THE REAL TIME HEALTHCARE PODCAST · Jun 15 · 21:07 min

#37 - Perinatal Care with Humber River Hospital's Dr. Andre LaRoche and Jhanvi Solanki

In this Episode:

In this podcast episode, Jeff Terry is joined by Dr. Andre LaRoche and Jhanvi Solanki from Humber River Hospital. They’ll be speaking about Humber’s journey with the Perinatal Tile, what it does, and how it came into being.

The Perinatal Tile presents and aggregates information gathered from other systems to improve visibility and workflow efficiency, based on hospital defined standards. Tiles do not make clinical determinations and are not intended for patient monitoring.

Jeff Terry
Hello and welcome. I'm Jeff Terry, very happy to be joined today by Dr. Andre LaRoche and Jhanvi Solanki from Humber River Hospital. We're going to speak today about the Perinatal Tile, which is in use at Humber River Hospital, what it does, how it came into being, et cetera. And to start, I'll just share the Tile and so you know what it is. On the left side of the Tile is regarding moms and labor, on the right side is new babies. All this is de-identified of course. At the top on the left scene, we see for today's scheduled deliveries, how many of them are C-sections versus not, how many of the moms are at home versus in the hospital. We see the census of mothers by their *triage score, and to the right, we see the census of mothers by the stage of labor. If we hover on those numbers, it tells us who the mom is, her location, et cetera.

*The Tile takes the triage score directly from the EMR.

Down below in this first section, we have alerts. If based on the triage score, either the nurse assessment or the physician visit is not what we would expect it to be, and then down below here, we're alerting based on certain risks. Those include abnormal fetal heart rate, risk of gestational hypertension, at risk of postpartum hemorrhage, no anti-natal record, and an elevated maternal early warning score. Importantly, all of those alerts are created in the EMR. We're surfacing them here and organizing them here, but we're not creating them in the Tile. On the right at the top, again, you see the census of new babies. To the right, we see the census by their location. We see alerts below that based on a newborn early warning score and each of the pills tells us the vital sign values that are contributing. And of course, if we are to hover on those, it would tell me the score and the times when each of those vitals was taken.

And then down below, we're monitoring several risks, again from the EMR that we're surfacing and organizing here relative to the new babies, and those are chord bilirubin, yellow bilirubin, glucose, risk of intercranial bleed as indicated by head circumference, RSV screening, and that newborn early warning score. And of course, all that's real time so it's changing every 30 seconds like the airport board. It's just constantly changing.

So with that, let's bring in Dr. LaRoche and Jhanvi, and Jhanvi, maybe I'll start with you. So obviously, this is the culmination of years of work to get this into practice. Can we go back to the beginning? Why did we embark on this? Where did the idea come from? How did the journey begin?

Jhanvi Solanki
So the journey really began with playing around with the concepts of what would generation two at Humber really be about? And there was multiple engagement sessions with stakeholders, physicians, frontline staff, clinical administrators, also nonclinical administrators, and just to really look at what were the pain points within the hospital, that if there was sort of a single silver bullet kind of solution, what kind of things would we like to focus on? And what happened was we came up with 350 ideas that were distilled down to 149 main concepts that further got distilled down to seven to 12 themes that landed in four generation two Tiles.

The perinatal space is very highly litigious, and it is one of those environments where escalation, communication, a lot of those themes are very ... They're very heightened and they need to be played out in a matter of minutes and seconds. And that was a concept that really was not explored in many different organizations, because it is a very complex system, and to try and break that down into something that we saw there at the perinatal Tile, that was a lot of work and a lot of different concepts all meshed together in there to actually build something out. And that journey really started with saying how do we reduce the risk that the hospital and the clinicians frontline, so physicians and nursing alike, experience in this kind of environment and how do we reduce the clinical risks to the patients as well?

So we know a lot of literature tells us there's direct cause and effect for how the interpartum process happens with mom, and then there's direct links to neonatal harm. So when we look at some of those pieces, and Dr. LaRoche can speak to some of those links a little bit more in depth, but when we look at that, there has been some very clear links established and that's essentially the journey that we've set out on is to reduce the risks to our moms and our babies that deliver here at Humber.

Jeff Terry
Wonderful. So it's both, obviously, both clinical and outcomes and financials. Good morning, by the way, Jhanvi, I forgot to say that.

Jhanvi Solanki
Good morning.

Jeff Terry
Good morning, Dr. LaRoche.

Dr. Andre LaRoche
Good morning.

Jeff Terry
So same question to you. What's your reflection on how this journey began and why we decided to focus on perinatal?

