Patient safety in obstetrics--the Hospital Corporation of America experience

Implementation of an Enhanced Prenatal Checklist to Increase Rates of Counseling of Prenatal Fetal Aneuploidy Testing

Aim This study aims to assess the effect of implementing an enhanced prenatal genetic checklist to guide the provider's discussion on both screening and diagnostic options for fetal aneuploidy testing at the initial prenatal visit. Methods A retrospective quality improvement (QI) project was performed at a single, large, urban academic medical center. The implementation of this project was prospective; however, data was examined retrospectively after the QI initiative was implemented for three months. Patients were included if they were less than 24 weeks gestational age with a live intrauterine gestation at their initial obstetric (OB) visit. Patients less than 18 years old at the initial OB visit were excluded. The results were analyzed using the statistical software R. Chi-squared tests were used to examine proportional differences between the pre- and post-intervention groups with respect to demographic and clinical characteristics and documented genetic counseling discussions. Results A total of 416 patients were included in the final cohort. As measured by documentation, the rate of discussion of diagnostic prenatal genetic testing increased significantly from the pre-intervention proportion of 54% to the post-intervention proportion of 72% (p < 0.001). In the subgroup analysis of patients with advanced maternal age, the rate of discussion of diagnostic prenatal genetic testing increased significantly from the pre-intervention proportion of 53% to the post-intervention proportion of 83% (p = 0.003), and the rate of genetics counseling referrals made at the initial prenatal visit increased significantly from 4% pre-intervention to 38% post-intervention (p < 0.001). Conclusions The use of an enhanced prenatal genetic checklist led to increased discussion of diagnostic fetal aneuploidy testing and increased rates of referral to genetics counseling.

European Guidelines on Perinatal Care - Oxytocin for induction and augmentation of labor[Formula: see text]

OF RECOMMENDATIONS1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation).2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation).3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation).4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation).5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation).[Table: see text]6. Use of oxytocin for induction and augmentation of labor should be regularly audited (Low quality evidence ++--; Strong recommendation).

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition

IMPORTANCE

Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking.

OBJECTIVE

To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity. Using a difference-in-differences design, this study evaluated changes in net income, charges, charge to cost ratios, case mix index (a measure of reported illness burden), share of discharges for patients with Medicare or Medicaid coverage, discharges per year, and aggregate hospital quality measures associated with private equity acquisition through 3 years after acquisition, adjusted for case mix, hospital beds, calendar year, and adjustment for multiple hypothesis testing. In subgroup analyses, changes in outcomes for private equity-owned Hospital Corporation of America (HCA) hospitals and non-HCA hospitals relative to matched controls were assessed.

PRIMARY OUTCOMES AND MEASURES

Eight hospital income and use measures and 3 aggregate hospital quality measures were examined.

RESULTS

Relative to 532 control hospitals, the 204 private equity-acquired hospitals showed a mean increase of $2 302 391 (95% CI, $956 660-$3 648 123; P = .009) in annual net income, an increase of $407 (95% CI, $296-$518; P < .001) in total charge per inpatient day, an increase of 0.61 (95% CI, 0.48-0.73; P < .001) in emergency department charge to cost ratio, an increase of 0.31 (95% CI, 0.26-0.37; P < .001) in total charge to cost ratio, an increase of 0.02 (95% CI, 0.01-0.02; P = .007) in case mix index, and a decrease of 0.96% (95% CI, 0.46%-1.45%; P = .002) in share of Medicare discharges. Medicaid's share of discharges (-0.16%; 95% CI, -0.86% to 0.53%; P > .99) and total hospital discharges (98; 95% CI, -54 to 250; P > .99) did not change differentially in a statistically significant manner. The aggregate quality score for acute myocardial infarction increased by 3.3% (95% CI, 1.6%-5.0%; P = .002), and the aggregate score for pneumonia increased by 2.9% (95% CI, 1.8%-3.9%; P < .001) in private equity-acquired hospitals relative to controls. The aggregate score for heart failure (1.3%; 95% CI, -0.2% to 2.7%; P = .92) did not differentially change in a statistically significant manner. In subgroup analyses, HCA hospitals showed similar findings to the entire sample. Among non-HCA hospitals, the only statistically significant relative changes were the increase in the emergency department charge to cost ratio (0.30; 95% CI, 0.12-0.48; P = .02) and the decrease in Medicare's share (-1.15%; 95% CI, -1.88% to -0.43%; P = .02). Non-HCA hospitals showed a decrease in the aggregate heart failure score (-3.3%; 95% CI, -5.3% to -1.3%; P = .01) and no statistically significant changes in the aggregate score for acute myocardial infarction (2.4%; 95% CI, -0.7% to 5.4%; P > .99) or pneumonia (0.2%; 95% CI, -1.4% to 1.7%; P > .99).

