Chapter 19: Checklists for Care: Care Maps for Pregnancy in the Obese Gravida

INTRODUCTION

Checklists and care pathways (synonymous with care maps, critical pathways, and clinical pathways) are document-based tools that link available evidence to health care practice with the intent to optimize clinical outcomes and patient safety.¹ They provide the foundation for translation of evidence into clinical guidelines and protocols. The World Health Organization (WHO) and Institute of Medicine (IOM) have both advocated of the use of checklists as a key concept in reducing medical errors and improving patient safety.^2,3 Checklists and care pathways have clearly shown improvement in many aspects of medical care and patient care.^1,4,5 In a recent study, the use of crisis checklists in critical processes among operating room teams participating in simulated operating room scenarios showed a 75% reduction in failure to adhere to critical management steps in common intraoperative emergencies.⁶ In addition, providers preferred checklists and bundles as memory aids. In the same study, almost all of the study participants (N = 67) stated their desire to have the checklist used if they experienced an intraoperative emergency.

This chapter summarizes the important concepts and provides a framework for the development of checklists and care pathways for obese women spanning preconception to the postpartum period. The checklists are based on the evidence presented in other chapters of this text as well as our own review and summary of the literature.

Checklists and Care Pathways in Pregnancy

One of the earliest reports on obstetric checklists was a 1998 article by Ransom et al.⁷ A 3-week pilot study was conducted with the implementation of a normal vaginal delivery clinical pathway that included standardized order sets. Despite difficulty with pathway development and implementation across sites, the study showed a decrease in length of hospital stay and an approximate $300 reduction in the cost of a vaginal delivery. In a follow-up study, Ransom et al. suggested that clinical pathways for both vaginal and cesarean delivery may reduce litigation costs.⁸ In 2010, the British Columbia Perinatal Health Program disseminated the BC Maternity Care Pathway in an effort to standardize care to pregnant women.⁹ Other examples of obstetric checklists include one for management of suspected placenta accreta, an airway checklist for general anesthesia, and a short, evidence-based checklist to reduce complications of cesarean delivery.^10,11,12

Clark et al. also credit the use of checklist-based protocols in process standardization as a major component in quality and safety improvements in obstetric care in a large health care system.¹³ Furthermore, the implementation of checklists has shown improved communication among obstetric teams.^14,15 In 2011, Fausett et al. published an article in the American Journal of Obstetrics and Gynecology’s Patient Safety Series on developing and implementing an effective checklist.¹⁶ Key concepts in checklist development included careful selection of the clinical process underlying the ...