Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality

摘要 分娩是美国最常见的住院指征；超过380万名妇女和她们的婴儿 每年都从产后护理中出院。患者周转迅速，最早在阴道分娩后24-48小时，48-96小时 剖腹产后数小时，限制了临床工作人员就优先健康问题对家庭进行教育的时间。目前，最高 数量大、停留时间相对较短、出院前需要完成多项行政任务，如果没有有效的 用于发病率检测的工具增加了患者受到伤害的风险。这种高吞吐量系统不能充分服务于婴儿和 母亲：在35个经合组织国家中，美国的婴儿死亡率排名第24位，我们是唯一一个 产妇死亡率上升的世界，非西班牙裔黑人妇女的死亡率是 非西班牙裔白人女性。需要跨学科的合作，以确定出生后的潜在贡献者 发病率和死亡率，并共同开发更有效、可持续和可扩展的产后护理。我们的长期目标是 重新设计临床产科护理制度，以更好地使新家庭茁壮成长。这项建议的目的是 定义产后单位问题并创建创新的个性化分娩系统，以实现更有效的母婴 产后住院和出院过渡到家期间的管理。北卡罗来纳大学 在教堂山，与俄亥俄州立大学和北卡罗来纳州立大学的系统工程合作 设计学院将建立北卡罗来纳州女子医院作为母婴跨学科学习实验室 产后医院单元和过渡期间的二元管理。我们将使用以下工具评估我们的系统重新设计 急诊科就诊和从出院到90天再入院减少20%的主要结果 母亲和婴儿产后使用。为了实现这一减少出生后发病率，我们计划提高患者的安全性和 三个交叉领域的护理价值：母婴康复、精确临床护理和医院转院护理 为家干杯。我们将通过以下具体目标实现我们的目标：目标1)确定优先领域。使用混合 方法，我们将分析目前母婴二元评估和管理的过程和程序。 通过母亲、临床医生、电子病历数据和其他关键利益相关者的视角，实现产后单位停留和出院过渡；目的 2)干预措施的迭代原型和评估。在已确定的设计种子的基础上，我们将在创意之间交替 生成和评估，直到原型出现，可以在低风险的实验室环境中实施和评估 改进，然后在临床环境中；目标3)实施和传播。在此阶段，我们将使用PDSA 在北控妇女医院产后病房全面实施成功创新的周期和评估我们的 产后90天内急性护理利用的主要结果。这项工作的结果将是一个以人为中心的 重新设计产后护理，以确保成长中的家庭更安全地过渡。该项目将使母亲们有一个更好的开端 以及提供一种更综合的、基于价值的护理模式，可以与其他医院共享 广泛实施。

ABSTRACT Childbirth is the most common indication for hospitalization the United States; more than 3.8 million women and their infants are discharged from postnatal care each year. Rapid patient turnover, as early as 24-48 hours following vaginal birth and 48-96 hours following cesarean birth, limits time for clinical staff to educate families on priority health issues. Currently, the high volume, relatively short stays, and multiple administrative tasks to be completed prior to discharge, in the absence of effective tools for morbidity detection, increases risk for patient harm. This high throughput system fails to adequately serve infants and mothers: The United States ranks 24 of 35 OECD countries for infant mortality, and we are the only high income country in the world in which maternal mortality rates are rising, with rates 3-4 times greater for non-Hispanic Black women than for non-Hispanic White women. Transdisciplinary collaboration is needed in order to identify underlying contributors to postnatal morbidity and mortality and co-develop more effective, sustainable, and scalable postnatal care. Our long-term objective is to redesign systems of clinical maternity care to better enable new families to thrive. The objective of this proposal is to define postnatal unit problems and create an innovative, individualized delivery system for more effective mother-infant management during postnatal hospitalization and the discharge transition to home. The University of North Carolina at Chapel Hill, in partnership with Systems Engineering at The Ohio State University and the North Carolina State University College of Design, will establish North Carolina Women's Hospital as transdisciplinary Learning Laboratory for mother-infant dyadic management on the postnatal hospital unit and during the transition home. We will evaluate our systems redesign using the primary outcome of a 20% reduction in emergency department visits and readmission from discharge to 90 days postpartum for mothers and infants. To achieve this reduction in postnatal morbidity, we plan to improve patient safety and care value in three intersecting domains: Mother/Baby Recovery, Precision Clinical Care, and Care Transition from Hospital to Home. We will achieve our objectives through the following Specific Aims: Aim 1) Define Priority Areas. Using mixed methods, we will analyze current processes and procedures for maternal-infant dyadic evaluation and management during the postnatal unit stay and discharge transition through the lens of mothers, clinicians, EHR data, and other key stakeholders; Aim 2) Iterative prototyping and evaluation of interventions. Building on identified design seeds, we will alternate between idea generation and evaluation until prototypes emerge that can be implemented and assessed in a low-stakes laboratory setting for refinement and then in the clinical setting; Aim 3) Implementation and dissemination. In this phase, we will use PDSA cycles to fully implement “bundles” of successful innovations on the postnatal unit at NC Women's Hospital and evaluate our primary outcome of acute care utilization within 90 days postpartum. The result of this work will be a human-centered redesign of postnatal care to ensure safer transitions for growing families. The project will enable a stronger start for mothers and their infants, as well as offering a more integrated, value-based model for care that can be shared with other hospitals for widespread implementation.