CONCLUSIONS AND RELEVANCE

Hospitals acquired by private equity were associated with larger increases in net income, charges, charge to cost ratios, and case mix index as well as with improvement in some quality measures after acquisition relative to nonacquired controls. Heterogeneity in some findings was observed between HCA and non-HCA hospitals.

Pregnancy-related mortality in the United States, 2003-2016: age, race, and place of death

BACKGROUND

Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors.

OBJECTIVE

The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues.

STUDY DESIGN

We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period.

RESULTS

Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P < .0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P < .0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups.

CONCLUSION

Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.

Electronic Fetal Monitoring Credentialing Examination: The First 4000

Objective  Recognized variability in fetal heart rate interpretation led the Perinatal Quality Foundation (PQF) to develop a credentialing exam. We report an evaluation of the 1st 4000 plus PQF Fetal Monitoring Credentialing (FMC) exams. Study Design  The PQF FMC exam is an online assessment for obstetric providers and nurses. The exam contains two question types: traditional multiple-choice evaluating knowledge and Script Concordance Theory (SCT) evaluating judgment. Reliability was measured through McDonald's Total Omega and Cronbach's Alpha. Pearson's correlations between knowledge and judgment were measured. Results  From February 2014 through September 2018, 4,330 different individuals took the exam. A total of 4,057 records were suitable for reliability analysis: 2,105 (52%) physicians, 1,756 (43%) nurses, and 196 (5%) certified nurse midwives (CNMs). As a measure of test reliability, total Omega was 0.80 for obstetric providers and 0.77 for nurses. There was only moderate correlation between the knowledge scores and judgment scores for obstetric providers (0.38) and for nurses (0.43). Conclusion  The PQF FMC exam is a reliable, valid assessment of both Electronic Fetal Monitoring (EFM) knowledge and judgment. It evaluates essential EFM skills for the establishment of practical credentialing. It also reports modest correlation between knowledge and judgment scores, suggesting that knowledge alone does not assure clinical competency.

A Standardized Postpartum Oxytocin Protocol to Reduce Hemorrhage Treatment: Outcomes by Delivery Mode

BACKGROUND

Postpartum hemorrhage prophylaxis guidelines lack consensus and do not address the major factor of delivery mode. This creates quality and safety concerns. The objective of this study was to evaluate the effect of implementing a standardized prophylaxis protocol on postpartum hemorrhage treatment by delivery mode.

METHODS

A secondary analysis was conducted of all women ≥ 24 weeks' gestational age who delivered from January 2010 to June 2015 at one perinatal center. Women were grouped according to delivery pre-protocol (nonstandardized postpartum oxytocin) or post-protocol (standardized postpartum oxytocin). This retrospective cohort study compared outcomes by delivery mode. The primary outcome was treatment for postpartum hemorrhage or uterine atony.

RESULTS

A total of 16,811 women were studied, stratified by three delivery modes: spontaneous vaginal (n = 10,542), operative vaginal (n = 963), and cesarean (n = 5,306). Delivery post-protocol introduction was associated with a lower treatment rate of postpartum hemorrhage for spontaneous vaginal (5.7% vs. 3.1%; p < 0.001) and cesarean (9.4% vs. 7.8%; p = 0.036) modes. Delivery post-protocol introduction was associated with a decreased risk of the primary composite outcome across all modes: spontaneous vaginal (adjusted odds ratio [AOR] = 0.537; 95% confidence interval [CI]: 0.442-0.653), operative vaginal (AOR = 0.490; 95% CI: 0.285-0.842), and cesarean (AOR = 0.812; 95% CI: 0.666-0.988).

