Toni Golen

Assessment of long-term knowledge retention following single-day simulation training for uncommon but critical obstetrical events

Objective: The objectives were to determine (i) whether simulation training results in short-term and long-term improvement in the management of uncommon but critical obstetrical events and (ii) to determine whether there was additional benefit from annual exposure to the workshop. Methods: Physicians completed a pretest to measure knowledge and confidence in the management of eclampsia, shoulder dystocia, postpartum hemorrhage and vacuum-assisted vaginal delivery. They then attended a simulation workshop and immediately completed a posttest. Residents completed the same posttests 4 and 12 months later, and attending physicians completed the posttest at 12 months. Physicians participated in the same simulation workshop 1 year later and then completed a final posttest. Scores were compared using paired t-tests. Results: Physicians demonstrated improved knowledge and comfort immediately after simulation. Residents maintained this improvement at 1 year. Attending physicians remained more comfortable managing these scenarios up to 1 year later; however, knowledge retention diminished with time. Repeating the simulation after 1 year brought additional improvement to physicians. Conclusion: Simulation training can result in short-term and contribute to long-term improvement in objective measures of knowledge and comfort level in managing uncommon but critical obstetrical events. Repeat exposure to simulation training after 1 year can yield additional benefits.

Risk Factors for Staphylococcus aureus Postpartum Breast Abscess

BACKGROUND Staphylococcus aureus (SA) breast abscesses are a complication of the postpartum period. Risk factors for postpartum SA breast abscesses are poorly defined, and literature is conflicting. Whether risk factors for methicillin-resistant SA (MRSA) and methicillin-susceptible SA (MSSA) infections differ is unknown. We describe novel risk factors associated with postpartum breast abscesses and the changing epidemiology of this infection. METHODS We conducted a cohort study with a nested case-control study (n = 216) involving all patients with culture-confirmed SA breast abscess among >30 000 deliveries at our academic tertiary care center from 2003 through 2010. Data were collected from hospital databases and through abstraction from medical records. All SA cases were compared with both nested controls and full cohort controls. A subanalysis was completed to determine whether risk factors for MSSA and MRSA breast abscess differ. Univariate analysis was completed using Students t test, Wilcoxon rank-sum test, and analysis of variance, as appropriate. A multivariable stepwise logistic regression was used to determine final adjusted results for both the case-control and the cohort analyses. RESULTS Fifty-four cases of culture-confirmed abscess were identified: 30 MRSA and 24 MSSA. Risk factors for postpartum SA breast abscess in multivariable analysis include in-hospital identification of a mother having difficulty breastfeeding (odds ratio, 5.00) and being a mother employed outside the home (odds ratio, 2.74). Risk factors did not differ between patients who developed MRSA and MSSA infections. CONCLUSIONS MRSA is an increasingly important pathogen in postpartum women; risk factors for postpartum SA breast abscess have not changed with the advent of community-associated MRSA.

Diabetes, Glycemic Control, and Urinary Incontinence in Women.

Objectives To estimate the association between urinary incontinence and glycemic control in women ages 20 to 85 years. Methods We included 7270 women from the 2005 to 2010 National Health and Nutrition Examination Survey, stratified into three groups of glycemic control defined by hemoglobin A1c (HbA1c): (i) those below the diagnostic threshold (HbA1c < 6.5%), (ii) those with relatively controlled diabetes (HbA1c, 6.5–8.5%), and (iii) those with poorly controlled diabetes (HbA1c > 8.5%) to allow for a different relationship between glycemic control and urinary incontinence within each group. The primary outcomes were the presence of any, only stress, only urgency, and mixed urinary incontinence. We calculated adjusted risk ratios using Poisson regressions with robust variance estimates. Results The survey-weighted prevalence was 52.9% for any, 27.2% for only stress, 9.9% for only urgency, and 15.8% for mixed urinary incontinence. Among women with relatively controlled diabetes, each one-unit increase in HbA1c was associated with a 13% (95% confidence interval, 1.03–1.25) increase for any urinary incontinence and a 34% (95% confidence interval, 1.06–1.69) increase in risk for only stress incontinence but was not significantly associated with only urgency and mixed incontinence. Other risk factors included body mass index, hormone replacement therapy, smoking, and physical activity. Conclusions Worsening glycemic control is associated with an increased risk for stress incontinence for women with relatively controlled diabetes. For those either below the diagnostic threshold or with poorly controlled diabetes, the risk may be driven by other factors. Further prospective investigation of HbA1c as a modifiable risk factor may motivate measures to improve continence in women with diabetes.

Health and Economic Burden of Post-Partum Staphylococcus aureus Breast Abscess

Objectives To determine the health and economic burdens of post-partum Staphylococcus aureus breast abscess. Study design We conducted a matched cohort study (N = 216) in a population of pregnant women (N = 32,770) who delivered at our center during the study period from 10/1/03–9/30/10. Data were extracted from hospital databases, or via chart review if unavailable electronically. We compared cases of S. aureus breast abscess to controls matched by delivery date to compare health services utilization and mean attributable medical costs in 2012 United States dollars using Medicare and hospital-based estimates. We also evaluated whether resource utilization and health care costs differed between cases with methicillin-resistant and -susceptible S. aureus isolates. Results Fifty-four cases of culture-confirmed post-partum S. aureus breast abscess were identified. Breastfeeding cessation (41%), milk fistula (11.1%) and hospital readmission (50%) occurred frequently among case patients. Breast abscess case patients had high rates of health services utilization compared to controls, including high rates of imaging and drainage procedures. The mean attributable cost of post-partum S. aureus breast abscess ranged from

Documentation improvements following multidisciplinary educational program on electronic fetal heart rate tracings.

