Mark D. Pearlman

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery. METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures. RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (–5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03). CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381056 LEVEL OF EVIDENCE: I

Frequent resistance of clinical group B streptococci isolates to clindamycin and erythromycin

Objective To determine both the frequency of reported penicillin allergy in parturients and the frequency of resistance in vitro of clinical isolates of group B streptococci to clindamycin and erythromycin. Methods One hundred clinical isolates of group B streptococci were tested to determine the frequency of resistance to clindamycin, erythromycin, penicillin G, vancomycin, and cefazolin. The frequency of beta-lactam allergy and reported allergic reaction also were recorded for all consecutive laboring women during the 4-month study. Results The frequency of group B streptococcal resistance to clindamycin was 15% and to erythromycin was 16%. No isolates were resistant to penicillin G, vancomycin, or cefazolin. Twelve percent of the 963 women who delivered during the study reported a penicillin allergy, but only 30% of those could describe their allergic reaction. Conclusion In vitro resistance of group B streptococci to clindamycin and erythromycin occurred frequently in this population. Whereas the importance of this finding in vivo is uncertain, it raises concern about the possibility of inadequate prophylaxis using currently recommended alternatives in penicillin-allergic patients. Artful questioning of women reporting penicillin allergy may lessen the likelihood of using these less desirable agents in the setting of intrapartum antimicrobial prophylaxis.

Assessing Quality in Obstetrical Care: Development of Standardized Measures

BACKGROUND No nationally accepted set of quality indicators exists in obstetrics. A set of 10 outcome measures and three quality improvement tools was developed as part of a study evaluating the effects of teamwork on obstetric care in 15 institutions and > 28,000 patients. Each outcome was assigned a severity weighting score. MEASURES Three new obstetrical quality improvement outcome tools were developed. The Adverse Outcome Index (AOI) is the percent of deliveries with one or more adverse events. The average AOI during the pre-implementation data collection period of the teamwork study was 9.2% (range, 5.9%-16.6%). The Weighted Adverse Outcome Score (WAOS) describes the adverse event score per delivery. It is the sum of the points assigned to cases with adverse outcomes divided by the number of deliveries. The average WAOS for the preimplementation period was 3 points (range, 1.0-6.0). The Severity Index (SI) describes the severity of the outcomes. It is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome. The average SI for the pre-implementation period was 31 points (range, 16-49). DISCUSSION The outcome measures and the AOI, WAOS, and SI can be used to benchmark ongoing care within and among organizations. These tools may be useful nationally for determining quality obstetric care.

Group B Streptococcus Colonization in Male and Nonpregnant Female University Students: A Cross-Sectional Prevalence Study

We describe the prevalence of colonization with group B Streptococcus species in a random sample of otherwise healthy male and nonpregnant female college students. Colonization with group B Streptococcus species occurs at a high frequency among healthy students, and there was a suggestion that it is associated with having engaged in sexual activity, tampon use, milk consumption, and hand washing done < or =4 times per day. However, larger studies are needed to verify these findings.

Automobile crash simulation with the first pregnant crash test dummy

OBJECTIVE Our goal was to develop a pregnancy insert for the Hybrid III (First Technology, Farmington, Mich.) crash dummy allowing evaluation of the effects of various restraint conditions on energy transmission to both the fetal and maternal compartments. STUDY DESIGN A pregnancy insert with an elasticized vinyl uterine shell, simulated silicon amniotic fluid, and a 28-week simulated fetus was fitted to a female crash dummy. The fetus was instrumented with accelerometers in the head and thorax and a transducer to measure force transmission through the uterus. Thirty-nine crash tests were run under six different restraint conditions at speeds ranging from 10 to 25 miles/hr. Fetal responses were compared for different restraint conditions. RESULTS Increasing speed of the crash resulted in greater force transmission through the uterus. Placement of the lap belt over the uterus instead of under the uterus resulted in a threefold to fourfold increase in force transmission through the uterus at all speeds tested. Air bag deployment in the unbelted or out-of-position dummy (laying against air bag) appears to impart significant energy transmission to the fetus. CONCLUSIONS Energy transmission can be measured in terms of both abdominal force and acceleration within the fetal head and thorax. This new dummy demonstrates substantial transmission of energy, which is accentuated in some restraint conditions commonly used by pregnant women. The use of the 3-point restraint system appears to reduce the likelihood of injury in this model.

Prevalence of Group B Streptococcus Colonization and Potential for Transmission by Casual Contact in Healthy Young Men and Women

Group B Streptococcus (GBS) causes disease in newborns, pregnant women, and adults with underlying medical conditions, but it is also a commensal organism that commonly colonizes the bowel. In this study, the prevalence of colonization was high among 241 women (34%) and 211 men (20%) living in a college dormitory; sexually experienced subjects had twice the colonization rates of sexually inexperienced participants. Other predictors of colonization varied by colonization site. Only 10 of the 142 roommate pairs had roommates who were both colonized with GBS, and 20% of these pairs shared identical strains, which is the same rate predicted by the population distribution. By contrast, a previous report found that 86% of co-colonized sex partners shared identical strains. GBS is likely transmitted by intimate contact, but transmission modes may vary by colonization site. Large prospective studies are needed to better understand colonization site-specific factors for GBS and to clarify potential transmission modes.