CONCLUSION

A standardized oxytocin protocol was associated with a lower postpartum hemorrhage treatment rate for cesarean and vaginal deliveries, but not for operative vaginal deliveries. The prophylactic effect of our higher dose protocol had the strongest benefit with women delivering vaginally.

A Contemporary Analysis of Medicolegal Issues in Obstetric Anesthesia Between 2005 and 2015

BACKGROUND

Detailed reviews of closed malpractice claims have provided insights into the most common events resulting in litigation and helped improve anesthesia care. In the past 10 years, there have been multiple safety advancements in the practice of obstetric anesthesia. We investigated the relationship among contributing factors, patient injuries, and legal outcome by analyzing a contemporary cohort of closed malpractice claims where obstetric anesthesiology was the principal defendant.

METHODS

The Controlled Risk Insurance Company (CRICO) is the captive medical liability insurer of the Harvard Medical Institutions that, in collaboration with other insurance companies and health care entities, contributes to the Comparative Benchmark System database for research purposes. We reviewed all (N = 106) closed malpractice cases related to obstetric anesthesia between 2005 and 2015 and compared the following classes of injury: maternal death and brain injury, neonatal death and brain injury, maternal nerve injury, and maternal major and minor injury. In addition, settled claims were compared to the cases that did not receive payment. χ, analysis of variance, Student t test, and Kruskal-Wallis tests were used for comparison between the different classes of injury.

RESULTS

The largest number of claims, 54.7%, involved maternal nerve injury; 77.6% of these claims did not receive any indemnity payment. Cases involving maternal death or brain injury comprised 15.1% of all cases and were more likely to receive payment, especially in the high range (P = .02). The most common causes of maternal death or brain injury were high neuraxial blocks, embolic events, and failed intubation. Claims for maternal major and minor injury were least likely to receive payment (P = .02) and were most commonly (34.8%) associated with only emotional injury. Compared to the dropped/denied/dismissed claims, settled claims more frequently involved general anesthesia (P = .03), were associated with delays in care (P = .005), and took longer to resolve (3.2 vs 1.3 years; P < .0001).

CONCLUSIONS

Obstetric anesthesia remains an area of significant malpractice liability. Opportunities for practice improvement in the area of severe maternal injury include timely recognition of high neuraxial block, availability of adequate resuscitative resources, and the use of advanced airway management techniques. Anesthesiologists should avoid delays in maternal care, establish clear communication, and follow their institutional policy regarding neonatal resuscitation. Prevention of maternal neurological injury should be directed toward performing neuraxial techniques at the lowest lumbar spine level possible and prevention/recognition of retained neuraxial devices.

Multidisciplinary obstetric critical care delivery: The concept of the "virtual" intensive care unit

With an increasing prevalence of chronic medical conditions and the associated potential for decompensation to critical illness among modern day parturients, we present here the concept of the "virtual" intensive care unit. We challenge the traditional association of the word "unit" to extend beyond a fixed physical setting to portray an individualized, predetermined patient care team capable of managing these complex patients in a variety of settings. In this model, obstetric critical care is provided through a multidisciplinary patient care team, with emphasis on early identification of complicated pregnancies, detailed antepartum planning, anticipation of complications, and retrospective review of clinical outcomes aimed at continued quality improvement. This structured approach in the provision of care to the critically ill pregnant patient will serve as a foundation for future attempts at reduction in rates of maternal morbidity and mortality.

The development and implementation of checklists in obstetrics

Checklists have been long used as a cognitive aid in various high-stakes environments to improve the reliability and performance of individuals and teams. When designed well, implemented thoughtfully, and monitored closely, they offer the opportunity to improve the performance of health care teams and advance patient safety. There are different types of checklists; examples include task lists, troubleshooting lists, coordination lists, discipline lists, and to-do lists. Each is useful in different situations and requires different implementation strategies. Checklists also are different from algorithms, care maps and protocols, and educational tools. Therefore, they are not useful in all situations. In appropriate selected clinical circumstances, checklists are tools that can help standardize care, improve communication, and help teams perform optimally.

