Episode #280 Speak Up to Save Lives

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are wrapping up our exciting series today all about the 2025 APSF Stoelting Conference: “Transforming Maternal Care: Innovations and Collaborations to Reduce Morbidity and Mortality.” If you weren’t able to attend the Stoelting conference this year, then we hope that you will enjoy this 5 part podcast  series and you can also check out recording from the conference on YouTube. Check out the show notes for more information.

Before we dive further into the episode today, we’d like to recognize Preferred Physicians Medical, a major corporate supporter of APSF. Preferred Physicians Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Preferred Physicians Medical – we wouldn’t be able to do all that we do without you!”

Now, it’s time to get back into the conference talks and return our focus to transforming maternal care. Thank you to our industry sponsors for supporting the 2025 APSF Stoelting Conference: BD, Medtronic, Solventum, and Intelliguard.

Our next session is Intrapartum Challenges and Emergencies. We are going rapid fire with lots of highlights.

The first speaker is May Pian-Smith, a senior obstetric anesthesiologist, to talk about Communication and Trust: Our problems are our opportunities. May reminds us that communication errors lead to sentinel events and in most cases, someone on the team knew something important but did not speak up. We know that despite our best intentions, errors still happen. This is why communication is so important to mitigate harm from inevitable errors. There is a cycle between communication as a marker for psychological safety and improving communication as a driver for improving safety culture. The opposite is also true. Distrust is a barrier to dissemination of best practices. Individual and systemic distrust affect access to care, management, treatment, and outcomes.

So, what is good quality communication? This is communication that is frequent, timely, accurate, and problem-solving. This is absolutely what we want from our colleagues in an emergency. Good relationships involve shared goals and knowledge with mutual respect and this leads to long term trust and respect which is a key for transforming outcomes. There are improved outcomes in areas with relational coordination and good quality communication and relationships. These include:

• Decreased hospital length of stay
• Mitigated harm from medical errors
• Mitigated harm form peri-op adverse events
• Decreased rates of infects.

Additional benefits for healthcare team members include:

• Improved resiliency
• Decreased clinician burnout
• Increased job satisfaction and engagement
• Increased self-efficacy and innovation
• Increased courage
• Increased gratitude

Let’s bring this onto the maternity ward. The combination of respectful maternity care, trusted messengers such as doulas or group prenatal care, and language access with interpreters can have a big impact on maternal patient safety. We also need shared mental models which involves pre-briefs, checklists, closed loop communication, and rapid debriefs. May provides some very practical advice. Invite team members to speak up during the case and when someone does speak up and even if they are wrong, it is important to thank them for speaking up. This helps team members to continue to speak up in the future. Another important consideration is how to gain trust quickly by applying the golden rule and being respectful and treating others how we would like to be treated. We can go one step further to the platinum rule: treat others as they would like to be treated. This means that there needs to be a pause since the patient may be coming from a totally different place. We need this pause to try to figure out where the patient is coming from.

Now, let’s head into the operating room to talk about Inadequately treated pain. Our speaker is Heather Nixon, a professor of anaesthesiology at the University of Illinois at Chicago. Have you listened to the podcast, The Retrievals Season 2? If not, you can add it to your list and I will include a link in the show notes. Heather gives us a call to action that pain during C-section is real and it is traumatic. Here are some of the lessons learned that she shares with us during her talk.

1. Neuraxial is NOT always enough. Not all of our neuraxial blocks cover visceral pain. So, even when the skin test is negative, patients can still feel pain.
   1. We may need to use adjuncts during C-section including other medications or conversion to GA.
2. For patients with a history of anxiety or being anxious, this does not mean that these patients are not experiencing pain.
   1. Check out the 2022 article by Keltz and colleagues which revealed that intraoperative pain occurred in about 12% of patients undergoing elective c-section delivery under spinal anesthesia. Anesthesia professionals underestimated the incidence of intraoperative pain. You can find the citation in the show notes.
3. Anesthesia professionals are bad at communicating with our patients.
4. Fear drives a lot of our choices: There is this belief, that if I have to induce GA, there is a chance that I will lose the airway and the patient will die. There is a fear of impacting breastfeeding and a fear of being judged.
5. Focus on the Fetus which may prevent us from treating in a timely manner if we need to wait until after delivery. In addition, if we say, that’s okay because the baby is okay, that may alienate patients who have suffered trauma.
6. The culture in the operating room is important. We need to make sure there is a shared mental model between the anesthesiologist, the OB and the nurses.
7. There are consequences to this untreated pain including decreased maternal infant bonding, decreased breastfeeding, PTSD, higher rates of depression, higher rates of divorce, and resistance to further pregnancy.

