To the Editor
We read with great interest the recently published article “Preoperative Multidisciplinary Team Huddle Improves Communication and Safety for Unscheduled Cesarean Deliveries: A System Redesign Using Improvement Science” by Girnius et al. Their intervention of introducing a bedside team huddle aimed to improve the communication processes surrounding Unscheduled Cesarean Deliveries (U-CD) due to dissatisfaction and near-miss patient safety events being attributed to poor communication between multidisciplinary team members (MDT). Their results demonstrated that satisfaction scores related to U-CD communication improved from 3.3/5 to 4.7/5; however, rates of general anesthesia (GA) remain unchanged and there was a slight increase in decision-to-incision time (DTI) of 7 minutes. As a group working in one of the largest obstetric units in the UK, we share similar thoughts that communication surrounding unscheduled cesarean deliveries is often unsatisfactory and can lead to avoidable patient safety events. We would also like to offer our thoughts on the authors’ intervention and its applicability to different obstetric centers, particularly in high-volume units such as ours.
First, it should be noted that U-CD are often high-pressure scenarios and the authors’ methodical application of performance improvement methodology to enhance patient safety and communication processes should be commended. Improving team satisfaction and engagement promotes improved teamworking and has been demonstrated to have potential benefits in improving patient safety. Furthermore, involving the patient in the team huddle provides patients with an opportunity to be part of the discussion of their own care and is a true demonstration of patient-centered care. It provides reassurance during a stressful situation as well as reducing the likelihood of potential litigious action due to poor communication.
However, there are certain aspects of the intervention we query particularly in comparison to our experiences in the UK practicing obstetric anesthesia. The authors make a distinction between what they describe as “unplanned but nonemergent” cesarean delivery and “emergent” cesarean delivery. The descriptions used here are somewhat confusing and differ compared to descriptions we use in the UK where we adhere to the Royal College of Obstetricians and Gynaecologists categorization of Cesarean Sections3 (Table) where effectively all cases of unplanned cesarean delivery are often described as emergency cases.
| Category of cesarean delivery | Description | Ideal decision-to-birth interval |
|---|---|---|
| Category 1 | Immediate threat to life of the woman or fetus (eg, suspected uterine rupture, cord prolapse, fetal hypoxia, etc) | Within 30 min of making the decision |
| Category 2 | Maternal or fetal compromise that is not immediately life-threatening | Within 75 min of making the decision |
| Category 3 | No maternal or fetal compromise but needs early birth | Nil definitive time—take into account condition of the woman and unborn baby |
| Category 4 | Birth timed to suit woman or health care provider | N/A |
We note the authors’ decision to exclude “emergent” cases of cesarean delivery from their intervention. We conclude that this is due to their time critical nature where a potential increase in DTI due to the team huddle would have led to unacceptable delays. Nevertheless, it is often the emergent cases of cesarean delivery where improved communication would be key to improving patient outcomes so it would be interesting to see whether this could be implemented in some format particularly as the authors’ original intervention for nonemergent cases did not demonstrate improvements in patient outcomes. Furthermore, we are sure readers will agree that the nature of obstetrics is such that an “unscheduled” cesarean delivery can rapidly become an “emergent” cesarean delivery and that the differentiation between them is not so black and white. We suggest that this intervention could benefit from the inclusion of cardiotocography (CTG) interpretation in the team huddle as a decision-making aid. As authors of a similar survey, the Royal College of Anaesthetists (RCoA) has acknowledged our suggestion that CTG interpretation could be useful in this manner for obstetric anesthetists. Anesthetists/anesthesiologists should have a basic understanding of CTG to not only elevate our practice as perioperative physicians in obstetrics but also allow for more advanced dialogue with obstetricians to come up with a more precise anesthetic plan. However, with a reported average increase in DTI of 7 minutes a clear balance would need to be struck as it could lead to unacceptable delays, particularly in UK cases of category 1 cesarean delivery where the decision-to-birth interval should be less than 30 minutes.
When comparing this intervention to similar current UK practice there are some similarities with regards to the use of structured checklists. The UK routinely uses the World Health Organization surgical safety checklist which adopts similar criteria to the authors’ checklist. However, the idea of extending this to a bedside huddle is a novel concept that could benefit UK obstetric practice, particularly in maintaining consistency for urgent cases. The intervention itself is also dependent on the availability of staff to attend the huddle which can be highly variable between centers. For example, we work in a 24-bed unit with over 8000 deliveries a year with less MDT staffing so therefore ensuring everyone is available for a bedside team huddle could lead to unacceptable delays and an increase in DTI time.
In conclusion, Girnius et al have demonstrated a well-executed approach to improving communication for unscheduled cesarean deliveries. Their intervention provides a model for other health care institutions but would benefit from exploring its potential in emergent cases of cesarean delivery where the greatest improvements in patient safety could be seen.