Clinical perspective: creating an effective practice peer review process-a primer

Peer review serves as an important adjunct to other hospital quality and safety programs. Despite its importance, the available literature contains virtually no guidance regarding the structure and function of effective peer review committees. This Clinical Perspective provides a summary of the purposes, structure, and functioning of effective peer review committees. We also discuss important legal considerations that are a necessary component of such processes. This discussion includes useful templates for case selection and review. Proper committee structure, membership, work flow, and leadership as well as close cooperation with the hospital medical executive committee and legal representatives are essential to any effective peer review process. A thoughtful, fair, systematic, and organized approach to creating a peer review process will lead to confidence in the committee by providers, hospital leadership, and patients. If properly constructed, such committees may also assist in monitoring and enforcing compliance with departmental protocols, thus reducing harm and promoting high-quality practice.

Worth the Wait? The Effect of Early Term Birth on Maternal and Infant Health

Early term birth is defined as birth at 37 or 38 weeks gestation. While infants born early term are not considered premature, the medical literature suggests that they have an increased risk of serious adverse health outcomes compared to infants born at term (39 or 40 weeks). Despite these known harms, we document a rise in early term births in the United States from 1989 to the mid-2000s, followed by a decline in recent years. We posit that the recent decline in early term births has been driven by changes in medical practice advocated by the American College of Obstetricians and Gynecologists, programs such as the March of Dimes’ "Worth the Wait" campaign, and by Medicaid policy. We first show that this pattern cannot be attributed to changes in the demographic composition of mothers, and provide some evidence that efforts to reduce early term elective deliveries (EEDs) through Medicaid policy were effective. We next exploit county-level variation in the timing of these changes in medical practice to examine the effect of early term inductions (our proxy for EEDs) on infant and maternal health. We find that early term inductions lower birth weights and increase the risks of precipitous labor, birth injury, and required ventilation. Our results suggest that reductions in early term inductions can explain about one-third of the overall increase in birth weights between 2010 and 2013 for births at 37 weeks gestation and above.

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study

OBJECTIVE

To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes.

METHODS

A retrospective cohort study of term neonatal outcomes before (1998-2004) and after (2005-2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed.

RESULTS

There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1-45.5%, RR 0.82, 95% CI 0.7-0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76-0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95-0.96).

CONCLUSIONS

Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

Triggers, bundles, protocols, and checklists--what every maternal care provider needs to know

The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.

Sustainability of improvements in perinatal teamwork and safety climate

The purposes of this study were to describe changes in perinatal nurse (n = 70) and physician (n = 88) perceptions of teamwork and safety climate after implementing a 6-month Crew Resource Management training program and compare responses between nurses and physicians. The Teamwork and Safety Climate Survey was administered prior to and 1 year after the intervention. There were significant improvements in nurse and physician perceptions of teamwork and safety climate; however, physicians perceived teamwork more positive than nurses.

Severe systolic hypertension and the search for safer motherhood

Timely and appropriate response to severe hypertension during gestation is an important component of quality, safe care for pregnant or puerperal mothers regardless of causation. The reduction of severe maternal morbidity and maternal mortality in the hypertensive mother is clearly enhanced by the addition of standard protocols for provider response to severe hypertension, particularly severe systolic hypertension. The program developed in New York State via the Safe Motherhood Initiative promotes the implementation of unit-specific safety bundles, especially one that is focused upon a standardized approach to handling the obstetric emergency of severe hypertension usually associated with preeclampsia/eclampsia. The comprehensive preeclampsia/eclampsia safety bundle as summarized by Drs. Moroz and colleagues is reviewed especially from the perspective of its focus on the timely and specific responses for health care providers to make when severe hypertension is detected in the pregnant patient. Evidence-based guidance to practice considerations and clinical care of patients with preeclampsia/eclampsia is embedded within the program outlined for New York State by Moroz and her District II ACOG colleagues. There is a central focus on timely and appropriate antepartum/postpartum management of severe hypertension, a core concept to lessen maternal risk for cerebral hemorrhage. Ten considerations for further integration into the New York program are suggested. Beyond blood pressure control, there is a need for systematic review of interventions and outcomes over time, attention to possible future variations of the protocol for racial/ethnic patient groups at highest risk for maternal morbidity and mortality, and the identification of biomarker(s) that further specify and quantify risk to the maternal brain and other organ systems when severe hypertension develops. Safer motherhood will happen when evidence for best practice is integrated into systems of care for all patients.

