
- Airway
- Respiratory distress
- Threatened airway
- Breathing
- Respiratory rate > 30/min
- Respiratory rate < 6/min
- SaO2 < 90% on oxygen
- Difficulty speaking
- Circulation
- Blood pressure < 90 mm Hg
despite treatment
- Pulse rate > 130/min
- Neurology
- Any unexplained decrease
in consciousness
- Agitation or delirium
- Repeated or prolonged seizures
- Other
- Concern about patient
- Uncontrolled pain
- Failure to respond to treatment
- Unable to obtain prompt assistance
Dandenong Hospital
Mary Draper
Turn to www.southernhealth.org.au/simcentre to see what’s on
offer. All CRM programs involve joint medical and nursing staff
training. That now familiar link between the medical team and
the air craft crew was employed to enhance teamwork amongst
anaesthetists. On this website you may learn of specific courses
for anaesthetists, emergency department staff and rural general
practitioners and nurses.
Susan Braybrook
Whoops correction for last month’s
website address www.nice.org.uk
ALSO (Advanced Life Support in Obstetrics) course
The ALSO course is an internationally
recognised and accredited educational
program designed to assist health
professionals in developing and maintaining
the knowledge and practical skills needed
to manage the emergencies that may arise
in maternity care. The philosophy that
underpins ALSO is that women and their
families will benefit from the standardised,
and multi-disciplinary approach to
maternity care that the ALSO provider
course engenders. Several staff members
at the RWH are accredited trainers and
many staff have attended the course.
It is usually over subscribed.
Some of the emergencies included
in the course are:
• Shoulder dystocia
• Postpartum haemorrhage
• Forceps and vacuum extraction
• Intrapartum fetal monitoring
• Medical complications of pregnancy
and many more.
Before the course, participants receive
a manual with pre-reading material.
The course involves both theory
and practical sessions on obstetric
emergencies. At the completion of the
course participants complete a theory
and practical exam.
The highlights of the course are the
clearer understanding of the theory behind
obstetric emergency management and
having the opportunity to practice, using
mannequins, in a small group setting. The
only negative aspect of the course is that
the manual is based on an American course
that is yet to be updated to an Australian
program.
As a midwife working in birth suites, the
family birth centre and antenatal clinics, the
course was a very worthwhile. The use of
mnemonics such as:
DR C BRAVADO which stands for:
Determine Risk
Contractions
Baseline Rate
Variability
Accelerations
Decelerations
Overall Assessment
provide logical and clear steps in dealing
with obstetric emergencies. I would
recommend it to other midwives and
doctors working in obstetrics. The cost of
the course is approximately $800 and all the
facilitators volunteer their time to run the
program.
In 2004 the ALSO program will continue
to be offered across Australia and New
Zealand. The next program in Melbourne is
July 31 – Aug 1. Further enquiries can be
sent to [email protected] or Helen
Balwin PO Box 4684 Alice Springs NT 0871
Glenys Jansen
Approach to the shocked patient in the Emergency Department
Shock is not a common presentation to
the RWH emergency department. However
it is one of the commonest emergencies
that we treat. Assessment and treatment of
the shocked patient occurs simultaneously.
Specific treatment is guided by the
diagnosis and a rapid assessment must
be made to generate a working diagnosis.
Common gynaecological diagnoses include
“cervical shock” which results in bradycardia and hypotension secondary to
dilation of the cervix by products of
conception (POC) in the cervix. Shock can
also be caused by hypovolaemia due to
occult blood loss secondary to a ruptured
ectopic pregnancy or a bleeding corpus
luteal cyst.
Vaginal bleeding from ante-partum
haemorrhage, miscarriage, or genital tract
trauma may also present as shock
secondary to hypovolaemia.
Other pregnancy related causes of shock
such as pulmonary embolism or amniotic
fluid embolism also need to be considered
during the initial assessment.
Sepsis can present as shock especially
in the elderly or in oncology patients post
chemotherapy. An uncommon form of
sepsis is toxic shock syndrome which
is caused by Staph Aureus sepsis. The
source of which may be a retained tampon.
Non gynaecological causes of shock
include anaphylaxis, myocardial conditions
(infarction or myocarditis) and drug
overdose.
