Lisa Nathan

Global health training in US obstetrics and gynaecology residency programmes: perspectives of students, residents and programme directors

Background Benefits of exposure to global health training during medical education are well documented and residents’ demand for this training is increasing. Despite this, it is offered by few US obstetrics and gynaecology (OBGYN) residency training programmes. Objectives To evaluate interest, perceived importance, predictors of global health interest and barriers to offering global health training among prospective OBGYN residents, current OBGYN residents and US OGBYN residency directors. Methods We designed two questionnaires using Likert scale questions to assess perceived importance of global health training. The first was distributed to current and prospective OBGYN residents interviewing at a US residency programme during 2012–2013. The second questionnaire distributed to US OBGYN programme directors assessed for existing global health programmes and global health training barriers. A composite Global Health Interest/Importance score was tabulated from the Likert scores. Multivariable linear regression was performed to assess for predictors of Global Health Interest/Importance. Results A total of 159 trainees (77%; 129 prospective OBGYN residents and 30 residents) and 69 (28%) programme directors completed the questionnaires. Median Global Health Interest/Importance score was 7 (IQR 4–9). Prior volunteer experience was predictive of a 5-point increase in Global Health Interest/Importance score (95% CI −0.19 to 9.85; p=0.02). The most commonly cited barriers were cost and time. Conclusion Interest and perceived importance of global health training in US OBGYN residency programmes is evident among trainees and programme directors; however, significant financial and time barriers prevent many programmes from offering opportunities to their trainees. Prior volunteer experience predicts global health interest.

Retention of skills 2 years after completion of a postpartum hemorrhage simulation training program in rural Rwanda

To evaluate the long‐term retention of skills gained by rural physicians who completed a postpartum hemorrhage simulation‐training program.

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial

Background The World Health Organizations Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.

Performance of Implementing Guideline Driven Cervical Cancer Screening Measures in an Inner City Hospital System

Objective: In 2006, the American Society for Colposcopy and Cervical Pathology updated evidence-based guidelines recommending screening intervals for women with abnormal cervical cytology diagnosis. In our low-income inner-city population, we sought to improve performance by uniformly applying the guidelines to all patients. We report the prospective performance of a comprehensive tracking, evidence-based algorithmically driven call back, and appointment scheduling system for cervical cancer screening in a resource-limited inner-city population. Materials and Methods: Outreach efforts were formalized with algorithm-based protocols for triage to colposcopy, with universal adherence to evidence-based guidelines. During implementation from August 2006 to July 2008, we prospectively tracked performance using the electronic medical record with administrative and pathology reports to determine performance variables such as the total number of Pap tests, colposcopy visits, and the distribution of abnormal cytology and histology results, including all cervical intraepithelial neoplasia 2, 3 diagnoses. Results: A total of 86,257 gynecologic visits and 41,527 Pap tests were performed system-wide during this period of widespread and uniform implementation of standard cervical cancer screening guidelines. The number of Pap tests performed per month varied little. The incidence of CIN 1 significantly decreased from 117 (68.4%) of 171 during the first tracked month to 52 (54.7%) of 95 during the last tracked month (p = 0.04). The monthly incidence rate of CIN 2, 3, including incident cervical cancers, did not change. The total number of colposcopy visits declined, resulting in a 50% decrease in costs related to colposcopy services and approximately a 12% decrease in costs related to excisional biopsies. Conclusions: Adherence to cervical cancer screening guidelines reduced the number of unnecessary colposcopies without increasing numbers of potentially missed CIN 2, 3 lesions, including cervical cancer. Uniform implementation of administrative-based performance initiatives for cervical cancer screening minimizes differences in provider practices and maximizes performance of screening while containing cervical cancer screening costs.

Sudden Obstetric Collapse

Pregnant women are generally considered to be a “low-risk” population, and a typical labor and delivery suite is not designed to manage a woman that may experience a collapse. However, even a “low-risk” pregnancy carries life-threatening risks. In 2010, worldwide maternal deaths were studied and over 50 % of the deaths occurred in six countries with the highest number occurring in India (Trends in Maternal Mortality 1990 to 2013. The World Bank and United Nation population division: trends in maternal mortality: 1990 to 2013. Geneva: WHO, 2014). It is not uncommon for a pregnant woman to be brought into a hospital in a collapsed condition. When the cause of maternal collapse is not known, there is too often a delay in diagnosis and treatment. This delay is associated with increased risk of maternal morbidity and mortality. One way to reduce the maternal morbidity and mortality of sudden maternal collapse is by prevention of the common antecedents to this condition. Recognition of the subset of patients at highest risk is imperative. Anticipation, early diagnosis, and rapid response are the three critical factors in preventing maternal deaths.