Developing and Testing a Vaginal Delivery Safety Checklist

Communication failures are the most common root causes of perinatal deaths and injuries. We designed and tested a Vaginal Delivery Safety Checklist to improve communication and assist delivery teams' risk assessments and plans for potential complications of vaginal birth. Delivery teams found the checklist easy, convenient, and helpful. Teams completed the checklist within 2 to 3 minutes and showed improved teamwork, communication, and decision making.

Cardiac Arrest in Pregnancy

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor

OBJECTIVE

The objective of the study was to examine the clinical impact of specific fetal monitoring-related practices during induced labor.

STUDY DESIGN

This was a prospective, nonrandomized study.

RESULTS

We studied 14,398 women undergoing oxytocin induction of labor. A decrease in the infusion rate of oxytocin in the face of specified category II fetal heart rate tracings was associated with a significantly reduced rate of neonatal intensive care unit admission (3.8% vs 5.2%, P = .01) and Apgar score less than 7 at 1 and 5 minutes (4.9% vs 6.4%, P = .01, 0.6% vs 1.1%, P = .04). Compliance with an in-use checklist was associated with both a reduction in the rate of neonatal intensive care unit admission (2.9 vs 4.4, P = .00) and a reduction in the cesarean delivery rate (15.8% vs 18.8%, P = .00).

CONCLUSION

Electronic fetal heart rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions. Utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes and a reduction in the cesarean delivery rate.

Society for maternal-fetal medicine (SMFM) special report: the maternal-fetal medicine subspecialists' role within a health care system

A maternal-fetal medicine (MFM) subspecialist has advanced knowledge of the medical, surgical, obstetrical, fetal, and genetic complications of pregnancy and their effects on both the mother and fetus. MFM subspecialists are complementary to obstetric care providers in providing consultations, co-management, or transfer of care for complicated patients before, during, and after pregnancy. The MFM subspecialist provides peer and patient education and performs research concerning the most recent approaches and treatments for obstetrical problems, thus promoting risk-appropriate care for these complicated pregnancies. The relationship between the obstetric care provider and the MFM subspecialist depends on the acuity of the maternal and/or fetal condition and the local resources. To achieve the goal of promoting early access and sustained adequate prenatal care for all pregnant women, we encourage collaboration with obstetricians, family physicians, certified midwives, and others, and we also encourage providing preconception, prenatal, and postpartum care counseling and coordination. Effective communication between all obstetric care team members is imperative. This special report was written with the intent that it would be broad in scope and appeal to a diverse readership, including administrators, allowing it to be applied to various systems of care both horizontally and vertically. We understand that these relationships are often complex and there are more models of care than could be addressed in this document. However, we aimed to promote the development of a highly effective team approach to the care of the high-risk pregnancy that will be useful in the most common models for obstetric care in the United States. The MFM subspecialist functions most effectively within a fully integrated and collaborative health care environment. This document defines the various roles that the MFM subspecialist can fulfill within different heath care systems through consultation, co-management, and transfer of care, as well as education, research, and leadership.

Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage

OBJECTIVE

The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data.

STUDY DESIGN

We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data.

RESULTS

Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases.

CONCLUSION

Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.

Are we (mis)guided by current guidelines on intrapartum fetal heart rate monitoring? Case for a more physiological approach to interpretation

Original interpretations of fetal heart rate (FHR) patterns equated FHR decelerations with 'fetal distress', requiring expeditious delivery. This simplistic interpretation is still implied in our clinical guidelines despite 40 years of increasing understanding of the behaviour and regulation of the fetal cardiovascular system during labour. The physiological basis of FHR responses and adaptations to oxygen deprivation is de-emphasised, whilst generations of obstetricians and midwives are trained to focus on, and classify, the morphological appearances of decelerations into descriptive categories, with no attempt to understand how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults, or the patterns that suggest progressive loss of compensation. Consequently, there is a lack of confidence, marked variation in FHR interpretation, defensive practices, unnecessary operative interventions, and a failure to recognise abnormal FHR patterns, resulting in adverse outcomes and expensive litigation.

Validation of the joint commission exclusion criteria for elective early-term delivery

OBJECTIVE

To evaluate whether current Joint Commission (JC) exclusion criteria for measure PC-01, "Elective Delivery" before 39 weeks of gestation, accurately identify valid, codeable indications for planned early-term delivery.