So, what can we do? Here are some important considerations for improving maternal patient safety during c-section.

• Preoperative Discussion about the risks of anesthesia and the options.
• Standardized Sensory assessments including skin test around the incision. Then, when patients report pain, it is important to localize the pain and treat depending on where we are in the surgery.
• Have a conversation about pain expectations and entrap communications.
• Surgical interventions which may involve not exteriorizing the uterus or shorter surgical times.
• Patient centered communication: You can let patients know that pain is important and every 15 minutes we will be monitoring pain scores. You are not supposed to suffer, but you need to let us know. If pain score greater than 3, stop the surgery and evaluate pain.
• Education and coaching.
• Accountability for the entire team to speak out.
• And finally, Debriefings: Did the patient have pain, could we predict this? Did we respond? How was our communication?

Heather leaves us with the call to action that this is a health risk. This is preventable harm. Going forward, we many need a safety bundle for pain during C-section delivery to help keep patients safe.

Our next speaker is Kokila Thenuwara, clinical professor of obstetric anesthesia to talk about simulation for addressing challenges in rural settings. Kokila outlines the scope of the problem with rural hospital closures, OB unit closures, and challenges to access OB services. These challenges stem from the high cost to maintain OB units. They are expensive with 24hr staffing, access to OR, and in rural areas, limited number of cases. Plus, clinicians working in these settings may have limited specialized training, no obstetricians, but family practitioners with OB training, low patient volumes so difficulty maintaining skills, and limited availability of critical resources including blood bank and lab services. There are limited resources available in these settings. Enter simulation training. This is a way to improve and maintain OB skills in rural hospitals. The Iowa Statewide Perinatal Care Program provides comprehensive quality and safety support to Iowa’s birthing hospitals. One of their programs is the OB ED Simulation Training Program which involves their statewide obstetric mobile simulation team to help educate ER and EMS providers with didactics and skills stations on normal deliveries, active management of 3^rd stage of labor, recognizing post-partum haemorrhage, recognizing severe preeclampsia, management of eclampsia, stabilizing and transfer to high risk OB patients. There is so much more to this program and we hope that you will check out the link in the show notes. Kokila leaves us with a call to action:

“What can anaesthesiologists do to help develop practical and sustainable solutions to improve maternal care in rural settings?” The answers to this question will be vital for improving maternal patient safety in rural settings going forward.

The final speaker for this session is Alex Hannenberg, a senior research scientist and core faculty member of Ariadne labs, to talk about Addressing obstetric crises with checklists. Alex makes the argument that we need these crises checklists because these are high stress and rare events, so we cannot rely on memory for the key steps of management. Plus, there is a high potential for morbidity and mortality and we need a rapid response. During an OB crisis, this is a situation where we need to create a shared mental model and make sure that we are all on the same page. There is overwhelming evidence that the way to do this is with a cognitive aid to improve performance. It is like having the answer sheet to the highest stakes test! So, what can you do to make sure that you are doing the best job you can for the patient? Using checklists is an important step as well as using real-time debriefings after events. This may require a change in practice and culture at your institution until using checklists is just part of the safety culture where every team member has a role from developing and refining checklists, trigger checklist use, reading the checklist, and advocating and supporting their use. A robust implementation program can help. Check out the show notes for more details!

Alex reminds us that these tools have value and can be embraced and used effectively in the presence of humility. We need to be able to accept the fact that we could miss something and when we pull out the checklist, that is best practice!!

Our next speaker is going to offer action items for how anesthesia professionals can move the needle on maternal safety. Brian Bateman is a professor of anesthesiology and chair at Stanford University. We have the skills and training with critically ill patients in the OR or ICU and we can bring this to the labor and delivery unit as well. Brian brings us through the 4 P’s for how anesthesia professionals can improve maternal patient safety. First, presence on the labor and delivery unit and in the OR when a rapid response is needed and also when we follow patients from labor to delivery and then postpartum. Next, Preemption which involves optimizing management and screening for high risk patients pre-delivery. This step allows us to intervene early when we can. The Obstetrics Comorbidity index is a tool that can help. I’ve included more information about calculating this in the show notes as well. The third P is for proficiency. Considerations here include using our expertise and training to help guide resuscitation and transfusion, pain management, and procedural expertise when it comes to lines, monitors, airway, regional, and neuraxial. We have a lot to offer when it comes to peripartum care. The final P is for Platform, which includes using standardized care pathways and order set defaults to drive quality improvement and reduce maternal morbidity and mortality. There is another plug for the important role of multidisciplinary collaboration, simulation, and debriefing in building a safety culture to reach these goals.