The basic principles of management are
a coordinated team approach in which
medical and nursing staff provide oxygen,
intravenous fluids, initiate monitoring and
institute a number of investigations. ECG’s,
ultrasound and biochemical analysis are
often performed.
Specific therapy is guided by the diagnosis
and may be as simple as removing POC
from the cervix in the case of cervical
shock or giving adrenaline for anaphylaxis.
However referral to an inpatient unit is
often required for definitive management
such as laparoscopy or urgent delivery.
Sheila Bryan
APRIL GRAND ROUND
How well do we
huff and puff ?
studies of neonatal resuscitation
On the 22nd of April the staff of The Royal
Women’s Hospital were treated to the
fourth grand round, and the first paediatric
Grand Round for the year. Introduced by
Dr Neil Roy, the presentation was led by
Dr Colm O’Donnell, neonatology research
fellow, and delved into the topic of neonatal
resuscitation and research in this field.
This is an international body of neonatologists which convenes every five
years to recommend evidence-guided
practice, but even still, this may fall short
of the ideal, as Colm went on to illustrate.
The current principles of neonatal
resuscitation as we know it are:
thermoregulation; observation and
evaluation; positive pressure ventilation
The impetus for such a discussion arose
(either via mask or endotracheal
from the fact that whilst neonatal
tube); and to a lesser extent
resuscitation is one of the
external cardiac massage
commonest practices in
Current
resuscitation
and pharmacotherapy.
neonatology, it is the least
Colm then proceeded to
studied area in this field,
based on adults is
discuss the ILCOR recomand our practices are
poorly evaluated in
mendations regarding these
poorly evidence-based.
the neonate
key steps and compared
Colm quoted 3% to 5% of
them to the evidence available.
babies delivered worldwide
Whilst ILCOR suggests rapid
will require some form of
drying of the newborn and wrapping
resuscitation at delivery, making it
the infant with pre-warmed wraps under
a common and important intervention.
a radiant heater, it did not discuss
Although we always aim to provide the
polyethylene wrapping, for which there is
best care, the problem is that current
evidence from randomised trials available.
resuscitation principles are based on adult
Whilst ILCOR advises evaluating the
resuscitation, and this approach is poorly
newborn’s heart rate with a stethoscope
evaluated in the neonate. Even with these
or feeling for cord pulsations, there is
techniques borrowed from adult medicine,
evidence that accuracy is poor when it
those used in neonatology are still primitive
comes to assessing heart rate by both
compared to those currently being
auscultation and palpation. ILCOR also
employed in intensive care situations.
advises the determination of cyanosis by
Also, our approach to resuscitation of the
examining central structures and mucous
newborn is based on Dawes’ model of
membranes, but it is well recognised that
single aspyhxial insult, which does not take
this is a generally poor gauge of oxyinto account the pathophysiology of acute
genation. In terms of positive pressure
versus chronic in-utero and intra-partum
ventilation, ILCOR states that ‘most newly
hypoxic insults. Despite all of this, there has
born infants can be adequately ventilated
been an attempt at providing guidelines
with a bag and mask’. Studies have,
and consistency in our practice via the
however, shown that adequate tidal volume
neonatology subcommittee of ILCOR
is rarely produced via the bag and mask
(International Liaison Committee on
in term infants, and there is a paucity of
Resuscitation).
information regarding positive pressure
ventilation via the bag and mask in preterm
infants. ILCOR also recommends the use of
100% oxygen in the management of central
cyanosis, however, there are randomised
trials which demonstrate that air is as
effective as oxygen and a meta-analysis
that shows the use of air decreasing
perinatal mortality. To complicate matters,
there is the inconsistency of our use of
100% dry oxygen at the delivery (either in
the delivery suite or in theatre) but then the
use of warmed, humidified gases once the
baby is transferred to NICU. Superimposed
on this is the concern of hyperoxia and
the potential for oxidative injury in
premature infants.
The situation is made even more difficult
when the issue of resuscitation of preterm
infants is thrown into the picture. These
infants are more prone to cold stress and
evaporative loss, and have a more variable
respiratory drive. They also have more
delicate lungs and are more likely to suffer
from cerebral haemorrhages than term
infants. Superimposed on these difficulties
is the even greater dearth of evidence
about resuscitation in premature infants.