METHODS

We performed a review and critical analysis of all cases recorded as noncompliant for the measure in a large health care system during the second half of 2012.

RESULTS

During the study period, of 107,145 total deliveries, 205 cases were reported as noncompliant with PC-01. Ten percent of compliance fallouts (ie, cases coded as noncompliant) resulted from valid indications for delivery identifiable by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding not included on the JC exclusion list; these were primarily unusual or extreme variations of these conditions. Twenty-five percent of fallouts represented valid indications not represented by an ICD-9-CM code. Eight percent of cases were reported as fallouts as a result of imprecise physician charting; only 2% represented chart abstraction errors. Fifty-five percent of cases involved stated indications for early-term delivery not generally recognized as such by the medical community. Compliance rates of 98% are achievable across a large population using the current ICD-9-CM-based metric for compliance assessment used by the JC (PC-01). The current exclusion list does not appear to be amenable to further improvement by inclusion of more or different ICD-9-CM codes. However, given the low volumes generated using the current PC-01 denominator definition, approximately 60% of facilities would have compliance rates below a 95% benchmark with even a single justified outlier if analyzed on a quarterly basis.

CONCLUSION

Our data validate the current JC exclusion criteria for this measure, which identify the vast majority of valid indications for early-term delivery used by obstetrician-gynecologists and identifiable with ICD-9-CM codes.

LEVEL OF EVIDENCE

III.

The case for an electronic fetal heart rate monitoring credentialing examination

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.

Fault and blame, insults to the perinatal brain may be remote from time of birth

There is a certainty in malpractice cases that neurodevelopmental deficits are caused by preventable events at birth when the onset, nature, and timing of the insult in the antenatal and natal period are unknown. The biggest problem is determining timing. Electronic fetal monitoring is given excessive importance in legal cases. Before assigning fault on events at birth, a better understanding of developmental neurobiology and limitations of the present clinical biomarkers is warranted. The issues of single versus repeated episodes, timing of antenatal insults, pros and cons of legal arguments, interaction of various etiologic and anatomic factors are discussed.

Quality of obstetric care in the sparsely populated sub-arctic area of Norway 2009-2011

Background

It is challenging to obtain high quality obstetric care in a sparsely populated area. In the subarctic region of Norway, significant distances, weather conditions and seasonable darkness have called for a decentralized care model. We aimed to explore the quality of this care.

Methods

A retrospective study employing data (2009–11) from the Medical Birth Registry of Norway was initiated. Northern Norwegian and Norwegian figures were compared. Midwife administered maternity units, departments at local and regional specialist hospitals were compared. National registry data on post-caesarean wound infection (2009–2010) was added. Quality of care was measured as rate of multiple pregnancies, caesarean section, post-caesarean wound infection, Apgar score <7, birth weight <2.5 kilos, perineal rupture, stillbirth, eclampsia, pregnancy induced diabetes and vacuum or forceps assisted delivery. There were 15,586 births in 15 delivery units.

Results

Multiple pregnancies were less common in northern Norway (1.3 vs. 1.7%) (P = 0.02). Less use of vacuum (6.6% vs. 8.3%) (P = 0.01) and forceps (0.9% vs 1.7%) (P < 0.01) assisted delivery was observed. There was no difference with regard to pregnancy induced diabetes, caesarean section, stillbirth, Apgar score < 7 and eclampsia. A significant difference in birth weight < 2.5 kilos (4.7% vs. 5.0%) (P < 0.04) and perineal rupture grade 3 and 4 (1.5% vs. 2.3%) (P < 0.02) were revealed. The post-caesarean wound infection rate was higher (10.5% vs. 7.4%) (P < 0.01).

Conclusion

Northern Norway had an obstetric care of good quality. Birth weight, multiple pregnancies and post-caesarean wound infection rates should be further elucidated.

Intrapartum management of category II fetal heart rate tracings: towards standardization of care

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

A multistate quality improvement program to decrease elective deliveries before 39 weeks of gestation

OBJECTIVE

Nonmedically indicated (elective) deliveries before 39 weeks of gestation result in unnecessary neonatal morbidity. We sought to determine whether implementation of a process improvement program will decrease the rate of elective scheduled singleton early-term deliveries (37 0/7-38 6/7 weeks of gestation) in a group of diverse community and academic hospitals.

