Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America

OBJECTIVE

To evaluate the effectiveness of the implementation of intervention packages for postpartum hemorrhage (PPH) management in pregnant women hospitalized in a High Obstetric Complexity Unit in a Latin American country.

METHODS

Retrospective cohort study including pregnant women with PPH attended between January 2011 to December 2019. Three periods of time were defined according to management strategies We performed univariate and multivariate robust Poisson regression logistic models for each of the outcomes derived from each period.

RESULTS

We included 602 patients. There was a reduction in period 3 of the incidence of massive PPH (16% versus 12% P < 0.001, relative risk [RR] 0.61, 95% confidence interval [CI] 0.44-0.85; P = 0.003), major surgery (24%, 13%, 11%, P = 0.002, RR 0.54, 95% CI 0.33-0.883; P = 0.014), and admission to the intensive care unit (ICU) (14%, 7%, 6.1%, P = 0.0, RR 0.40, 95% CI 0.17-0.96 P = 0.00).

CONCLUSION

The implementation of PPH intervention packages in a hospital in a middle-income country from Latin America, led to a significant decrease in the incidence of massive bleeding, the rate of major surgery, and the ICU stay of pregnant women affected by this condition.

Identification of Clinician Training Techniques as an Implementation Strategy to Improve Maternal Health: A Scoping Review

Training is a key implementation strategy used in healthcare settings. This study aimed to identify a range of clinician training techniques that facilitate guideline implementation, promote clinician behavior change, optimize clinical outcomes, and address implicit biases to promote high-quality maternal and child health (MCH) care. A scoping review was conducted within PubMed, CINAHL, PsycInfo, and Cochrane databases using iterative searches related to (provider OR clinician) AND (education OR training). A total of 152 articles met the inclusion/exclusion criteria. The training involved multiple clinician types (e.g., physicians, nurses) and was predominantly implemented in hospitals (63%). Topics focused on maternal/fetal morbidity/mortality (26%), teamwork and communication (14%), and screening, assessment, and testing (12%). Common techniques included didactic (65%), simulation (39%), hands-on (e.g., scenario, role play) (28%), and discussion (27%). Under half (42%) of the reported training was based on guidelines or evidence-based practices. A minority of articles reported evaluating change in clinician knowledge (39%), confidence (37%), or clinical outcomes (31%). A secondary review identified 22 articles related to implicit bias training, which used other reflective approaches (e.g., implicit bias tests, role play, and patient observations). Although many training techniques were identified, future research is needed to ascertain the most effective training techniques, ultimately improving patient-centered care and outcomes.

Preventing and Treating Torsades de Pointes in the Mother, Fetus and Newborn in the Highest Risk Pregnancies with Inherited Arrhythmia Syndromes

The number of women of childbearing age who have been diagnosed in childhood with ion channelopathy and effectively treated using beta blockers, cardiac sympathectomy, and life-saving cardiac pacemakers/defibrillators is increasing. Since many of these diseases are inherited as autosomal dominant, offspring have about a 50% risk of having the disease, though many will be only mildly impacted during fetal life. However, highly complex delivery room preparation is increasingly needed in pregnancies with inherited arrhythmia syndromes (IASs). However, specific Doppler techniques show meanwhile a better understanding of fetal electrophysiology. The advent of fetal magnetocardiography (FMCG) now allows the detection of fetal Torsades de Pointes (TdP) ventricular tachycardia and other LQT-associated arrhythmias (QTc prolongation, functional second AV block, T-wave alternans, sinus bradycardia, late-coupled ventricular ectopy and monomorphic VT) in susceptible fetuses during the second and third trimester. These types of arrhythmias can be due to either de novo or familial Long QT Syndrome (LQTS), Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), or other IAS. It is imperative that the multiple specialists involved in the antenatal, peripartum, and neonatal care of these women and their fetuses/infants have the optimal knowledge, training and equipment in order to care for these highly specialized pregnancies and deliveries. In this review, we outline the steps to recognize symptomatic LQTS in either the mother, fetus or both, along with suggestions for evaluation and management of the pregnancy, delivery, or post-partum period impacted by LQTS.