In an effort to address the obvious
deficiencies in our knowledge base of
neonatal resuscitation, Colm and his team
developed a research plan to describe our
practice at the Royal Women’s Hospital.
Specifically, he was hoping to investigate
the efficacy of positive pressure ventilation,
the utility of pulse oximetry and the
performance of staff at resuscitation
procedures.
This was done via a variety of techniques,
including video camera recordings of the
resuscitation itself, with pulse oximetry and
physiological data (primarily a flow sensor
and pressure line that measures tidal
volumes and airway pressures). He then
confirmed how clearly the video recordings
were able to demonstrate the process of
resuscitation by playing a taped example.
The pilot results of the study included 54
taped resuscitations, with no objections
from staff members and agreement from 52
sets of parents to allow the video tape for
use for audit and educational purposes
(only 1 set of parents refused permission on
grounds unrelated to the study). Colm also
managed to address the ethical issues in
research such as this, when parents often
find themselves in a stressful and emotive
period in their lives. Prior to commencement, the Human Research and Ethics
Committee endorsed the study. However,
permission was of course sought from the
parents prior to using the video recordings
for research purposes (hopefully at a time
when they are more removed from the
acute anxiety of delivery). He outlined the
sensitive and confidential manner in which
the tapes were handled, where no staff
member or patient could be identified,
and that they were securely stored and
viewed in private, and then erased after
their analysis.
Colm then finished his highly enjoyable
and informative presentation by concluding
that the study was acceptable to both staff
and family members, and that it allowed
us to accurately study our resuscitation
techniques at The Royal Women’s Hospital.
This has vast potential value in assessing
performance and education, as well as
defining the use of oximetry and positive
pressure ventilation in the resuscitation
of newborns. Ultimately, this can only
serve to improve our practice.
Weiqing Huang
TEAMWORK IN OBSTETRIC EMERGENCIES
0“It’s not what you know,
rather who you know”
Our disciplinary backgrounds differ
hence our professional cultural emphasis
in turn may also vary. As obstetricians,
anaesthetists and midwives, we aim to
arrive at the same conclusions regarding
our patients. In emergency situations,
however, our differences are exposed and
the potential for medical error is magnified.
In the United States, medical error is
the eighth most common cause of death.
Research in safety critical industries tells
us that to overcome this problem we must
better understand the system used to
deliver care 1.
The system, however, is often reliant on a
group of people who are working in a highpressure environment and are often coping
with stress and fatigue. As we well know,
this combination of factors may have a
detrimental impact on our teamwork.
These factors have a prevailing impact
on our labour ward environment. Unlike
the operating theatre where surgeons,
anaesthetists, nurses and technicians work
together on a daily basis 2, the ‘Labour Ward
Emergency Team’ only comes together in
an urgent situation.
Medical training emphasises technical
skills in managing crises. Making the
correct diagnosis, prescribing medication
and dissecting the appropriate tissue are
paramount above communicating in a
courteous yet effective manner with all our
colleagues. Our performance as healthcare
professionals is undermined in emergency
situations when our colleagues choose
to bark orders instead of communicating
and in some extreme cases, even hurl
instruments. This type of behaviour has
been the standard for too long in medicine.
We need to look for proactive ways to
improve our working environment as well
as encourage team work. I believe teams
function better if they have met before
hand. Whilst this is often difficult in large
hospitals, it is not impossible. Attending
each other’s staff meetings, introductions in
the labour ward and theatre or ‘coffee’ are
informal ways that we can encourage team
interaction. Communication is made easier
when the barrier of hierarchy is removed.
The aviation industry has used methods
such as simulated emergencies specifically
challenging team performance in an
emergency situation. Although not verified,
the aviation ‘Crew Resource Management’
approach has more than likely contributed
to the dramatic increase in aviation safety 3.
As we face more deliveries and complex
obstetric cases each year, we should add
non-technical skills to our training focus
in the labour ward.
Because, there is no ‘I’ in team!
Barbara Chia
Fellow in Anaesthesia RWH
References
1. Leape LL, Error in Medicine. JAMA.
1994; 272:1851-7.
2. Sexton JB, Thomas EJ, Helmreich RL, Error,
stress and teamwork in medicine and aviation:
cross sectional surveys. BMJ 2000; 320:745-749.
