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Society for Maternal-Fetal Medicine Special Statement: A maternal transport briefing form and checklist

Published:August 27, 2020DOI:https://doi.org/10.1016/j.ajog.2020.08.065
      When performing a maternal transport between two facilities, numerous pieces of information must be communicated between physicians, nurses, and transport personnel, including the health status of 2 patients (mother and fetus), availability of bed space and personnel in 2 units at the receiving facility (labor and delivery unit and neonatal intensive care unit), arrangements for transportation, and inpatient and outpatient records. The amount and complexity of information creates a risk of medical error due to communication lapses. A cognitive aid such as a standardized form can help the team prepare for a transfer and provide a consistent framework for a handoff briefing among healthcare professionals. SMFM presents a sample briefing form to ensure that key elements are communicated for every maternal transport. Practical suggestions are given to help facilities customize the form and implement it on their units.

      Key words

      Introduction

      Pregnant and postpartum patients sometimes require transfer to a hospital with a higher level of care. A common reason for transfer is the threat of preterm birth owing to preterm labor (PTL), preterm premature rupture of membranes (PPROM), hypertensive disorders, or bleeding. In such cases, the goal of maternal transport is to assure that delivery occurs at a center with appropriate resources to care for a preterm newborn. Since the 1970s, regionalized perinatal care systems have been adopted in the United States,
      • Yu V.Y.
      • Dunn P.M.
      Development of regionalized perinatal care.
      with each birthing facility having a designated Neonatal Level of Care as defined by the American Academy of Pediatrics
      ACOG Committee on Obstetric Practice, AAP Committee on Fetus and Newborn
      Guidelines for perinatal care.
      ,
      American Academy of Pediatrics Committee on Fetus and Newborn
      Levels of neonatal care.
      and often formalized by state licensing regulations. Another reason for maternal transport is that a patient requires a higher level of care because of serious illness, cardiac disease, surgical issues, or other problems. The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have developed a classification system for Levels of Maternal Care
      American Association of Birth Centers; Association of Women's Health, Obstetric and Neonatal Nurses; American College of Obstetricians and Gynecologists, et al
      Obstetric care consensus #9: Levels of maternal care.
      : basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal healthcare centers (level IV). Some states have adopted regulations that all maternity hospitals must have a designated level of maternal care as defined by this system.
      In addition to establishing levels of maternal and neonatal care, guidance must also be provided to clinicians faced with a patient whose maternal or fetal status necessitates a transfer. The Emergency Medical Treatment and Labor Act

      Examination and treatment for emergency medical conditions and women in labor, 42 USC 1395dd (1986).

      regulates the transfer of patients between hospitals that accept federal and state healthcare payments to ensure that patients with emergency and obstetrical conditions are not turned away because of the inability to pay. Under the statute, a pregnant individual with an emergency obstetrical condition cannot be transferred unless stabilized (which may require delivery) and unless a trained medical professional judges that the benefits of transfer outweigh the risks. Currently, although institutions have implemented policies and procedures pertaining to levels of care, there are no national recommendations to guide the transfer of critically ill pregnant individuals.
      The transfer of a patient between facilities is a highly specialized type of patient handoff. A patient handoff from 1 healthcare professional to another carries a risk of medical error owing to inadequate communication. Communication errors are a leading cause of preventable serious patient harm. Many factors must be communicated when performing a maternal transport, including the health status of 2 patients (mother and fetus), availability of bed space and personnel in 2 units at the receiving facility (labor and delivery unit and neonatal intensive care unit), arrangements for transportation, and gathering and collating records. Communication is needed among various types of healthcare professionals, including physicians, nurses, and transport personnel. Lapses in any 1 of these areas can lead to patient harm.
      In such situations, in which many details must be collected and verified in a short time and often with an ill patient in need of urgent care, a cognitive aid such as a standardized form can help the team prepare for a transfer
      • Bernstein P.S.
      • Combs C.A.
      • et al.
      Society for Maternal-Fetal Medicine (SMFM)
      The development and implementation of checklists in obstetrics.
      and can provide a consistent framework for a handoff briefing among healthcare professionals. A structured handoff briefing can improve communication and reduce medical errors and adverse events.
      • Starmer A.J.
      • Spector N.D.
      • Srivastava R.
      • et al.
      Changes in medical errors after implementation of a handoff program.
      A sample briefing form designed to ensure that key elements are communicated for every maternal transport is presented in the Box. In addition, practical advice to help facilities customize the form and implement it on their units is also included.
      Sample maternal transport briefing form and checklist
      EBL, estimated blood loss; EDD, estimated “due date”; EFM, electronic fetal monitoring; EFW, estimated fetal weight; FFP, fresh/frozen plasma; G, gravidity; H&P, history & physical; ICU, intensive care unit; NICU, neonatal intensive care unit; P, parity; PMH, past medical history; PRBC, packed red blood cell; PSH, past surgical history.
      Gibson. SMFM Special Statement: A maternal transport briefing form and checklist. Am J Obstet Gynecol 2020.

