Inside and outside today’s hospital walls, physicians are partnering across disciplines to create processes that contribute to patient safety and quality of care. That interdisciplinary commitment is evident at NewYork-Presbyterian/Lawrence Hospital.
Patient safety has come to the forefront of public — and institutional— awareness over the past decade. The Journal of Patient Safety recently estimated that as many as 440,000 U.S. patients may die each year of preventable, hospital-acquired conditions such as infections and pneumonia. However, cross-disciplinary, systematic approaches can greatly improve safety. NewYork-Presbyterian/Lawrence Hospital has initiated protocols and brought together personnel to support safe, quality care. In the Department of Obstetrics and Gynecology, this meticulous approach encompasses everything from nursing care to advanced surgical practices.
Patient Safety and Quality of Care
Anna Burgansky, MD, FACOG, Director of Obstetrics and Gynecology (OB/GYN), Chief of the Division of General OB/GYN at NYP/Lawrence Hospital, and Assistant Professor of Obstetrics and Gynecology at Columbia University Medical Center (CUMC), has maintained a focus on patient safety throughout her career, conducting research and taking leadership roles at NYP/Lawrence and other institutions where she has served on the medical staff. Fostering safety for new mothers and infants is a singular endeavor, she says.
“Obstetrics is unique in terms of the obstetrician being the caretaker of two patients — the mother as well as the developing fetus,” she says. “We are challenged to provide quality and safe care for both and to ensure positive outcomes.”
Jaclyn Coletta-Lucas, MD, FACOG, works alongside Anna Burgansky, MD, FACOG, to assist a patient with an ultrasound examination.
Screening, prevention and preparation make up a large portion of safety protocols established for obstetrics service, she explains. While other hospital patients are often admitted for unexpected conditions, pregnant women may be coached and monitored for the duration of their pregnancies, leading to thorough oversight that can mitigate problematic conditions.
“Historically, we have shown significant improvements in the outcomes of newborns due to enhancements in the standard of care for fetal conditions or maternal conditions that affect the fetus,” Dr. Burgansky says. “For instance, we screen all mothers to prevent Group B strep infection in the newborn and give steroids to all mothers in preterm labor to improve fetal lung maturity. We administer magnesium sulfate to improve the neuro-developmental outcomes in premature babies.”
Joanne Young, RN, discusses the birth of a baby with Dr. Coletta-Lucas in NYP/Lawrence’s state-of-the-art nursery.
Institutional changes over the past decades have improved survival and other outcomes for preterm infants, she notes, referring to the regionalization of newborn care and the institution of multiple levels of newborn ICUs. However, maternal health presents a different challenge, with national statistics showing maternal mortality and morbidity rising even as infant death rates fall.
“One of the most frustrating facts is that maternal death hasn’t really decreased over the last 30 years, largely because there are significant disparities in healthcare outcomes between different socioeconomic and racial groups,” says Jaclyn Coletta-Lucas, MD, FACOG, Section Chief of Maternal-Fetal Medicine at NYP/Lawrence and Assistant Professor of Obstetrics & Gynecology at CUMC. “Many women are also delaying childbearing, so more women who are pregnant have chronic medical diseases.”
“We know that almost 50 percent of maternal deaths are preventable, and most are caused by very common obstetric complications,” Dr. Burgansky says. “The obstetric challenge is to achieve the same improvement in maternal outcomes that we have already seen in fetal outcomes.”
As a result, NYP/Lawrence has adopted evidence-based guidelines to keep women and infants safe. The hospital has also joined regional and national endeavors to foster quality and safety.
The Safe Motherhood Initiative
The American Congress of Obstetricians and Gynecologists’ District II Safe Motherhood Initiative, instituted in 2013, has a mandate to reduce maternal mortality by standardizing care around three leading causes of maternal death among women in New York state: obstetric hemorrhage, severe hypertension in pregnancy and venous thromboembolism. NYP/Lawrence is a committed participant in the initiative.
Implementation of this initiative involved a multimodal approach, including didactic education and hands-on training of physicians and nurses to improve skills at the bedside, as well as in-situ simulation drills to evaluate institutional preparedness and improve communication across all disciplines. As a result of the Safe Motherhood Initiative implementation, today all NYP/Lawrence patients are screened for OB hemorrhage risk factors on admission; all patients with severe hypertension receive appropriate therapy within 60 minutes; and all patients receive prophylactic anticoagulation following Caesarean section to prevent postoperative thromboembolism.