3. Pizzi L, Goldfarb NL, Nash DB. Chapter 44.
Crew Resource Management and its Applications
in Medicine. Making Health Care Safer. A Critical
Analysis of patient safety practices. University
of California at San Francisco 2/09/03.
Pharmacy news
Metronidazole Dosing
Oral or IV? 12 hourly or 8 hourly? There is
a wide variation in dosing practice at the
RWH.
Metronidazole (Flagyl®, Metrogyl®,
Metronide®) has a serum peak 1-2hrs after
an oral dose and a half life of 6-14hrs. The
minimum inhibitory concentration (MIC)
of metronidazole required to inhibit 90% or
more of most Gram-negative and Grampositive anaerobes ranges from 0.25 to
4 mg/L (Freeman et al, 1997).
Items discontinued by manufacturer
Vitamin B Group and ascorbic acid injection
Morphine-aspirin tablets
Conjugated oestrogens injection
Cefotetan injections
Intravite®
Morphalgin®
Premarin IV ®
Apatef®
Stock items currently unavailable
Oxycodone 30mg suppositories (expected late April 2004)
(consider oral oxycodone tablets or morphine injections)
Metaraminol 10mg injection (expected late April 2004)
(consider phenylephrine injections – see dosage chart – avail in operating theatres)
Recent Australian Adverse Drug Reaction Bulletins
‘For the treatment of mixed aerobic and
anaerobic infection in these guidelines,
metronidazole is recommended in a dose
of 400 mg orally and 500 mg IV, with a
12-hourly dosing schedule. This is based
on pharmacokinetic data and minimum
inhibitory concentrations of the pathogens
involved, rather than formal clinical
studies.’(Antibiotic Guidelines 2003).
So, the dosage recommended is: 400 mg
orally every 12hours or 500 mg IV every
12hours or 500mg rectally every 12 hours.
As excellent absorption means that tablets
and suppositories achieve optimal blood
levels, always consider, is IV use
necessary?
Swee Wong
There have been several recent reports in the Australian Adverse Drug Reaction
(ADR) Bulletins that are relevant to the Royal Women’s Hospital these are worth
a browse. Details can be found on www.tga.health.gov.au/adr
Australian ADR Bulletin Edition
Report
June 2003
Pregnancy despite medroxyprogesterone
Implanon and vaginal bleeding
Hyponatraemia with SSRIs
August 2003
Maternal SSRI use and neonatal effects
October 2003
Anti-epileptic drugs, pregnancy
and foetal malformations
Hormone replacement therapy
December 2003
Meningococcal C vaccine: early experience
Post-partum NSAIDs may cause hypertension
February 2004
Serotonin syndrome
Victorian Travelling Fellowship Program
The Victorian Travelling Fellowship Program is for health professionals, clinicians
and managers presently working within the Victorian Public Health System and
aims to increase innovation and improve patient care by encouraging international
learning and information sharing. The Program gives Fellows a chance to conduct
short professional investigations that will be of value professionally and personally.
The program offers short fellowships of up to 12 weeks to study a host country’s
health system and to exchange interventions, methodologies and experiences with
overseas colleagues. Fellows will receive funding up to a maximum of A$12,000.
See http://www.health.vic.gov.au/travelfellowships/ for details.
Applications close 18th July 2004.
Mary Draper, telephone: (03) 9344 2722 or email: [email protected]
Please let the associate editors have your views on
the contents of this newsletter, or any other matters involving
clinical practice which may be of interest to our readers.
Susan Braybrook, telephone: (03) 9344 2606 or email: [email protected]
The Quality and Safety Unit homepage www.rwh.org.au/quality_rwh
Weiqing Huang, email: [email protected] Jean Wong, telephone: (03) 9344 2752
041341 Designed by the Educational Resource Centre, Women’s & Children’s Health. May 2004
Surgical patients given either
METRONIDAZOLE 400 mg orally every
12 hours or METRONIDAZOLE 500 mg
intravenous (IV) every 12 hours achieved
and maintained serum concentrations in
excess of the MICs for most obligate
anaerobes. Trough serum concentrations
averaged 5.5 mg/L and 6.7 mg/L with
the oral and IV routes, respectively
(Earl et al, 1989).