Anesthesia professionals can use the 4 P’s framework to help move the needle at their institutions as safety champions who build safety into the systems so that interventions stick and create a system that is constantly learning. One way to move the needle on a wider regional, national, or international scale is continued work on multidisciplinary guidelines to help guide safe care. We hope that you will check out the 2025 “Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder.” These are multidisciplinary guidelines published just this year. You can find the citation in the show notes as well. And finally, Brian leaves us with a call to action when it comes to research. We need to partner with experts across the clinical and research spectrum to move beyond epidural dosing to examine big ideas for the most pressing problems in maternal health.

We are going to switch gears now to talk about Coordinating in the community can help decrease serious postpartum morbidity. Our speaker is Melissa Bauer, an associate professor of anesthesiology, who shares her experiences with implementation of the sepsis bundles with the goal to work throughout the entire time period from pregnancy, labor and delivery, and postpartum with the help of community leaders and patient involvement. Since most patients do not have risk factors and may not present with fever, how can we help patients know when to seek care and feel heard when they do seek care? The Alliance for Innovation on Maternal Health Consensus Bundle on Sepsis in Obstetric Care has some important resources including standardized patient education including the severe maternal morbidity warning signs. Patient education may involve phone discharge education or a business card with a QR code that provides the information that they need. Community dissemination of information is also important and can be done through public health campaigns, community-based organizations, houses of worship, doulas, and home visiting nursing programs. Keep in mind, when patients think that something is wrong, they don’t call their doctor, they call their friends and family, so we need to get this information out there so that the friend can say, oh you need to go to the hospital.

Let’s continue the conversation in the community with our next talk given my Megan Rosenstein, anesthesiologist and associate chief medical officer at Overlook Medical Center, “From Clinic to Birth, a Team approach.”

Megan introduces the scope of the problem at her institution, high hemorrhage rates despite trying to align the team with best practices. So, here’s what they did: brought together a multidisciplinary team with 3 phases including antepartum, intrapartum, and postpartum. In the antepartum phase, the team evaluated risk factor modification for anemia with department endorsement and involvement of stakeholders. The plan involved practice visits to identify barriers early, followed by reducing barriers to care with priority consultation to make it easier for patients to get diagnosed and iron infusions, and continued work with scorecard integration for monitoring.

The intrapartum phase involved hemorrhage prevention, reducing avoidable c-sections, hemorrhage prophylaxis, and considerations for surgical technique. The postpartum phase included early recognition and management, quantitative blood loss, and situational awareness with enhanced recognition and management. Megan reminds us that these are not novel strategies, but when used consistently and all together, they can be effective and the anesthesiologist has an important role in teaming and change management to improve maternal patient safety.

Our final speaker is Yasuko Nagasaka the chair and professor in Anesthesia at Tokyo Women’s Medical University to talk about Enhancing maternal and pediatric anesthesia safety in Japan. Yasuko asks some important questions about the impact of epidurals on maternal mental health. We still don’t know the answer to this one since there are conflicting results. What about the safety of medications given during labor and delivery on the developing brain? The GAS study was the first prospective clinical trial to explore the effects of anesthetics on the developing  brain. It was an international and multicenter randomized controlled trial that compared regional and awake to regional plus Sevoflurane with no significant differences between the groups at ages 2 and 5. Another important question for pediatric patient safety is Why do small children develop emergence agitation and delirium? There is an interesting study that evaluated EEG-guided titration of sevoflurane with reduced pediatric emergence delirium. The control group was given standard fixed level of sevoflurane administration while the intervention group received sevoflurane administration titrated to EEG. The intervention group had lower scores for agitation and emergence delirium with 25 minutes faster emergence and 20 minutes earlier discharge. Going forward, EEG may be an important tool to help improve pediatric anesthesia safety.

And that’s a wrap on the 2025 APSF Stoelting Conference. We hope that you enjoyed this series and are inspired to continue the work to transform and improve maternal patient safety going forward. We hope that you will share this podcast with one person, tell a friend or a co-worker, or a trainee, or an administrator even one person can help make a big difference. We want to get the word out so that more people are working to transform maternal care and improve anesthesia patient safety.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links and citations to all the topics we discussed today.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2025, The Anesthesia Patient Safety Foundation