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documentation of this program. Finally, long-term
goals involve promoting depression screening in
all obstetrician o⁄ces associated with this hospital
and supporting a collaborative network within the
community dedicated to improving the mental
health of perinatal women.
Packed and Wearing Pink: Damage Control
Surgery in the Obstetric Operating Room
Poster Presentation
Evaluation of hospital practice standards to im-
prove practice and patient outcomes must
occur on a routine schedule. During a review of our
hospitals Sponge, Sharp and Instrument Count
Policy, it was identi¢ed that a communication sys-
tem needed to be developed for the severely
injured, unstable, surgical patient who required ab-
dominal packing and required immediate transfer to
a surgical trauma intensive unit for stabilization.
Damage control surgery has had a major impact
on the survival rate in the severely injured trauma
patient, especially one who has sustained a life-
threatening injury such as liver rupture. Although
damage control surgery continues to be a mainstay
in trauma surgery, its use in the obstetric (OB) pop-
ulation within our institution has become a
standard of care when the unexpected occurs in
the OB operating room. Damage control surgery
has had a direct impact on the survival of patients
who experienced a liver rupture and unstable, sur-
gical, amniotic emboli patients.
Evidence suggests that abdominal packing and a
staged repair of hepatic and retroperitoneal injury
are more e¡ective if instituted early as part of the
resuscitative e¡orts in the management and pre-
vention of the lethal triad of hypothermia, acidosis,
and coagulopathy. Because the time to reoperation
varies between 8 hours and 10 days, a team of op-
erating room nurses, intensive care nurses, and
obstetric nurses developed a patient safety process
to prevent retained sponge(s) following damage
control surgery. Communication between the OB
unit, Surgical Intensive Care Unit, and Operating
Unit is a critical safety factor that needs to be initi-
ated with the packing procedure and continues
through the ¢nal operative procedure and removal
of packing.
The team decided that when a patient has damage
control surgery, a pink bracelet would be applied to
alert the Intensive Care Unit bedside nurse that the
patient has abdominal packing, and a packing log
is included in her chart to be used when packing is
removed or when packing is added. The presenta-
tion discusses the development the packing log
process to prevent retained sponges following dam-
age control surgery in the OB patient. Included in
the presentation are three OB patient scenarios
where favorable outcomes depended on damage
control surgery and communication between
disciplines.
Scheduled Cesarean Delivery: Start-Time
Performance Improvement Initiative
Poster Presentation
Service e⁄ciency and e¡ectiveness are impor-
tant concerns for many hospitals today. This is
particularly true in the operating room (OR), which is
one of a hospital’s largest revenue-producing cost
centers.The Scheduled Cesarean Section (C/S) pro-
ject began in 2005 with the perception that cases
were delayed and the Obstetric OR was run in aman-
ner that did not meet the surgeon, anesthesia,
or the patient needs. These perceptions often led to
frustration and hostility among team members,
which greatly a¡ected employee, physician, and pa-
tient satisfaction. This performance improvement (PI)
Nancy Skinner, MSN, RNC,
Women’s & Children’s Ser-
vices, Christiana Care Health
Services, Newark, DE
Childbearing
JOGNN 2010; Vol. 39, Supplement 1 S39
Skinner, N. I N N O V A T I V E P R O G R A M S
Proceedings of the 2010 AWHONN Annual Convention
project was developed to identify barriers and put
into place recommended system changes to improve
obstetric OR e⁄ciency and e¡ectiveness, increase
teamwork and pride, and improve overall satisfaction
among caregivers.
To accomplish the PI project, a task force consisting
of physicians, labor and delivery room (LDR) sta¡
nurses, LDR leadership, and anesthesia was
formed to enhance productivity and e⁄ciency in
the OR that would balance patient safety and sta¡
satisfaction.
It was then decided that baseline data were needed
to validate the physician’s perceptions and evaluate
any improvements that may occur. Review and
analysis of the retrospective data by the task force
identi¢ed three major reasons for delay. Behaviors
of physicians, nurses, and anesthesiologists were
identi¢ed as the top three barriers to starting
scheduled cases on time. The task force discussed
actions and strategies that would e¡ectively
change the behaviors of the groups involved. The
¢rst strategy was to have all parties involved use
the same de¢nition of start time of the procedure.
Start time was de¢ned for all disciplines involved.
Next the task force considered what actions would
best help the OR sta¡ to reach the goal set at 90%
of all scheduled C/S cases starting on time.
After reaching and consistently maintaining the
goal of 90% on time starts, the unit and the organi-
zation continue to reap the bene¢ts gained from the
Scheduled C/S on-time PI project for the past 5
years. From a quality perspective, the project results
have improved throughput in the OR, increased
professionalism and collaboration between disci-
plines, and created a positive work environment for
the clinicians and sta¡ members.
Decision to Incision Time for Unscheduled
Cesarean Deliveries: Can We Meet the
Standard?
Poster Presentation
The national standard for performing unsched-
uled Cesarean delivery is 30 minutes from the
time of decision for Cesarean delivery to the time of
the incision.There is little evidence supporting a re-
lationship between the decision-to-incision interval
and maternal or neonatal outcomes. Despite the
lack of evidence, the 30-minute standard is the
benchmark in medical-legal proceedings where
the timeliness of Cesarean delivery is questioned.
Published studies indicate that the 30-minute stan-
dard is met in only 50% to 75% of cases of
emergency Cesarean delivery.
Observations in our facility suggested that we were
not meeting the standard. Review of 36 cases of un-
scheduled Cesarean delivery performed for
nonreassuring fetal status demonstrated that the
average time from decision to incision was 39 min-
utes, with a range of 10 to 90 minutes. The 30-
minute standard was met in 25% of cases. This
prompted a full review of the process and resources
for performing unscheduled Cesarean deliveries.
In 2008, 5,988 mothers delivered in our facility,1,226
by unscheduled Cesarean delivery. In 1998, 615 la-
boring women, from a total of 4,728 deliveries,
required unscheduled Cesarean delivery. Despite
the near doubling of unscheduled Cesarean deliv-
eries, the process had changed minimally and the
resources (personnel and physical) had not in-
creased, making it di⁄cult to meet the standard.
Data were shared with medical and nursing sta¡,
and a concerted e¡ort was started to improve per-
formance. An audit form was completed for each
unscheduled Cesarean delivery allowing measure-
ment of the following:
� Average time from decision to incision for un-
scheduled Cesarean deliveries
� Frequency of meeting 30-minute standard by
indication for Cesarean
� Reasons for delay when standard not met
With increased awareness, the frequency of
meeting the 30-minute standard for cases of
nonreassuring fetal status quickly increased to
44% and remained 43% to 47% over the next
year. An interdisciplinary team under the direction
Donna Smith, MSN, RNC-OB,
Women’s and Children’s Ser-
vices, Christiana Care Health
System, Newark, DE
Barbara A. Temple, RN,
Christiana Care Health
System, Newark, DE
Childbearing
Beverly VanderWal, MN,
RNC, MemorialCare Center
for Women, Miller Children’s
Hospital, Long Beach Memo-
rial Medical Center, Long
Beach, CA
Childbearing
S40 JOGNN, 39, S19-S41; 2010. DOI: 10.1111/j.1552-6909.2010.01119.x http://jognn.awhonn.org
I N N O V A T I V E P R O G R A M S
Proceedings of the 2010 AWHONN Annual Convention