Teaming Up for Safety
Since she arrived at NYP/Lawrence in 2014, Dr. Burgansky has instituted daily briefings on labor and delivery and regular multidisciplinary meetings where safety concerns are discussed, facilitating cross-departmental communication and cooperation. All the members of the team foster a sense of urgency around patient safety. For instance, Michael C. Pitter, MD, FACOG, Director of Robotic Surgery at NYP/Lawrence, Director of the Center for Research and Advanced Fibroid Treatment at NYP/Lawrence, and Assistant Professor of Obstetrics and Gynecology at CUMC, has a background in working to improve the safety of laparoscopic and robotic surgery.
Michael C. Pitter, MD, FACOG, sits at the console of NYP/Lawrence’s new da Vinci Xi Surgical System.
Dr. Pitter consults with a patient.
“I was a member of the Robotic Surgery Credentialing Committee set up by the American Association of Gynecologic Laparoscopists,” he says. “We developed a template to track the number of virtual and real-world procedures a surgeon should perform to become credentialed. Now instituted at NYP/Lawrence, it measures, monitors and documents a surgeon’s performance and patient outcomes.
“The robotic surgical system is made up of three components. The surgeon sits at a console and manipulates instruments using both hands and both feet while observing the operative field with an immersive, 3-D view. Obviously, it takes awhile for a surgeon to learn how to be facile with this complex device, so we created the certification template, which many other disciplines are now using or considering.”
When it comes to maternal-fetal medicine, Dr. Coletta-Lucas also works with a continuum of providers to offer collaborative, standardized care.
Doris Martinez, RN, and Annie Mathew, RN, help a new mom with her twin girls.
“We hold a daily briefing with all disciplines, including obstetricians, gynecologists, maternal-fetal medicine specialists, anesthesiologists, neonatologists and nursing staff so we can review the cases of all patients on the obstetric service,” Dr. Coletta-Lucas says. “We focus on those who are currently on the labor floor and those who are scheduled to deliver that day. That way, we can anticipate and prepare for any potential complications.”
Teamwork leads to sound preventive medicine, Dr. Coletta-Lucas says. Every caregiver is alerted to each patient’s condition and needs.
“One way to prepare for possible complications is to make sure the entire team is aware of the patient’s history and then discuss potential risk factors,” she says. “For example, if there is a patient having her fifth baby and she had a postpartum hemorrhage after her fourth delivery, then she is at significant risk for this to happen again. Educating all the providers on the potential treatment for the complication is one way we work to reduce maternal morbidity.”
Advanced Surgical Techniques
At NYP/Lawrence, advanced technology supports safety initiatives and interdepartmental collaboration to enhance patient outcomes. Though of little value without the seasoned judgment of a skilled surgeon, robotic approaches can form the focal point of a patient-centered surgical OB/GYN department.
Lactation specialist Judy McArdle helps a patient breastfeed her new baby.
Minimally invasive surgery, including robotic procedures, is known to shorten hospital stays and reduce postoperative pain. Its benefits can be further enhanced by an expert understanding of what such procedures can do. Dr. Pitter differentiates between laparoscopic and robotic surgery, describing the robotic approach as sharing aspects of both open and laparoscopic procedures.
“I like to categorize robotic surgery as open surgery through laparoscopic access,” he says. “We are able to perform complex procedures that would normally be relegated to open abdominal surgery. What makes robotic surgery different is that we can tackle more complex procedures, such as stage 4 endometriosis requiring delicate retroperitoneal dissection or multiple myomas that require extensive suturing to recreate or repair any defects in the myometrium once the fibroids are removed.”
Hysterectomy in which the uterus is too large for a laparoscopic approach may also warrant a robotic procedure, he says. And, with increasing frequency, early stage endometrial and cervical cancer operations are performed robotically. The safety of these procedures is constantly being refined as surgeons learn more about the capabilities and challenges of robotic surgery. For instance, Dr. Pitter says, NYP/Lawrence surgeons do not use the morcellator for laparoscopic hysterectomy for benign indications or myomectomy procedures, but rather have developed new methods of removing the uterus or myomas with much less potential for spreading cancer cells.
Local access to minimally invasive and robotic procedures is especially beneficial to patients. The new affiliation with NewYork-Presbyterian Columbia University Medical Center (NYP/CUMC) has enabled an expansion of minimally invasive surgery into the suburbs, providing the same level of care patients in the city were receiving, Dr. Pitter says.
