title: Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time.
abstract: Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity.
  
  
  
  To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center.
  
  
  
  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, χ2test, analysis of covariance, and multinomial logistic regression.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX. Electronic address: alirezashamshirsaz@yahoo.com.
authors.forename: Alireza A
authors.initials: AA
authors.lastname: Shamshirsaz
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Karin A
authors.initials: KA
authors.lastname: Fox
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Hadi
authors.initials: H
authors.lastname: Erfani
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Clark
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Bahram
authors.initials: B
authors.lastname: Salmanian
authors.affiliation: Department of Anesthesiology and Obstetric and Gynecologic Anesthesiology, Texas Children's Hospital, Houston, TX.
authors.forename: B Wycke
authors.initials: BW
authors.lastname: Baker
authors.affiliation: Department of Urology, Baylor College of Medicine, Houston, TX.
authors.forename: Michael
authors.initials: M
authors.lastname: Coburn
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Amir A
authors.initials: AA
authors.lastname: Shamshirsaz
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Zhoobin H
authors.initials: ZH
authors.lastname: Bateni
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Jimmy
authors.initials: J
authors.lastname: Espinoza
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut Egypt.
authors.forename: Ahmed A
authors.initials: AA
authors.lastname: Nassr
authors.affiliation: Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Edwina J
authors.initials: EJ
authors.lastname: Popek
authors.affiliation: Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Shiu-Ki
authors.initials: SK
authors.lastname: Hui
authors.affiliation: Department of Pathology & Transfusion Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Jun
authors.initials: J
authors.lastname: Teruya
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Celestine Shauching
authors.initials: CS
authors.lastname: Tung
authors.affiliation: Department of Urology, Baylor College of Medicine, Houston, TX.
authors.forename: Jeffery A
authors.initials: JA
authors.lastname: Jones
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Martha
authors.initials: M
authors.lastname: Rac
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Gary A
authors.initials: GA
authors.lastname: Dildy
authors.affiliation: Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Belfort
mesh_terms: D000328:Adult; D001724:Birth Weight; D016063:Blood Loss, Surgical; D002585:Cesarean Section; D000077324:Crystalloid Solutions; D017707:Erythrocyte Transfusion; D005260:Female; D005865:Gestational Age; D006801:Humans; D007044:Hysterectomy; D007231:Infant, Newborn; D033183:Interdisciplinary Communication; D007552:Isotonic Solutions / Q000008:administration & dosage; D010348:Patient Care Team; D010921:Placenta Accreta / Q000628:therapy*; D006473:Postpartum Hemorrhage / Q000628:therapy; D011247:Pregnancy; D011787:Quality of Health Care; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions
keywords: center of excellence; morbidity adherent placenta; multidisciplinary team learning; placenta accreta; placenta increta; placenta percreta; pregnancy complications; quality of health care