2,340–

Robotic Assistance in Coordination of Patient Care

4,012, depending on the methods and data sources used. Mean attributable costs were not significantly higher among methicillin-resistant vs. –susceptible S. aureus cases. Conclusions Post-partum S. aureus breast abscess is associated with worse health and economic outcomes for women and their infants, including high rates of breastfeeding cessation. Future study is needed to determine the optimal treatment and prevention of these infections.

Queueing theoretic analysis of labor and delivery

Objective. To measure the effectiveness of a multifaceted, multidisciplinary, evidence-based educational program designed to achieve compliance with the National Institute of Child Health and Human Development (NICHD) definitions and three-tier system for electronic fetal heart rate (FHR) monitoring. Methods. This prospective study began with a literature review focusing on creating change within complex systems. Evidence-based elements of program development and implementation were incorporated to promote the adoption of the NICHD guidelines for electronic FHR monitoring. A systematic, stratified random sample of charts was reviewed to evaluate compliance with the NICHD recommendations prior to and following program initiation. Results. Compliance rates for documentation of all components of a FHR tracing and a category in SOAP notes increased from less than 1% to 90%. Of the remaining charts, following program implementation, 70% had all components of the FHR tracing documented. Following the educational intervention, only 1% of SOAP notes lacked a category and at least one component of FHR tracing compared to 39% prior to the program. Conclusions. Incorporating evidence-based strategies for systemic change is an important step in program development in obstetrics. A multifaceted, multi-disciplinary program with frequent audits and feedback can yield high compliance in adoption of guidelines and result in practice change.

Improvement in Perinatal HIV Status Documentation in a Massachusetts Birth Hospital, 2009–2013

We conducted a study to investigate trust in and dependence upon robotic decision support among nurses and doctors on a labor and delivery floor. There is evidence that suggestions provided by embodied agents engender inappropriate degrees of trust and reliance among humans. This concern represents a critical barrier that must be addressed before fielding intelligent hospital service robots that take initiative to coordinate patient care. We conducted our experiment with nurses and physicians, and evaluated the subjects’ levels of trust in and dependence upon highand low-quality recommendations issued by robotic versus computer-based decision support. The decision support, generated through action-driven learning from expert demonstration, produced high-quality recommendations that were accepted by nurses and physicians at a compliance rate of 90%. Rates of Type I and Type II errors were comparable between robotic and computer-based decision support. Furthermore, embodiment appeared to benefit performance, as indicated by a higher degree of appropriate dependence after the quality of recommendations changed over the course of the experiment. These results support the notion that a robotic assistant may be able to safely and effectively assist with patient care. Finally, we conducted a pilot demonstration in which a robot-assisted resource nurses on a labor and delivery floor at a tertiary care

Robotic assistance in the coordination of patient care

Childbirth is a complex clinical service requiring the coordinated support of highly trained healthcare professionals as well as management of a finite set of critical resources (such as staff and beds) to provide safe care. The mode of delivery (vaginal delivery or cesarean section) has a significant effect on labor and delivery resource needs. Further, resource management decisions may impact the amount of time a physician or nurse is able to spend with any given patient. In this work, we employ queueing theory to model one year of transactional patient information at a tertiary care center in Boston, Massachusetts. First, we observe that the M/G/∞ model effectively predicts patient flow in an obstetrics department. This model captures the dynamics of labor and delivery where patients arrive randomly during the day, the duration of their stay is based on their individual acuity, and their labor progresses at some rate irrespective of whether they are given a bed. Second, using our queueing theoretic model, we show that reducing the rate of cesarean section – a current quality improvement goal in American obstetrics – may have important consequences with regard to the resource needs of a hospital. We also estimate the potential financial impact of these resource needs from the hospital perspective. Third, we report that application of our model to an analysis of potential patient coverage strategies supports the adoption of team-based care, in which attending physicians share responsibilities for patients.

Meeting Milestones: Results of a Quality-Improvement Curriculum to Achieve Cost-Conscious Care

BACKGROUND AND OBJECTIVES: Despite recommendations for universal HIV testing during routine prenatal care, maternal HIV status is not always available at the time of delivery, which may lead to missed opportunities for antiretroviral prophylaxis. We completed a quality improvement project focused on increasing the availability of maternal HIV status documentation at our perinatal facility. Our primary aim was to improve documentation rates from 50% to 100% between 2009 and 2013. Our secondary aim was to identify predictors of documentation. METHODS: After an initial needs assessment, we performed a multidisciplinary quality improvement effort to address lack of HIV documentation in perinatal charts. The interventions included a switch to a verbal-only consent process, a rapid HIV testing protocol, and a simplified newborn admission document. To assess the impact of our intervention, we audited 100 charts per month and formally analyzed a second random sample of 200 charts in the postimplementation phase. RESULTS: Rates of HIV status documentation improved between 2009 and 2013, from 55.5% to 96.5%. Multivariable models revealed that before our interventions, mothers receiving care at freestanding offices (versus community-based outreach clinics) and those privately insured (versus publicly) were less likely to have HIV status documented. In 2013, neither ambulatory site nor insurance type predicted documentation. CONCLUSIONS: We demonstrated improvement in maternal HIV status documentation on admission to labor and delivery after implementation of a 3-pronged intervention. Next steps include investigating persistent barriers to achieving universal screening and documentation.