The Obstetric Hemorrhage Initiative (OHI) in Florida: The Role of Intervention Characteristics in Influencing Implementation Experiences among Multidisciplinary Hospital Staff

Objectives Obstetric hemorrhage is one of the leading causes of maternal mortality. The Florida Perinatal Quality Collaborative coordinates a state-wide Obstetric Hemorrhage Initiative (OHI) to assist hospitals in implementing best practices related to this preventable condition. This study examined intervention characteristics that influenced the OHI implementation experiences among Florida hospitals. Methods Purposive sampling was employed to recruit diverse hospitals and multidisciplinary staff members. A semi-structured interview guide was developed based on the following constructs from the intervention characteristics domain of the Consolidated Framework for Implementation Research: evidence strength; complexity; adaptability; and packaging. Interviews were audio-recorded, transcribed and analyzed using Atlas.ti. Results Participants (n = 50) across 12 hospitals agreed that OHI is evidence-based and supported by various information sources (scientific literature, experience, and other epidemiologic or quality improvement data). Participants believed the OHI was 'average' in complexity, with variation depending on participant's role and intervention component. Participants discussed how the OHI is flexible and can be easily adapted and integrated into different hospital settings, policies and resources. The packaging was also found to be valuable in providing materials and supports (e.g., toolkit; webinars; forms; technical assistance) that assisted implementation across activities. Conclusions for Practice Participants reflected positively with regards to the evidence strength, adaptability, and packaging of the OHI. However, the complexity of the initiative adversely affected implementation experiences and required additional efforts to maximize the initiative effectiveness. Findings will inform future efforts to facilitate implementation experiences of evidence-based practices for hemorrhage prevention, ultimately decreasing maternal morbidity and mortality.

Hospital Variations in Unexpected Complications Among Term Newborns

OBJECTIVES

To examine contributing factors and potential reasons for hospital differences in unexpected newborn complication rates in Florida.

METHODS

We conducted a population-based retrospective cohort study of linked birth certificate and hospital discharge records from 2004 to 2013. The study population included 1 604 774 term, singleton live births in 124 hospitals. Severe and moderate complications were identified via a published algorithm. Logistic mixed-effects models were used to examine risk factors for complications and to estimate the percentage of hospital variation explained by factors. Descriptive analyses were performed to explore reasons for the differences.

RESULTS

Hospital total complication rates varied from 6.7 to 98.6 per 1000 births. No correlation between severe and moderate complication rates by hospital was identified. Leading risk factors for complications included medically indicated early-term delivery, no prenatal care, nulliparity, prepregnancy obesity, tobacco use, and delivery in southern Florida hospitals. Hospital factors such as geographic location, level of care or birth volume, and Medicaid births percentage explained 35% and 27.8% of variation in severe and moderate complication rates, respectively. Individual factors explained an additional 6% of variation in severe complication rates. Different complication subcategories (eg, infections, hospital transfers) drove the hospital factors that contributed to severe and moderate complications.

CONCLUSIONS

Variation in unexpected complication rates is more likely to be related to hospital rather than patient characteristics in Florida. The high proportion of variation explained by hospital factors suggests potential opportunities for improvement, and identifying specific complication categories may provide focus areas. Some of the opportunities may be related to differences in hospital coding practice.

New perspectives on sustainable development and barriers to relevant information

Sustainable development may mean different things to people with different worldviews. We sketch four worldviews, drawing on a schema developed by Bryan Norton. Of these four worldviews, i.e. exploitist, utilitist, integrist and inherentist, the third is the most consistent with the Brundtland Report (WCED 1987) and the Great Lakes Water Quality Agreement (GLWQA 1987).The integrist perspective combines analytic reductionistic study with comparative contextual study, with emphasis on the latter. This integrative approach moves from over-reliance on utilist information services such as impact assessment towards transactive study. Our own compromise emphasizes a stress-response approach to a partial understanding of complex cultural-natural interactions within ecosystems. Both cultural and natural attributes of ecosystems must be addressed.Currently the federal Canadian government tends toward an exploitist worldview; current government R&D funding and subsidies reflect this view. Old-fashioned scientists who rely on a monocular analytical vision of the world's minutiae may find contextual historical study offensive; these scientists hold sway on some advisory boards and hence research funding. Difficulty in finding funding for integrist information services should not be interpreted as a lack of need for this information; rather this difficulty results from resistance to a changing worldview.