METHODS

Policies and procedures for scheduling inductions and cesarean deliveries were implemented and patient and health care provider education was provided. Outcomes for scheduled singleton deliveries at 34 weeks of gestation or higher were submitted through a web-based data entry system. The rate of scheduled singleton elective early-term deliveries as well as the rates of early-term medically indicated and unscheduled deliveries, neonatal intensive care unit admissions, and singleton term fetal mortality rate were evaluated.

RESULTS

A total of 29,030 scheduled singletons at 34 weeks of gestation or higher were delivered in 26 participating hospitals between January 2011 and December 2011. Elective scheduled early-term deliveries decreased from 27.8% in the first month to 4.8% in the 12th month (P<.001); rates of elective scheduled singleton early-term inductions (72%, P=.029) and cesarean deliveries (84%; P<.001) decreased significantly. There was no change in medically indicated or unscheduled early-term deliveries. Neonatal intensive care unit admissions among scheduled early-term singletons decreased nonsignificantly from 1.5% to 1.2% (P=.24). There was no increase in the term fetal mortality rate.

CONCLUSION

A rapid-cycle process improvement program substantially decreased elective scheduled early-term deliveries to less than 5% in a group of diverse hospitals across multiple states.

LEVEL OF EVIDENCE

III.

A collaborative interdisciplinary approach to electronic fetal monitoring: report of a statewide initiative

Intrapartum electronic fetal monitoring (EFM) is one of the most common procedures in obstetrics. Current consensus statements provide clinicians with a common language for EFM as well as provide a basis for a simplified approach to interpretation and management. This article presents a summary of the content and implementation of a statewide initiative in interdisciplinary EFM education and training designed to give clinicians of all backgrounds a shared mental model in EFM. Challenges to implementation at individual institutions may include physician and nursing engagement as well as time and cost constraints.

Maternity care and liability: pressing problems, substantive solutions

BACKGROUND

This paper summarizes a new report presenting the best available research about the impact of the liability environment on maternity care, and policy options for improving this environment. Improved understanding of these matters can help to transcend polarized discourse and guide policy intervention.

METHODS

We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable.

FINDINGS

The best available research does not support a series of widely held beliefs about maternity care and liability, including the economic impact of liability insurance premiums on maternity care clinicians, the existence of extensive defensive maternity care practice, and the impact of limiting the size of awards for non-economic damages in a malpractice lawsuit. In the practice of an average maternity caregiver, negligent injury of mothers and newborns seems to occur more frequently than any claim and far more frequently than a payout or trial. Many important gaps in knowledge relating to maternity care and liability remain. Some improvement strategies are likely to be more effective than others.

CONCLUSIONS

Empirical research does not support many widely held beliefs about maternity care and liability. The liability system does not currently serve well childbearing women and newborns, maternity care clinicians, or those who pay for maternity care. A number of promising strategies might lead to a higher functioning liability system, whereas others are unlikely to contribute to needed improvements.

Maternity care and liability: most promising policy strategies for improvement

BACKGROUND

The present liability system is not serving well childbearing women and newborns, maternity care clinicians, or maternity care payers. Examination of evidence about the impact of this system on maternity care led us to identify seven aims for a high-functioning liability system in this clinical context. Herein, we identify policy strategies that are most likely to meet these aims and contribute to needed improvements. A companion paper considers strategies that hold little promise.

METHODS

We considered whether 25 strategies that have been used or proposed for improvement have met or could meet the seven aims. We used a best available evidence approach and drew on more recent empirical legal studies and health services research about maternity care and liability when available, and considered other studies when unavailable.

FINDINGS

Ten strategies seem to have potential to improve liability matters in maternity care across multiple aims. The most promising strategy--implementing rigorous maternity care quality improvement (QI) programs--has led to better quality and outcomes of care, and impressive declines in liability claims, payouts, and premium levels.

CONCLUSIONS

A number of promising strategies warrant demonstration and evaluation at the level of states, health systems, or other appropriate entities. Rigorous QI programs have a growing track record of contributing to diverse aims of a high-functioning liability system and seem to be a win-win-win prevention strategy for childbearing families, maternity care providers, and payers. Effective strategies are also needed to assist families when women and newborns are injured.