Dr. Andre LaRoche
Yeah, I mean, when you look at the hospital, you have to kind of look at different areas where you want to improve outcomes. So the command center has its different Tiles that we're looking at and one of the areas that had great potential was for the perinatal space. It is a large program within our hospital. The long-term outcomes of the babies kind of reflect your kind of longterm outcomes at the hospital, the engagement of the patients to come back to the hospital, depending on how their experience was, and how the outcomes of their delivery was. So it's a really important area to focus on. But not only that for obviously, the health of the mother and the baby.

And I remember when we started this process, it also kind of coincided with Jhanvi and I kind of taking over the program, so we also reflected and looked back and said historically, what are the adverse events, the trend in adverse events that took place over say the last five years? Where are the big themes? And let's try to focus on working on improving those outcomes so that our long-term outcomes are improved. And within that 350 themes, that came down to 149, working down and whittling down to major themes that we would work on in the Tile because we could look at all 149, but that would make a very messy Tile. So we had to kind of break down and look at what are the kind of bang for your buck items that we can work on and then go from there to get the best results and best outcomes that we have.

Jeff Terry
And so that started at the journey, and then, so obviously, then went into a design process, specified all the data and all the things you have to do, went into practice, I guess, about a year ago, I think. How is it used in a day-to-day basis?

Dr. Andre LaRoche
I kind of break up our day as so we start become one service, so for our OBs, we're here for 24 hours. So we'll come to our handover regroup with anesthesia, the nursing team, and the OBs that were coming on, which would be say myself and the OB that just finished working 24 hours and our learners. And we sit in front of the board and we look at the board and it allows us to kind of first, group all of our ideas of where what's coming in for the day, what kind of patients are already here, what potential patients could end up with a C-section, what could be delayed, and kind of giving us an overall view of what's happening right now on the floor.

And it also helps to prioritize, but also to ensure that we're not missing anything because hand over is one of those places where we know that there's ability to lose information from kind of like that telephone game, you pass it on from one person to the next to the next and it's easy to miss something along the way or change the information along the way. So this allows us to consolidate everything in one space. And then from there during the day it allows us to come back and look at that screen, remind us okay, this is what's happening, this is what still needs to happen, because it is a big unit and most labor and delivery areas are fairly big and expanding now.

And with increased volumes, it's easy to kind of lose track of who's around and what's coming in, what's going out. But then the alerts from a real-time aspect, every time that something changes in the patient's status, that alert comes up on the screen, and then we're also getting those alerts to our phones depending on what the action is that we created for that alert. So it just allows us to have a better sense of what's going on and to ensure that we're providing the best patient care that we can.

Jeff Terry
Where do you see it, the screen, do you have it on an LCD up on the wall, on a PC? Both?

Dr. Andre LaRoche
Yeah, so we have it ... There's different places that it can be displayed. So it can be displayed on any computer really. We have at first at our main nursing station where kind of everybody gathers around. We have a satellite nursing station where we also display that. We have it displayed in our triage area as well, so that we can ... Because those are kind of the three main areas where we're working. But again, like I said, we can pull it up anywhere to kind of reflect on what's happening.

Jeff Terry
Brilliant. Thank you. And Jhanvi, same question to you. How is it used in practice sort of from a nursing perspective?

Jhanvi Solanki
Sure. So everything that is displayed on the Tile starts really with the nurse and the patient, as soon as they enter into the system, the first triage assessment is completed and that is our obstetrical triage acuity scale. And as soon as that's completed in our EMR, within four seconds, it starts to display on the command center Tile. And then the nice part about that, the perinatal Tile, is it can be used anywhere like Dr. LaRoche mentioned.

So we have it up and it's a really good overview for our resource nurses as well, because when they're at the desk it's very hard to be in multiple places at the same time. We're a very new hospital, so we're a lot farther than we used to be in the older sites. So in the older sites, you'd have a nursing station and your beds would sort of surround the nursing station and your resource nurse really wasn't traveling very far in terms of mileage.

Here, our triage unit is quite far from our main unit and the NICU, although close, it's still quite far. So when you actually look at just the footprint of the fourth floor where the [inaudible 00:11:00] program is located, it really is very important for the resource nurse, especially on labor and delivery, to have a really good handle on what's really happening in triage and what's happening on the unit.

So the scale, which is the first left-hand quadrant of the Tile really provides that situational awareness, and they can actually help start planning their day. As you have emergencies coming in, as you're discharging patients that are being induced, and then the patients that you're expecting to come back, they can actually start to plan a flow for their day. And just the labor stage awareness also allows them to actually have those conversations with the obstetrician and anesthesia to really better coordinate what's happening and what's going on. So that's that aspect.

