Roger D. Smith

Contemporary hysteroscopic methods for female sterilization.

A permanent contraceptive method that avoids abdominal incisions and general anesthetic should be safer than sterilization by laparoscopy or laparotomy. In theory, the transcervical route ought to be ideal for female sterilization. However, past attempts have not seen widespread success, and contemporary efforts demonstrate that challenges to the creation of an ideal transcervical sterilization technique continue to exist. After 6 years of use, clinical data and real‐world experience indicate that the Essure permanent birth control system is a viable option. Efficacy of 99.74% has been demonstrated. Adverse effects and risks are low. Patient satisfaction is high. Successful placement is observed in worldwide marketing. It can be placed in the office setting, which offsets the relatively high cost of the device. Recent data suggest that patients and surgeons are choosing hysteroscopic sterilization over laparoscopic and postpartum sterilization. Adiana emerged in 2009 as a second hysteroscopic sterilization option. Challenges continue to exist for transcervical sterilization. Compliance with post‐procedure confirmation imaging is not universal. Real‐world contraception failures are seen in a setting of protocol non‐compliance. However, extrapolation of the failure rates in real‐world use seems to be comparable with other laparoscopic and abdominal sterilization methods.

Evaluation of a simulation-based curriculum for implementing a new clinical protocol.

To evaluate the implementation of a new clinical protocol utilizing on‐unit simulation for team training.

Use of a novel electronic maternal surveillance system to generate automated alerts on the labor and delivery unit

BackgroundMaternal early warning systems reduce maternal morbidity. We developed an electronic maternal surveillance system capable of visually summarizing the labor and delivery census and identifying changes in clinical status. Automatic page alerts to clinical providers, using an algorithm developed at our institution, were incorporated in an effort to improve early detection of maternal morbidity. We report the frequency of pages generated by the system. To our knowledge, this is the first time such a system has been used in peripartum care.MethodsAlert criteria were developed after review of maternal early warning systems, including the Maternal Early Warning Criteria (MEWC). Careful consideration was given to the frequency of pages generated by the surveillance system. MEWC notification criteria were liberalized and a paging algorithm was created that triggered paging alerts to first responders (nurses) and then managing services due to the assumption that paging all clinicians for each vital sign triggering MEWC would generate an inordinate number of pages. For preliminary analysis, to determine the effect of our automated paging algorithm on alerting frequency, the paging frequency of this system was compared to the frequency of vital signs meeting the Maternal Early Warning Criteria (MEWC). This retrospective analysis was limited to a sample of 34 patient rooms uniquely capable of storing every vital sign reported by the bedside monitor.ResultsOver a 91-day period, from April 1 to July 1, 2017, surveillance was conducted from 64 monitored beds, and the obstetrics service received one automated page every 2.3xa0h. The most common triggers for alerts were for hypertension and tachycardia. For the subset of 34 patient rooms uniquely capable of real-time recording, one vital sign met the MEWC every 9.6 to 10.3xa0min. Anecdotally, the system was well-received.ConclusionsThis novel electronic maternal surveillance system is designed to reduce cognitive bias and improve timely clinical recognition of maternal deterioration. The automated paging algorithm developed for this software dramatically reduces paging frequency compared to paging for isolated vital sign abnormalities alone. Long-term, prospective studies will be required to determine its impact on patient outcomes.

On-Unit Obstetrics Team Simulation Enhances Implementation of a New Electronic Health Record [345].

INTRODUCTION: Implementation of a new electronic health record must address the needs of multiple team members and various workflows. Patient safety can be compromised if users are underprepared. This study evaluated the effectiveness of a simulation training curriculum based on pairing physicians and nurses together to learn a new electronic health record. Rapid-cycle improvement was used to identify and fix workflow issues. METHODS: Faculty and residents from obstetrics and family medicine, midwives, and nurses participated in 64 simulations over 4 weeks. Physician–nurse teams admitted, delivered, and treated a postpartum hemorrhage on a birthing simulator while documenting in the actual electronic health record. Learners completed presurveys and postsurveys regarding their satisfaction with this experience. Each session lasted 2 hours, including a 30-minute debrief. Data collection included workflow optimizations reported to the electronic health record build teams for rapid-cycle improvement. RESULTS: A total of 188 participants (faculty: 47, certified nurse–midwives: 23, residents: 31, burses: 87) completed training. The intervention was perceived as useful, created the desire to participate in more simulations, and decreased anxiety. Debrief session observations resulted in a 20-item FAQ distributed to increase uniform use of the electronic health record. CONCLUSION: This study demonstrates that simulation provides a useful platform for preparing a large health care team for a new electronic health record. Participants found the training useful, believed it improved understanding of workflow, and found it reduced anxiety. Workflow problems and conflicts were identified and resolved before rollout.

Board 258 - Program Innovations Abstract Implementing a Simulation- ased Curriculum for On-Unit Use: the University of Michigan Cesarean Section Urgency Classification Project (Submission #1057)

Introduction/Background The University of Michigan Department of Obstetrics planned to institute a new classification system for cesarean section urgency. Specific protocols for paging clinical teams when an urgent or emergent event occurs do exist but compliance had been inconsistent and there was little shared understanding of the levels of urgency. Recent adoption of a more defined prioritization scheme for urgency led to the need to educate our clinical staff of the new protocols. These protocols included specific definitions for urgent, emergent, add-on and scheduled cases. We designed and implemented a program to educate a large number of learners from multiple disciplines in a short time interval about these levels of urgency and the requisite paging protocol for each level of urgency. Our secondary goal was to introduce faculty and staff to the use of in-situ simulation. Methods A curriculum was designed with a three-pronged approach: 1) Web based educational model, 2) On-unit simulations and 3) Evaluation for sustainability. A web based power point presentation was created that reviewed each of the new urgency classifications. All participants were instructed to complete the module, which included a post-test evaluation. A simulation curriculum was created with 12 cases representing clinical cases for each of the 4 categories. Over a six month period, bi-weekly simulations were run with participants from Obstetrics, Anesthesia, Nursing and OR staff. Debriefing exercises were performed to address agreement on the level of urgency, the use of simulation for learning a new protocol and attitudes toward the new paging protocol. Participants included faculty, residents, nurses and scrub technicians from the both obstetrics and anesthesia (N=72). The level of agreement in urgency for emergent vs. urgent cases was congruent (p<0.000, t-test). Overall, simulation was rated a valuable activity. (See Table 1). The new paging system overall was rated as positive. (See Table 2) Results: Conclusion A simulation-based curriculum can be used to educate a large multidisciplinary team to a new protocol. The University of Michigan successfully used a simulation–based curriculum prior to a policy change as a means of reaching all members of the team. For many participants, this was their first simulation experience. For all participants, this was their first exposure to in-situ simulation. Overall both the use of simulation and the attitude toward the new paging protocol was positive. After completion of all faculty participation (this program continued beyond the six month study period), the University of Michigan Department of Obstetrics and Gynecology has made participation in obstetric simulations a mandatory requirement for maintenance of privileges. Simulation was a useful tool to publicize the policy change and educate participants through hands on, in-situ learning. This program innovation can serve as a means to implement new protocols across disciplines. Disclosures None.