Faculty Bibliography

INTRODUCTION/BACKGROUND:A large-scale in situ simulation initiative on cardiac arrest in pregnancy was implemented across NYC Health + Hospitals. In situ simulation must be safely balanced with clinical conditions such as through application of no-go considerations or standardized reasons to cancel or postpone the simulation. Our objective is to describe our findings on the application of no-go considerations during this simulation initiative. METHODS:NYC Health + Hospitals/Simulation Center developed an in situ simulation program focused on cardiac arrest in pregnancy, implemented at 11 acute care facilities. The program's toolkit included no-go considerations for in situ simulation safety: situations prompting a need to cancel, reschedule, or postpone a simulation to ensure patient and/or staff safety. RESULTS:Data were collected from June 2018 through December 2019. The simulation sites reviewed the 13 established no-go considerations before each simulation event to assess if the simulation was safe to "go". After the conclusion of the initiative, all data related to no-go considerations were analyzed.Two hundred seventy-four in situ simulations were scheduled and 223 simulations (81%) were completed. Fifty-one no-go events were reported, with 78% identifying a reason by category. Twenty-two percent did not report a reason or category. Four of the 13 suggested no-go considerations were not reported. CONCLUSIONS:The no-go considerations framework promotes standardized and strategic scheduling of in situ simulation. Analysis of no-go consideration application during this system-wide initiative provides a model for the usage of tracking no-go data to enhance safety and inform future simulation planning.

INTRODUCTION: Postoperative opioid use presents pain management dilemmas because mothers should be alert and engaged with their neonates. Mothers with neonates in intensive care (NICU) have additional stresses and may desire 'round the clock' vs 'prn' pain management. We compared post-operative opioid usage in mothers with neonates in regular nursery ('regular') vs. NICU.
METHOD(S): From January 1, 2013 through December 12, 2018, postoperative opioid use for days 0 until discharge was retrospectively reviewed. Mothers with 'regular' neonates constituted Group 1, and NICU neonates were Group 2. Perioperative substance abusers or chronic opioid users were excluded.
RESULT(S): All the 8136 charts reviewed had orders for narcotic and non-narcotic analgesics. Both agents were used by 84% and only nonnarcotic analgesics by 16% of mothers. None used narcotics exclusively. All received narcotic prescriptions at discharge, regardless of postoperative opioid use. Group 1 had 6509 and Group 2 had 1627 mothers. Group 2 diagnoses included prematurity (12%), sepsis (4%), neonates with life threatening anomalies requiring major surgery (3%). No differences occurred in opioid usage between the 2 Groups (43% vs 45%, POD1; 81% vs 80%, POD2; 72% vs 70%, POD3; 20% vs 23%, POD4). Significantly more opioid usage occurred in mothers of neonates with life threatening anomalies.
CONCLUSION(S): Mothers with NICU neonates did not demonstrate increased postoperative opioid usage, in spite of the perceived added stresses. However, mothers with neonates having life threatening diagnoses utilized larger amounts of narcotics post-operatively. These findings may have future implications for post discharge pain management

Introduction: Uterine rupture is a rare but catastrophic complication with significant perinatal morbidity and mortality. The initial signs and symptoms can be non-specific, thus delaying definitive, life saving interventions. The purpose of this study was to identify maternal and/ or fetal "alarm criteria" in patients at risk for uterine rupture whole undergoing TOLAC.
Method(s): A retrospective chart review was conducted of patients undergoing TOLAC, from March 2013 through December 2017. Inclusion criteria: patients aged 18-54 years, with 1 or 2 previous Cesarean sections (C/S), with singleton, vertex, >/= 34 weeks gestations. Exclusion criteria: patients with fetal demise, preterm gestation, contraindications to vaginal birth.
Result(s): There were 30,000 deliveries during the study period. Of these, 12,900 (43%) underwent TOLAC and 2486 of these patients had 2 prior C/S. Uterine rupture at delivery was confirmed in 193 (1.5%) women, with 172 (88.8%) being identified at C/S and 21 (11.1%) at vaginal delivery. Anterior or side wall ruptures occurred in 136 (70.4%) patients. Of these, 86 (63%) were located in the previous uterine scar. Category II or III fetal heart tracings occurring within the last hour of the diagnosis of rupture and/ or delivery, were noted in 164 (85.2%) patients. Abdominal pain, rated by the patients as "moderate/severe" in spite of previously adequate epidural analgesia, occurred in 185 (96%) patients. Intrapartum vaginal bleeding (>/=75 cc), occurred in 78 (40.7%) and loss of station of the presenting part in 57 (29.6%) patients. Loss of adequate uterine contraction pattern occurred in 57 (29.6%) patients.
Conclusion(s): The most frequent indicator of uterine rupture was moderate/ severe pain in spite of previously adequate analgesia versus FHR abnormalities, which are noted in the literature as being the most frequent and reliable indicator. We suggest that pain in this clinical setting is THE alarm criterion which should initiate interventions to mitigate adverse outcomes in these patients