Providing Global Health Training in an Obstetrics and Gynecology Residency Program [125]

INTRODUCTION: Very few obstetrics and gynecology residency programs offer global health training for their residents. Participants of a structured global health program were surveyed to assess the perceived benefits of the training. METHODS: Albert Einstein College of Medicines Department of Obstetrics and Gynecology created a global womens health program in 2010. This comprehensive program includes a seminar series, simulation training, journal club, specialty clinics, and three types of international experience: research, clinical rotations, and public health initiatives. It has three arms: medical student program, residency track, and clinical and research program for fellows. Anonymous surveys assessing the global health program and perceptions of the benefits of the program on overall training were sent electronically to all past participants. Descriptive statistics were used to analyze the data. RESULTS: Twelve of the 14 participants (86%) completed the survey. Rwanda, Uganda, Benin, Ethiopia, and Uganda were the reported sites for international field experience. Sixty-seven percent of respondents used vacation time to complete these electives. The majority of respondents (67%) participated in clinical rotations, research implementation, and public health initiatives during their field experience. The most commonly cited benefit of global health training was an increased commitment to work with medically underserved populations (33%). After completing the global health training program, 58% reported they were more surgically skilled, 75% reported they were more clinically skilled, and 92% reported they were more culturally sensitive. CONCLUSION: There are many diverse benefits of global health training in residency programs.

Retention of Skills 2 Years After Postpartum Hemorrhage Simulation Training in Rural Rwanda [137]

INTRODUCTION: Obstetric hemorrhage is the leading cause of maternal mortality in Rwanda. Retention of skills was assessed 2 years after a postpartum hemorrhage simulation training at a rural Rwandan hospital. METHODS: In 2012, two African generalist physicians working in a rural Rwandan hospital conducted simulation-based training in postpartum hemorrhage management for their colleagues. These 11 physicians were approached again in 2014 and asked to participate in the current study. Retention simulation drills were conducted using the same simulation scenario as in the initial training. Median scores and interquartile ranges were calculated. The Wilcoxon signed-rank-sum test was used to compare preintervention and postintervention scores and retention scores in three performance areas: communication, evaluation, and management. RESULTS: Six of the original 11 participants were available and consented to participate. Comparisons of the preintervention and 2-year retention scores in each of three performance areas revealed retention-of-skill scores that were not significantly different than the postintervention scores after the original simulation training: median (interquartile range) preintervention compared with retention communication: 0.5 (0, 2) compared with 3.5 (2, 4) (P=.03) and postintervention compared with retention communication: 3.5 (3, 4) compared with 3.5 (2, 4) (P=1.0); preintervention compared with retention evaluation: 2 (2, 4) compared with 5 (4, 5) (P=.03) and postintervention compared with retention evaluation: 4.5 (2, 5) compared with 5 (4, 5) (P=.16); and preintervention compared with retention management: 2.5 (2, 5) compared with 7 (7, 10) (P=.09) and postintervention compared with retention management: 10 (7, 12) compared with 7 (7, 10) (P=.46). CONCLUSION: Simulation-based training may be an effective method for teaching communication, evaluation, and management skills for postpartum hemorrhage in rural Africa.

Using a prenatal electronic medical record to improve documentation within an inner-city healthcare network.

OBJECTIVE To study the impact of a prenatal electronic medical record (EMR) on the adequacy of documentation. STUDY DESIGN The authors reviewed paper prenatal records (historical control arm and contemporaneous control arm), and prenatal EMRs (study arm). A prenatal quality index (PQI) was developed to assess adequacy of documentation; the prenatal record was assigned a score (range, -1 to 2 for each element, maximum score = 30). A PQI raw score and PQI ratio-that controlled for which elements of care were indicated for a patient-were calculated and compared between the study arm versus historical control arm and then the study arm versus contemporaneous control arm. RESULTS The median PQI raw score was significantly lower in the study arm compared with historical control arm; however, the PQI ratios were similar between these groups. The PQI raw score was similar in both the study arm and contemporaneous control arm; however the PQI ratio was significantly higher in the study arm when compared with the contemporaneous control arm. CONCLUSION Implementation of this prenatal EMR did not have a significant impact on completeness of documentation when compared with a standardized paper prenatal record. Adequacy of documentation seems to be related to the type of practice.

M169 ENGAGING YOUTH IN THE DESIGN OF AN ADOLESCENT SEXUAL HEALTH PROGRAM: EVALUATION OF KNOWLEDGE, BEHAVIOR, AND PERCEIVED NEEDS

Methods: Retrospective data were collected from the postgraduate ob/gyn residency program based on fulfillment of curricular objectives and from the Orotta Maternity National Referral Hospital case logbooks in Asmara, Eritrea. Data were analyzed with Stata-IC-10. Results: Curricular objectives in theory, research, and basic gynecologic/obstetrical practice were fulfilled. Subspecialty practice in gynecologic oncology, minimally invasive procedures and reproductive infertility were limited due to limited number of qualified professionals and local resources. Within one year, surgical gynecologic cases increased 42% and the waiting list of over 100 patients decreased to <5. Outpatient visits increased 12% with a 45% decrease in repeat visits. Cesarean sections increased 2.2% with a 7% decrease in stillbirths. Conclusions: Efforts to utilize local professional and educational resources are a sustainable option for low-resource countries willing to commit the time, money, and effort it takes to implement effective postgraduate education. Continued identification of gaps and upgrading of local physicians, staff, and resources is necessary for a continued viable and productive program.