TY - JOUR
T1 - Multidisciplinary team learning in the management of the morbidly adherent placenta
T2 - outcome improvements over time
AU - Shamshirsaz, Alireza A.
AU - Fox, Karin A.
AU - Erfani, Hadi
AU - Clark, Steven L.
AU - Salmanian, Bahram
AU - Baker, B. Wycke
AU - Coburn, Michael
AU - Shamshirsaz, Amir A.
AU - Bateni, Zhoobin H.
AU - Espinoza, Jimmy
AU - Nassr, Ahmed A.
AU - Popek, Edwina J.
AU - Hui, Shiu Ki
AU - Teruya, Jun
AU - Tung, Celestine Shauching
AU - Jones, Jeffery A.
AU - Rac, Martha
AU - Dildy, Gary A.
AU - Belfort, Michael A.
N1 - Publisher Copyright:
© 2017 Elsevier Inc.
PY - 2017/6
Y1 - 2017/6
N2 - Background Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. Objective To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center. Study Design All singleton pregnancies with pathology-confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann-Whitney U test, χ2 test, analysis of covariance, and multinomial logistic regression. Results A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty-eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475-3000] vs T2: 1500 [1000-2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0-7] vs T2: 1 [0-4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600-5000] vs T2: 3400 [3000-4000], P < .01) were significantly less in T2. Also, a massive transfusion protocol was instituted more frequently in T1: 15/59 (25.4%) vs 3/59 (5.1%); P < .01. Neonatal outcomes and surgical complications were similar between the 2 groups. Conclusion Our study shows that patient outcomes are improved over time with increasing experience within a well-established multidisciplinary team performing 2−3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.
AB - Background Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. Objective To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center. Study Design All singleton pregnancies with pathology-confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann-Whitney U test, χ2 test, analysis of covariance, and multinomial logistic regression. Results A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty-eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475-3000] vs T2: 1500 [1000-2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0-7] vs T2: 1 [0-4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600-5000] vs T2: 3400 [3000-4000], P < .01) were significantly less in T2. Also, a massive transfusion protocol was instituted more frequently in T1: 15/59 (25.4%) vs 3/59 (5.1%); P < .01. Neonatal outcomes and surgical complications were similar between the 2 groups. Conclusion Our study shows that patient outcomes are improved over time with increasing experience within a well-established multidisciplinary team performing 2−3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.
KW - center of excellence
KW - morbidity adherent placenta
KW - multidisciplinary team learning
KW - placenta accreta
KW - placenta increta
KW - placenta percreta
KW - pregnancy complications
KW - quality of health care
UR - http://www.scopus.com/inward/record.url?scp=85016573886&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=85016573886&partnerID=8YFLogxK
U2 - 10.1016/j.ajog.2017.02.016
DO - 10.1016/j.ajog.2017.02.016
M3 - Article
C2 - 28213059
AN - SCOPUS:85016573886
SN - 0002-9378
VL - 216
SP - 612.e1-612.e5
JO - American Journal of Obstetrics and Gynecology
JF - American Journal of Obstetrics and Gynecology
IS - 6
ER -