Randomized Controlled Simulation Trial to Compare Transfer Procedures for Emergency Cesarean

OBJECTIVE

To test the hypothesis that capping intravenous and epidural lines would reduce time to transfer women in labor to the operating room and time to readiness for general anesthesia for emergency cesarean. The secondary purpose was to identify latent threats to patient safety.

DESIGN

Mixed methods analysis of a randomized, controlled, in situ simulation trial.

SETTING

Labor and delivery unit at high-risk referral center.

PARTICIPANTS

Fifteen interprofessional teams that included labor and delivery nurses and anesthesiology residents.

METHODS

Immediately before simulation, we randomized bedside nurses and anesthesiology residents to one of two groups: usual transfer or the cap and run procedure. Simulation scenarios started with fetal heart rate decelerations that necessitated position changes followed by emergency cesarean. An embedded simulated obstetrician announced the decision for cesarean; completion of an OR checklist confirmed team readiness to induce general anesthesia. Postsimulation debriefing was focused on teamwork and opportunities to improve safety, and we used qualitative analysis to synthesize results.

RESULTS

We found no statistically significant difference in the overall time from decision for cesarean to readiness for general anesthesia between the two groups (usual transfer median = 445 seconds [interquartile range, 425-465] vs. cap and run 390 seconds [interquartile range, 383-443], p = .12). The time in the operating room was less in the cap and run group than in the usual transfer group (median = 300 seconds vs. 250 seconds, p = .038). Qualitative analysis of the debriefing data indicated advantages of the capping procedure, including better bed maneuverability and fewer tangled lines.

CONCLUSION

We found no evidence of decreased overall time from decision for cesarean to readiness for general anesthesia based on whether the nurse capped the intravenous and epidural lines or pushed the intravenous pole alongside the bed. However, nurses perceived improved patient safety with the cap and run procedure.

Knowledge of intrapartum care among obstetric care providers in rural Kenya

BACKGROUND

Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya.

METHODS

This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications.

RESULTS

Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care.

CONCLUSIONS

Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival.

A Survey on the Educational Needs and Competence of Nurses in Maternal Fetal Intensive Care Unit

PURPOSE

Maternal Fetal Intensive Care Unit (MFICU), which provides intensive care to high-risk mothers with increasing maternal age and high-risk newborns, has become a new field of nursing work in South Korea. The present study was conducted to identify the educational needs and self-assessing clinical competence of nurses in MFICU.

METHODS

The education needs and competencies of MFICU nurses were measured through prepared questionnaires by researchers based on the previous studies on job analysis of nurses in MFICU. Data were collected from January 2019 to March 2019. The study involved 168 nurses working in MFICUs at 12 hospitals nationwide as study subjects. The data were analyzed using the SPSS WIN 23.0 program.

RESULTS

The education needs of nurses in MFICU had an average of 4.21 points (±0.50) and their nursing competence was average 3.38 points (±0.60). The items reported as high education needs but low competency by nurses in MFICU were as following: 'postpartum hemorrhage and shock,' 'cardiopulmonary resuscitation (CPR) for neonate,' 'CPR during pregnancy,' 'disseminated intravascular coagulation,' 'sepsis,' and 'mechanical ventilation during pregnancy.'

CONCLUSION

Based on these results, it is proposed that a comprehensive education program for nurses in MFICU should be developed by considering low capabilities among MFICU nurses as a priority factor.

Readiness: Utilizing bundles and simulation

Postpartum hemorrhage is an important contributor to maternal morbidity, and is one of the most common worldwide causes of preventable maternal mortality. Preventing significant morbidity and mortality from postpartum hemorrhage necessitates preparedness on both a unit and patient level. Our objectives are to define a bundle, to review the elements of the Council on Patient Safety in Women's Healthcare Obstetric Hemorrhage Bundle and to highlight simulation-based training opportunities, focusing on readiness for this significant obstetric emergency.

Diabetes Educators' Intended and Reported Use of Common Diabetes-Related Technologies: Discrepancies and Dissonance

BACKGROUND

Technology provides adjuvant and/or alternative approaches to care and may promote self-care, communication, and engagement with health care services. Common recent technologies for diabetes include continuous subcutaneous insulin infusions (insulin pumps), continuous glucose monitoring systems, smartphone and tablet applications, and telehealth (video conferencing). This study reports Australian diabetes educators' intentions and reported professional use of these technologies for people with type 1 diabetes, and factors predictive of this.