The second aspect is this obstetrical alerts, and so as the nurse continues to assess the patient at the bedside, they continue to enter this information. A lot of it is algorithms, pearls of wisdom, that already exists within SOGC, which is the governing body for obstetrics in Canada and also in the Children's Pediatric Society. And we've taken a lot of those algorithms that are used in clinical practice that are sort of chocked up as this is your clinical judgment, and what we've tried to do is we've tried to distill them into tangible sort of alerts.

So all of these information points are fed into our EMR by the nurse and we have a surveillance module that lives in our EMR that actually helps create some of these alerts and feeds them to the command center again, within four seconds. Great situational awareness that there is a mom struggling with potentially gestational hypertension alert or a postpartum hemorrhage that requires the command center to help coordinate with interventional radiology.

So again, that's where it really becomes very effective with the command center or clinical expediter intervening when the charge nurse needs at most, because previously you would make multiple phone calls, you'd have to call the command center, but now it's a bit of a pull system, if you will, in a different sort of aspect where the clinical teams are not trying to continue to push for the resources, but the clinical expediter is actually pulling resources and providing to the clinical team. And that's a really different concept for us as well, and we're loving the benefits of that because we just had a code Omega the day before yesterday and the way that it was coordinated quite seamlessly.

Jeff Terry
And remind me of code Omega, was that ...?

Jhanvi Solanki
It's a mass transfusion protocol. So it's somebody bleeding that requires intervention right away. And they were able to quite nicely actually align resources with interventional radiology and the support needed as well. So again, it's those types of situations that really ... Where all of the delays in care are quite quickly reduced and the team comes together quite quickly. Although there is actual standardized protocols for protocols and procedures, the overarching coordination of resources, hospitals still struggle with that and it's something that this Tile has really significantly helped us with reducing.

The other aspect of the Tile, which is the neonatal piece, is very much used in our postpartum and our NICU and the early warning scores with the neonatal Tile has actually been quite ... It's been designed by our pediatricians with our nursing teams and the fetal health ... Sorry, the new needle alerts themselves have also been designed with our pediatric team and it's the same concept where the nurse enters assessments into the EMR and they continue to flag on the command center and we're able to align the right resources and ensure that assessments are done in a timely fashion and the escalations happen appropriately.

Jeff Terry
Brilliant. Well same with you Jhanvi, and you alluded to one example where the command center in general helped to coordinate through a tough situation, and I know we haven't published on impact yet from the perinatal work, but what's your sense of the impact that the Tile has delivered?

Jhanvi Solanki
So in terms of anecdotal data, we have seen a reduction of transfers of babies from mother baby unit to our NICU. I don't know if that's a good thing or a bad thing because we're reducing our NICU occupancy quite significantly, but what's happening is we're not having to do those transfers. Because of the early warning score and the alerting, we're able to catch these issues early and the teams are able to intervene early. So as a result of that, we might have more transfers from our mother baby unit directly to tertiary centers as opposed to transfers to NICU and then potential transfers to tertiary.

So we've definitely seen, and they're proactive transfers mind you, they're not actually where patients have deteriorated, they're actually proactive transfers. So we are definitely seeing that on the neonatal side. We have seen a lot more communication on the obstetrical side and actually when we actually launched the Tile, the Tile was filled with alerts and timeframes for an assessment and admission and that sort of stuff, and what we now see is more scaled back in terms of alerts, but more focused alerts.

So we're still getting used to this concept in the perinatal space, I'll be very honest, because this is not something that's natural within the perinatal environment, but it is something where the alerts are becoming more focused, and at any given point, if you actually look at the Tile, it gives you a really good indication of what is the risk level on the unit. And so from an anecdotal standpoint, we've definitely seen a lot of gains from that communication and that situational awareness as well.

Jeff Terry
Brilliant. And I should mention, by the way, I'm asking the result of the Tile. Obviously, the Tile is a piece of it. The nurses, the physicians, are delivering the value, but the Tile helps to bring things into focus clearly, so just to clarify for the audience. And Dr. LaRoche, same question to you. I know we haven't published, but what's your sense of the impact?

Dr. Andre LaRoche
Yeah, so I mean, from a physician standpoint, one piece is just the communication piece that seems to flow a lot better. I think because each alert has a predetermined set of actions and then an escalation process if those actions aren't taken, it just really helps improve the communication part of things. So we are really aware of what's happening with our patients at all times.