“To that end, we [NYP/CUMC] worked together with NYP/Lawrence to begin a robotics program, which involved purchasing the latest da Vinci robotic surgical system, the Xi platform,” says Dr. Pitter, who has started two robotic programs in New Jersey. “They also recruited top surgeons from Columbia to help grow the program at Lawrence.”
Dr. Burgansky is developing an obstetric quality improvement program at NewYork-Presbyterian/Lawrence, with a focus on improving patient safety and reducing medical complications.
The Xi boasts improved safety features and results in better cosmetic outcomes, Dr. Pitter says.
“We are now operating with a resolution of 1080p, and the colors are dynamic,” he says. “We are able to manipulate our instruments in multiple quadrants in the abdomen and can actually move the endoscope from 30 degrees facing upward to 30 degrees facing downward without actually changing the telescope.”
Dr. Pitter’s reputation has contributed to building a program that attracts patients from near and far; in fact, he performed his first robotic surgery at NYP/Lawrence on one of his previous patients who drove up from southern New Jersey.
“She went home the same night,” Dr. Pitter says.
Though the new da Vinci robot at NYP/Lawrence has been online only since March 2015, as of this January, surgeons had performed more than 100 robotic gynecologic procedures at the hospital, with myomectomies and uterine preservation procedures being the most common, Dr. Pitter says. The robot also has been used effectively for general surgery. Because robotic surgery rarely requires blood transfusion, the availability of the da Vinci Xi robot has also attracted patients seeking bloodless surgery to the hospital.
Quality Care, Taking Root in the Outpatient Setting
Outpatient medicine is an important bridge from the community to the hospital, especially when caring for women and infants. CUMC physicians now provide outstanding outpatient care at the new ColumbiaDoctors location at 696 White Plains Road in Scarsdale. Physicians handle the most basic well-woman care and obstetrics. They also deliver care for complex and surgical needs.
The events of a pregnancy — and a woman’s health before becoming pregnant — have a profound effect on the outcome.
“One of the most important things is to establish and discuss the birth experience with patients in a clinical office prior to their arrival at the hospital,” says Dr. Coletta-Lucas, who runs the hospital’s perinatal testing unit. “You have to set expectations in the office so patients have the best possible experience and outcomes when they come in for delivery.”
Members of the ColumbiaDoctors Obstetrics and Gynecology staff provide professional and compassionate services to their patients. From left, standing, are Barbara Crowley, Yokasta Lopez, Blanca Baizan and Sanela Sarac. From left, sitting, are Camille Taylor and Kathryn McCormack.
Community gynecologists refer patients to Dr. Coletta-Lucas’ practice for routine gynecologic ultrasounds, she says. She employs a saline-infused sonohysterogram technique, which involves introducing saline to help evaluate the uterine cavity.
“For a patient with abnormal uterine bleeding, saline enables you to visualize the uterine cavity and determine if the abnormal bleeding is due to a endometrial polyp or fibroid,” she says.
However, outpatient maternal-fetal medicine and obstetrics consists of far more than screening and diagnosis. Dr. Coletta-Lucas and her colleagues educate patients about their health and how to maintain safe, satisfying pregnancies and give birth to healthy infants.
“It’s important to initiate preconception counseling,” she says. “If OB/GYNs and family physicians send patients to us early, we can follow them throughout pregnancy and establish co-management between different disciplines so that we can address complex cases and be prepared when the patient is admitted to the hospital.”
A Referrer’s First Choice
The commitment to safety, accessibility of advanced technology, and seamless interaction among departments and between inpatient and outpatient care make NYP/Lawrence the ideal referral destination for patients with routine or complex gynecologic or obstetric needs.
Dr. Pitter, whose reputation garners referrals from across the region, emphasizes pre- and postoperative communication. He also makes it a personal mission to return patients to their referring providers.
“As a referral-based practice, we see the patients and take very good care of them, documenting all our findings and communicating them to the referring physicians on a regular basis,” he says. “We keep them in the loop in regard to what is happening and send patients back for follow-up.”
Additionally, at NYP/Lawrence, patients interact directly with departmental leadership, Dr. Burgansky says.
“During their stay, our maternity unit patients have a visit from one of us to check in and make sure they had a good experience and to hear any concerns,” she says. “This is part of a hospital-wide initiative called ‘Making Care Better’ — we try to connect with every patient on our service to discuss the plan of care, address any concerns and hear what she has to say about her experience.”
To learn more about the Department of Obstetrics and Gynecology at NewYork-Presbyterian/Lawrence Hospital, visit www.nyplawrence.org.