METHODS

An anonymous, web-based questionnaire based on the technology acceptance model was distributed to members of the Australian Diabetes Educators Association through their electronic newsletter. Exploratory factor analysis revealed a 5-factor solution comprising confidence and competence, improving clinical practice, preparation (intentions and training), ease of use, and subjective norms. Logistic regression analyses identified factors predicting intention and use of technology.

RESULTS

Respondents (n = 228) had high intentions to use technology. The majority reported using continuous subcutaneous insulin infusions, continuous glucose monitoring systems, and applications with patients, but usage was occasional. Confidence and competence independently predicted both intentions and use of all 4 technologies. Preparation (intentions and training) independently predicted use of each technology also.

CONCLUSIONS

Discrepancies and dissonance appear between diabetes educators' intentions and behavior (intentions to use and reported technology use). Intentions were higher than current use, which was relatively low and not likely to provide significant support to people with type 1 diabetes for disease management, communication, and engagement with health care services. Continuing education and experiential learning may be key in supporting diabetes educators to align their intentions with their practice.

A nurse-led intervention improves detection and management of AKI in Malawi

BACKGROUND

Acute kidney injury is common and has significant impact on mortality and morbidity. There is a global drive to improve the lack of knowledge and understanding surrounding the recognition, diagnosis and management of patients with AKI in resource poor healthcare systems.

OBJECTIVES

We propose a nurse-led education programme to medical and nursing staff of the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, will improve the overall care and understanding of patients with AKI that will still be effective 3 months later.

METHODS

This was a three phase, prospective interventional pilot study which evaluated base line knowledge and clinical practice amongst healthcare workers, provided a comprehensive combination nurse-led class room and ward based teaching programme and evaluated the change in knowledge and clinical management of patients in the high dependency areas of the hospital immediately, and 3 months, after the teaching intervention.

RESULTS

The nurse-led intervention significantly improved the healthcare workers attitudes towards detecting or managing patients with suspected AKI (p < 0.0001). There were also significant improvements in the completion of fluid charts and recording of urine output (p < 0.0001), corner stones of AKI management. Knowledge and clinical intervention was still present three months later. There was however little change in the understanding that AKI could be a significant clinical problem in QECH and that it may have a major impact on mortality and working practice and this needs to be addressed in future teaching programmes.

CONCLUSIONS

A low cost, nurse-led AKI educational intervention improved the knowledge and management of AKI at QECH, which was still evident 3 months later.

Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study

Objective. To evaluate confidence, knowledge, and competence after a simulation-based curriculum on maternal cardiac arrest in an Obstetrics & Gynecologic (OBGYN) residency program. Methods. Four simulations with structured debriefing focusing on high yield causes and management of maternal cardiac arrest were executed. Pre- and post-individual knowledge tests (KT) and confidence surveys (CS) were collected along with group scores of critical performance steps evaluated by content experts for the first and final simulations. Results. Significant differences were noted in individual KT scores (pre: 58.9 ± 8.9 versus post: 72.8 ± 6.1, p = 0.01) and CS total scores (pre: 22.2 ± 6.4 versus post: 29.9 ± 3.4, p = 0.007). Significant differences were noted in airway management, p = 0.008; appropriate cycles of drug/shock-CPR, p = 0.008; left uterine displacement, p = 0.008; and identifying causes of cardiac arrest, p = 0.008. Nonsignificant differences were noted for administration of appropriate drugs/doses, p = 0.074; chest compressions, p = 0.074; bag-mask ventilation before intubation, p = 0.074; and return of spontaneous circulation identification, p = 0.074. Groups remained noncompetent in team leader tasks and considering therapeutic hypothermia. Conclusion. This study demonstrated improved OBGYN resident knowledge, confidence, and competence in the management of third trimester maternal cardiac arrest. Several skills, however, will likely require more longitudinal curricular exposure and training to develop and maintain proficiency.