The other part that Jhanvi had already talked about is the process of when there is an emergency happening, kind of streamlining the process of having assistance. So prior to this, say if we were dealing with a severe hemorrhage, we'd have to be calling into ... We'd have to stop managing the patient, call interventional radiology ourselves, call the ICU and try to manage to get the patient transferred there. Whereas now the command center is kind of that step in between that helps coordinate all of that for us so that we can keep our attention to the patient.

Jeff Terry
Let me just confirm there that, Jhanvi mentioned that as well, that coordination, that's the clinical expediter, that's the person who's doing it?

Jhanvi Solanki
Right.

Dr. Andre LaRoche
Exactly. And then the other aspect of that is because of our early warnings, we have been able to reduce the amount of severe preeclampsia, [inaudible 00:18:45] ending up in ICU, the amount of postpartum hemorrhages, trying to kind of act on those ahead of time prophylactically getting medications to try to prevent them from having a post-partum hemorrhage in the first place then ending up requiring multiple transfusions. So I think just heightening the alertness and the awareness of everybody about potential risk has really decreased our adverse events that we've been experiencing.

Jeff Terry
That's amazing, right? That's ... Yeah, safety begins with vigilance and if we're contributing to vigilance ... Brilliant. And Dr. LaRoche staying with you, feedback from clinicians, and I ask that sort of conscious, at Humber and at other places that early on in these journeys, there's a lot of questions about big brother and second guessing, and over time it sort of falls into place. Has that happened? What's your sense of the reaction or your personal reaction and that of the other physicians?

Dr. Andre LaRoche
So for sure, I mean, anytime that something like this comes into a hospital, I think there's always that sense of big brother. I know in the command center before we even had the perinatal title, just the command center itself, physicians had this, "Oh my God, why do they need to watch us?" And then after time ... and they realize the benefits of the command center, that kind of dissipates. And then now you create the new perinatal Tile and everybody is saying, "Why do you need to watch us?" So there's always that kind of initial resistance and hesitancy that kind of goes by the wayside afterwards once they see the benefits and the outcomes that are happening.

I think also at the beginning, because we had more alerts and have kind of cut those back over time to realize what works and what doesn't work, what do we need to alert about, how fast do we need to alert, and we've kind of adapted those and change those over time, then the amount of alerts that we're getting is also less so that helps with the acceptance of this type of program as well.

But at the beginning, we ... because it was a bit of a novel idea, we had to alert more and say, "Okay, we're going to start with all these alerts and see ... I know it's probably going to irritate people." Me included, I was a little bit irritated at the beginning when everybody was getting all these alerts, but it helped us allow and get the feedback from people what is working, what's not working, and then from there, work down into something that's a little bit more streamlined and working smoother for us now.

Jeff Terry
And I've heard that sort of called shining, it's shining a bright light into the corners because you're a mirror, right? Giving you a good sense of in real time the situation that otherwise may be tough to know, and then having to titrate and learn from that. Which I guess like you, I think early on in my experience, we used to be freaked out when people, but now we've learned that that's part of the journey, that you may be surprised, but we'll figure out how to titrate, adjust, the practice will change, et cetera. Brilliant. Jhanvi, your sense of that feedback from the clinicians over time.

Jhanvi Solanki
I think it's just exactly that, shining a light into a dark corner. I find in my journey with gen two, I find a lot of people find data quite scary. Although everybody says that they would love to see all this data, once you actually present people with data, it's actually quite scary and it is actually ... I mean, I would say it is a bit of a revelation in its own because sometimes we think the way we practice is not what comes out when we look at the data. Sometimes gaps with documentation come out.

And there's a lot of internal process work that had to happen for the perinatal Tile. We actually, amidst designing the perinatal Tile, we also changed EMRs within our perinatal unit because there was some gaps within the EMR. And so just navigating some of those pieces and some of those documentation intricacies I would say was quite interesting and quite challenging for some of the staff as well, because some things are second nature, but some things are not. And data is actually, I find everybody says, "You know what? Let's take a look at the data." And then you present the data and everyone's like, "Let's never look at that data ever again."

And you know what? It is not a Humber thing because I've experienced this in many different organizations and something as simple as vital signs or something as simple as sort of assessments. And it's very interesting because there is a whole psychological safety component attached to some of these pieces and being a high reliability organization, redundancy is something that we like to create in our processes.

And so when you actually marry all of the concepts together and conceptually you have a framework that you're following, and then when you actually look at the clinical practice and the way that the systems are set up as well, it really provides an opportunity to look at this from a systems perspective too, for those improvements as well. So initially we had a lot of pushback saying, "Perinatal nursing is an art and not a science, and I'm not really sure where you're coming at with this."