      Maternal Transport Briefing Form and Checklist

      The briefing form is intended to be used as a tool to facilitate communication when transferring pregnant patients to a higher level of maternal or neonatal care. The goal is to improve the safety of patients requiring transfer by ensuring that appropriate treatment is initiated and all critical information is readily available. Its use should lead to improved documentation, communication, and continuity of care before, during, and after a maternal transfer.
      The form includes the most relevant information that should be considered before transfer and that will be needed at the receiving institution. The design of the form follows the guidelines published in A Checklist for Checklists by Ariadne Labs.
      Ariadne Labs
      A checklist for checklists.
      For example, the form uses a sans-serif font, avoids the use of color, and includes a version date. The form has a simple, uncluttered format and fits on 1 page. Efforts were made to include only essential items that are likely to be overlooked or forgotten.
      The form is intended to be completed at the sending facility. If most of the elements are completed before the initial phone call to initiate a maternal transfer, it will greatly facilitate communication. Some elements will need to be updated as final preparations are made for transport.

      Suggestions for Implementation

      The form shown in the Box should be considered a sample because each receiving hospital will need to customize it. For example, contact phone numbers should be inserted at the top of the form to make it easy for the referring hospital to call and to fax information. The receiving hospital should decide whether they prefer documents to be sent with the patient or to be faxed so that they will arrive before the patient. The form should be revised to reflect this preference. Each hospital should decide whether to include a space at the bottom for a signature and date of completion. For the initial customization of the form, it will likely be sufficient to have a small team of relevant stakeholders at the receiving hospital, including maternal-fetal medicine subspecialists, nurses, and the nursing transport coordinator to review the form and make any needed changes.
      After the form has been customized, receiving hospitals may want to print and bind copies as “tear sheets” to distribute to the referring hospitals in their region. Paper forms will likely be faster and easier to implement than digital forms integrated into electronic health records. An important limitation of digital forms is that many hospitals within a region do not typically share a common platform for electronic health records. Even if a hospital adapts this form to its electronic record system, other hospitals may not be able to use it.

      Follow-up and Quality Indicators

      Once the form has been adopted, it is essential to monitor its use so that any needed revisions can be made. After each transport, the transport coordinator or other relevant leader at the receiving facility should obtain feedback from involved physicians and nurses at both sending and receiving hospitals and elicit suggestions for improving the transport process or for improving the form itself. If the form is revised, the version date should be updated, and sending facilities should be instructed to discard any older versions.
      Although not directly related to this form, an effective regional maternal transport program must have quality assurance processes in place to evaluate outcomes and to look for areas for future improvement. The following lists examples of quality indicators that both sending and receiving facilities might want to use:
      • 1.
        A detailed review of any case involving delivery en route, delivery within 15 minutes after arrival, or deterioration of maternal condition requiring diversion to another facility (sentinel events)
      • 2.
        A formal periodic review of maternal transports for each referring institution, including frequency of any requested transfers that were declined and reasons for declining
      • 3.
        Standard clinical management guidelines for the most common indications for maternal transport (eg, PTL, PPROM, hypertensive disorders) developed by the receiving hospital and shared with all the referring hospitals in the region
      • 4.
        Tracking of measures of the efficiency of transport (eg, time from initial transport request to arrival at receiving hospital, time from initial request to formal acceptance of transfer) and appropriateness of transport
      • 5.
        A specified process to update referring physicians and prenatal care professionals on the outcome or condition of the patient who was transported

      References

        • Yu V.Y.
        • Dunn P.M.
        Development of regionalized perinatal care.
        Semin Neonatol. 2004; 9: 89-97
        • ACOG Committee on Obstetric Practice, AAP Committee on Fetus and Newborn
        Guidelines for perinatal care.
        7th ed. American College of Obstetricians and Gynecologists, Washington, DC2013
        • American Academy of Pediatrics Committee on Fetus and Newborn
        Levels of neonatal care.
        Pediatrics. 2012; 130: 587-597
        • American Association of Birth Centers; Association of Women's Health, Obstetric and Neonatal Nurses; American College of Obstetricians and Gynecologists, et al
        Obstetric care consensus #9: Levels of maternal care.
        Am J Obstet Gynecol. 2019; 221: B19-B30
      1. Examination and treatment for emergency medical conditions and women in labor, 42 USC 1395dd (1986).

        • The Joint Commission
        Sentinel Event Alert 58: Inadequate hand-off communication. 2017.
        (Available at:)
        • Bernstein P.S.
        • Combs C.A.
        • et al.
        • Society for Maternal-Fetal Medicine (SMFM)
        The development and implementation of checklists in obstetrics.
        Am J Obstet Gynecol. 2017; 217: B2-B6
        • Starmer A.J.
        • Spector N.D.
        • Srivastava R.
        • et al.
        Changes in medical errors after implementation of a handoff program.
        N Engl J Med. 2014; 371: 1803-1812
        • Ariadne Labs
        A checklist for checklists.
        (Available at:)