Maternal and transplacental pharmacokinetics of cefazolin

OBJECTIVE To evaluate the intrapartum pharmacokinetics of cefazolin, including delivery to amniotic fluid (AF) and fetal compartments, and to ascertain that adequate cefazolin concentrations are attained to exceed the mean concentration inhibiting 90% (MIC90) of group B streptococcus strains. METHODS Cefazolin (1 g) was administered intravenously at five separate time intervals (0.5, 1, 2, 4, and 6 hours) before elective cesarean at term to 26 women with intact membranes and with no significant infections or cardiovascular, liver, or renal disease. Samples of maternal blood, cord blood, and AF were obtained at the time of delivery. Exact collection times relative to cefazolin infusion were noted. Amniotic fluid contaminated with blood or meconium was excluded. Cefazolin concentration was measured by high‐pressure liquid chromatography. RESULTS All maternal and cord plasma cefazolin levels, except one, were above the MIC90 for Streptococcus agalactiae (group B streptococcus). For AF, all cefazolin levels, except two, were above the MIC90. CONCLUSIONS Cefazolin concentrations greater than or equal to the MIC90 for group B streptococcus were attained in nearly all maternal, fetal, and AF samples. This information, together with the knowledge that there is rare resistance of group B streptococcus to cefazolin, supports the use of cefazolin as a better alternative than clindamycin or erythromycin for group B streptococcus prophylaxis in patients with a nonanaphylactic penicillin allergy.

Correlates of antibiotic-resistant group B streptococcus isolated from pregnant women ☆

OBJECTIVE: Despite antibiotic prophylaxis for at‐risk mothers during labor and delivery, group B streptococcus still causes substantial morbidity and mortality among newborns. Resistance to antibiotics recommended for penicillin‐allergic pregnant women, such as erythromycin and clindamycin, has increased. A better understanding of factors associated with group B streptococcus resistance is essential to effectively prevent group B streptococcus disease. METHODS: A total of 117 sequential group B streptococcus isolates were obtained between August 1999 and March 2000 from pregnant women at the University of Michigan Medical Center. Serotype and susceptibility to ten antimicrobials using disk diffusion with E‐test for confirmation were determined, and the association between several host factors and colonization with a resistant strain was evaluated. RESULTS: Group B streptococcus was frequently resistant to erythromycin (29%) and clindamycin (21%) but was susceptible to all other antimicrobials tested. A stepwise logistic regression model revealed that black ethnicity (P = .02) and carriage of a serotype V strain (P = .01) were associated with group B streptococcus resistance. CONCLUSION: Among this population of pregnant women, black ethnicity and serotype V were the strongest predictors of colonization with an erythromycin‐ or clindamycinresistant group B streptococcus strain. A better understanding of factors associated with antibiotic resistance is needed to minimize group B streptococcus disease risks and to maximize effective chemoprophylaxis. (Obstet Gynecol 2003;101:74‐9.

Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint

OBJECTIVE This project was undertaken to improve understanding of factors associated with adverse fetal outcomes of pregnant occupants involved in motor-vehicle crashes. STUDY DESIGN In-depth investigations of crashes involving 57 pregnant occupants were performed. Maternal and fetal injuries, restraint information, measures of external and internal vehicle damage, and details about the crash circumstances were collected. Crash severity was calculated using vehicle crush measurements. Chi-square analysis and logistic regression models were used to determine factors with a significant association with fetal outcome. RESULTS Fetal outcome is most strongly associated with crash severity (P < .001) and maternal injury (P = .002). Proper maternal belt-restraint use (with or without airbag deployment) is associated with acceptable fetal outcome (odds ratio = 4.5, P = .033). Approximately half of fetal losses in motor-vehicle crashes could be prevented if all pregnant women properly wore seat belts. CONCLUSION Higher crash severity, more severe maternal injury, and lack of proper seat belt use are associated with a higher risk of adverse fetal outcome. These results strongly support recommendations that pregnant women use properly positioned seatbelts.

Outcome of unexpected adnexal neoplasia discovered during risk reduction salpingo-oophorectomy in women with germ-line BRCA1 or BRCA2 mutations

OBJECTIVE This study computed the risk of clinically silent adnexal neoplasia in women with germ-line BRCA1 or BRCA2 mutations (BRCA(m+)) and determined recurrence risk. METHODS We analyzed risk reduction salpingo-oophorectomies (RRSOs) from 349 BRCA(m+) women processed by the SEE-FIM protocol and addressed recurrence rates for 29 neoplasms from three institutions. RESULTS Nineteen neoplasms (5.4%) were identified at one institution, 9.2% of BRCA1 and 3.4% of BRCA2 mutation-positive women. Fourteen had a high-grade tubal intraepithelial neoplasm (HGTIN, 74%). Mean age (54.4) was higher than the BRCA(m+) cohort without neoplasia (47.8) and frequency increased with age (p < 0.001). Twenty-nine BRCA(m+) patients with neoplasia from three institutions were followed for a median of 5 years (1-8 years.). One of 11 with HGTIN alone (9%) recurred at 4 years, in contrast to 3 of 18 with invasion or involvement of other sites (16.7%). All but two are currently alive. Among the 29 patients in the three institution cohort, mean ages for HGTIN and advanced disease were 49.2 and 57.7 (p = 0.027). CONCLUSIONS Adnexal neoplasia is present in 5-6% of RRSOs, is more common in women with BRCA1 mutations, and recurs in 9% of women with HGTIN alone. The lag in time from diagnosis of the HGTIN to pelvic recurrence (4 years) and differences in mean age between HGTIN and advanced disease (8.5 years) suggest an interval of several years from the onset of HGTIN until pelvic cancer develops. However, some neoplasms occur in the absence of HGTIN.