We did a lot of change management. We had a lot of sessions with legal. We had a lot of sessions with the nursing societies. We brought in very prominent speakers and then things started to stick. So that was a very long journey and it was a very long engagement as well within the perinatal space for the nursing staff for sure.

Jeff Terry
That's brilliant. And it is funny, I can relate to it. I mean, I like to see data on other people's performance.

Jhanvi Solanki
Right?

Jeff Terry
But if someone presents data on my own, that's a whole different experience. Brilliant. Well, Jhanvi, thank you so much, Dr. LaRoche, thank you so much. And congratulations on the work and thank you, by the way, for pushing GE. This was among the things, the Tiles that we've done.,This was one of the more difficult ones and you did not let us take no for an answer and I think in the long run, we're all glad we got there. So thank you. And with that, thanks to the audience, and I'll close the podcast.

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The Discharge Barriers Tile outlines the key actions the care team can take to facilitate ...
Jun 18 · 14:18 min
The Discharge Barriers Tile outlines the key actions the care team can take to facilitate patients who are identified ...
Jun 18 · 14:18 min
10:31 min
#11 - Boarders Tile Cover Image
The Boarders Tile provides facility and system level visibility to all inbound pressure ...
Jun 16 · 10:31 min
The Boarders Tile provides facility and system level visibility to all inbound pressure on the system to take patients ...
Jun 16 · 10:31 min
14:43 min
#10 - Capacity Snapshot Tile Cover Image
The Capacity Snapshot Tile provides insight on bed capacity both in the moment and after ...
Jun 11 · 14:43 min
The Capacity Snapshot Tile provides insight on bed capacity both in the moment and after we process decisions.
Jun 11 · 14:43 min
07:36 min
#09 - Critical Resources Tile Cover Image
From State-level to Unit-level, Real Time awareness of available beds.
Jun 9 · 07:36 min
From State-level to Unit-level, Real Time awareness of available beds.
Jun 9 · 07:36 min
06:46 min
#08 - Infectious Disease Tile Cover Image
The Infectious Disease Tile was developed in response the COVID-19 pandemic. It provides ...
Jun 4 · 06:46 min
The Infectious Disease Tile was developed in response the COVID-19 pandemic. It provides visualization of patient load ...
Jun 4 · 06:46 min
05:08 min
#07 - Post Acute Placement Tile Cover Image
The Post Acute Placement Tile is used to reduce excess days and facilitate outplacement ...
Jun 2 · 05:08 min
The Post Acute Placement Tile is used to reduce excess days and facilitate outplacement of patients from an inpatient ...
Jun 2 · 05:08 min
06:49 min
#06 - Imaging Expediter Tile Cover Image
The Imaging Expediter Tile provides Real Time visibility to available capacity by ...
May 28 · 06:49 min
The Imaging Expediter Tile provides Real Time visibility to available capacity by modality and supports operational ...
May 28 · 06:49 min
04:20 min
#05 - Care Progression Tile Cover Image
The Care Progression Tile provides hospitals the ability to track patients throughout ...
May 26 · 04:20 min
The Care Progression Tile provides hospitals the ability to track patients throughout their inpatient stay.
May 26 · 04:20 min
05:15 min
#04 - Risk of Harm Tile Cover Image
The Risk of Harm Tile provides visibility to track variations in practice versus hospital ...
May 21 · 05:15 min
The Risk of Harm Tile provides visibility to track variations in practice versus hospital defined care plans.
May 21 · 05:15 min
05:51 min
#03 - Seniors Care Tile Cover Image
The Seniors Care Tile helps ensure geriatric inpatients outside the geriatric unit ...
May 19 · 05:51 min
The Seniors Care Tile helps ensure geriatric inpatients outside the geriatric unit receive best practice care in ...
May 19 · 05:51 min
08:46 min
#02 - Discharge Planning and Escalation Tile Cover Image
The Discharge Planning Tile empowers rounding across the system by providing a fast way ...
May 14 · 08:46 min
The Discharge Planning Tile empowers rounding across the system by providing a fast way to review patients, log ...
May 14 · 08:46 min
06:34 min
#01 -  Cover Image
The Clinical Deterioration Tile brings real-time, all-the-time awareness of the status of ...
Aug 1 · 06:34 min
The Clinical Deterioration Tile brings real-time, all-the-time awareness of the status of the most critically ill ...
Aug 1 · 06:34 min

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