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380万妇女及其婴儿 每年都有100多名妇女从产后护理中出院。快速的患者更替，早在阴道分娩后24-48小时，48-96小时 在剖腹产后24小时，限制了临床工作人员就优先健康问题教育家庭的时间。目前，高 数量，相对较短的停留时间，以及在出院前要完成的多项行政任务， 用于发病率检测的工具，增加了患者伤害风险。这种高通量系统不能充分地服务婴儿， 母亲：美国的婴儿死亡率在35个经合组织国家中排名第24位，我们是世界上唯一的高收入国家。 孕产妇死亡率正在上升的世界，非西班牙裔黑人妇女的死亡率是非西班牙裔黑人妇女的3-4倍。 非西班牙裔白色女性。需要跨学科的合作，以确定潜在的贡献者，产后 发病率和死亡率，并共同发展更有效，可持续和可扩展的产后护理。我们长远的目标是 重新设计临床产妇护理系统，以更好地使新家庭茁壮成长。这项建议的目的是 定义产后单元问题，并创建一个创新的，个性化的交付系统，更有效的母婴 产后住院期间的管理和出院回家的过渡。北卡罗来纳州 在查佩尔山，与俄亥俄州州立大学和北卡罗来纳州州立大学的系统工程合作 设计学院，将建立北卡罗来纳州妇女医院作为母婴跨学科学习实验室 对产后住院单位和过渡期间的家庭进行双重管理。我们将评估我们的系统重新设计使用 从出院到90天，急诊就诊和再入院减少20%的主要结局 产后的母亲和婴儿。为了降低产后发病率，我们计划改善患者安全， 三个交叉领域的护理价值：母婴康复、精确临床护理和医院护理过渡 回家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：分析当前母婴二元评价和管理的流程和程序， 通过母亲、临床医生、EHR数据和其他关键利益相关者的透镜，实现产后住院和出院过渡;目的 2)干预措施的迭代原型设计和评价。在确定的设计种子的基础上，我们将在以下想法之间交替 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， 完善，然后在临床设置;目标3）实施和传播。在此阶段，我们将使用PDSA 循环，以充分实施“捆绑”的成功创新产后单位在数控妇女医院，并评估我们的 产后90天内急性护理利用的主要结局。这项工作的结果将是一个以人为本的 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始 和他们的婴儿，以及提供一个更综合的，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.