18 Dec

PeriCALM Tracings Release 03.18.02

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The new features & fixes you asked for:

PeriGen is very committed to ongoing improvement of  PeriCALM products, especially in answer to customer suggestions and needs.  The newest release illustrates this.  We’ve added features that enable more documentation on the strip, focusing specifically on your most time-sensitive observations.  Documentation now includes systems assessments, pain scoring, and FHR interpretations.

Sites using Epic and those clients subscribing to the PeriCALM full documentation suite will see additional improvements.  Here’s a summary of the new features added in release 03.18.02:

New tabs & fields on the tracing annotation dialog:
The following tabs and multi-select fields were added to the tracing annotation screens:

  • Systems Assessment: Integumentary, Neurological, Cardiovascular, Respiratory, Gastrointestinal, Breast, Extremities, Psychological
  • Risk Assessment: Fall Risk Assessment, VTE Risk Assessment, Skin Assessment, Hemorrhage Risk Assessment
  • Recovery Room: Fundus (U+/-), Fundal Height, Uterine Tone, Bleeding Flow, Blood Clots, Bladder, Extremities Movement

These tabs and fields will provide additional flexibility to customers who wish to complement their OB documentation with the official EMR at the site.  All additional fields are also included in the read-only Intrapartum Flowsheet view.

Additions/changes to existing fields on the tracing annotation dialog:
The following fields were added to the existing tabs of the tracing annotation screens:

  • Maternal Assessment: Added Pain Scales and Interventions fields.
  • Fetal Assessment: Added Category field.
  • Exam: Added a read-only auto-calculated Bishop Scale (see below).

Added new auto-calculated Bishop Score field:
Under the Exams tab in the Add Annotation dialog, a new auto-calculated field was added.  The Bishop Score is automatically calculated based on the values of its five components: Dilatation, Effacement, Station, Cervical Position, and Consistency.  The calculation takes into account values observed up to one hour prior to the current exam.  The Bishop Score is recalculated when one of the source values is changed.  When a maximum score is reached for one of the components, though, it is used for the calculation regardless of its observed time.

A new Acquire Server service for better control of tracings acquisition processes:
The new Acquire Server Service will provide the capability to start and stop acquisition process from Windows Services subsystem as well as control and restart processes that are in an error state or down altogether.  This will provide better flexibility to IT staff as well as increased resiliency of tracing Up-time for clinical staff.

GBS field added to the Admin Admission screen:
Starting with this version, a GBS field is added to the Admin Admission screen.  This new field is identical to the one present in the Nursing Assessment under Prenatal and Labs section, and can be used as a Chalkboard column with color coding.

Support for Active Directory authentication:
PeriCALM Tracings can now be configured to authenticate users through Active Directory (AD).  The PeriCALM Tracings group-based user privilege logic is maintained and only groups (new or existing) have to be replicated in AD to enable authentication.  In AD mode, built-in users are only allowed to login when AD is unavailable.  In AD mode, since PeriCALM Tracings does not manage or control user accounts, all internal fields that list users are converted to free-text fields

FOR DOCUMENTATION SUITE USERS

Additional fields in Nursing Assessment and Delivery Summary:
Several new fields were added and some existing fields modified to provide better Intrapartum charting coverage especially for customers using PeriCALM documentation to complement the EMR record.  The printed reports were updated to reflect the additions and changes accordingly.  See Release Notes for details.

FOR EPIC USERS

Support for Epic Single Sign-On using FileDrop protocol:
When used in collaboration with Epic, clinicians can now use the single sign-on module to automatically synchronize login/logoff events on a common workstation.  The single sign-on capability assumes an Active Directory authentication configuration on both PeriCALM and Epic.

11 Dec

What Have We Learned & Where Are We Going?

by Emily Hamilton, MDCM
Senior Vice President, Clinical Research, PeriGen

“In the New Year, you carry all the experiences of the past years and that is the greatest power of every New Year! This year, you are less student and more master!”
~Mehmet Murat Ildan, Contemporary Novelist & Playwright

 

Flling rates of intrapartum-related neonatal encephalopathy

Figure 1. Falling rates of intrapartum-related neonatal encephalopathy

Just as individuals gain experience and wisdom on life’s journey, so do organizations, professions and companies. Experience helps because as professionals we are entrusted with responsibility both at a personal and organizational level to provide safe maternity care. Among the myriad of challenges crying for our attention, which ones are critical, have a chance for success, or bring the greatest benefit for our mothers, babies and their families? With the New Year beginning it is time to pause and reflect on some of the lessons learned and past accomplishments because they will help us plan our journey for the coming year. As you read on, note the clarity of insights gained by using “Big Data” and “Wide Lenses” for time and geography.

One of the United Nation’s Millennium Goals – to reduce child mortality, has brought us more reliable data on an important obstetrical topic: namely, intrapartum-related neonatal encephalopathy (IP-NE). On a world scale, intrapartum-related hypoxic events are estimated to have a huge impact – contributing to ¼ of neonatal deaths and ½ of late pregnancy stillbirths. They make the largest single-condition contribution to disability adjusted life-years. 1-4

When one examines progress over 20 years in multiple countries, steady incremental improvement is evident. Figure 1 shows the falling rates of IP-NE in regions including and most similar to the US1 Rates in all the other geographical regions were much higher. They all showed progressive descent fell except for the region of Sub-Saharan Africa.

Two other recent and large studies provide further important insights regarding the nature of IP-NE and related clinical care. 5, 6 Researchers in Sweden, where infant mortality rates are generally amongst the best in the world, examined 71,189 birth records to investigate the association between EFM patterns and neonatal outcome. 5 The rates of neonatal encephalopathy were very low at 1.1 per 1000 births. They concluded that moderate and severe encephalopathy was attributable to asphyxia in 60% of their NE cases and most evolved during labor.

Moving closer to home, Clark et al examined the effect of compliance vs non-compliance with an oxytocin administration protocol in 14,398 women undergoing induction of labor at HCA.6 Oxytocin misuse is a common finding in births with severe metabolic acidosis. 7-9 Furthermore, oxytocin misuse is a modifiable risk factor. In this most recent study compliance was associated with:

  • Fewer admissions to the NICU (3.8% vs  5.2% P=0.01)
  • Fewer low Apgar scores (4.9% vs 6.4% P=0.04)
  • Fewer cesareans     (15.8% vs 18.8% P<0.01)
Figure 2. PeriCALM Patterns display showing the analysis related to uterine tachysystole.

Figure 2. PeriCALM Patterns display showing the analysis related to uterine tachysystole

Members of our own PeriGen family have experienced similar success stories. 10 MedStar Franklin Square Medical Center launched a highly successful IT initiative focusing on uterine tachysystole (overly frequent contractions). PeriCALM Patterns fetal monitoring software with built-in pattern recognition and specialized long-term graphical displays was introduced in 2011. At a glance any clinician could detect if uterine tachysystole (UT) was present, if it was transient or persistent, if it provoked fetal heart rate decelerations and see the Montevideo units as is shown in Figure 2.

This study involved the systematic re-examination of each 30-minute segment of tracing from all 10,518 monitored term labors. Comparing years before immediately before and after the introduction of PeriCALM Patterns they observed that:

  • The rate of UT with oxytocin fell from 22.7% to 17.3% P<0.0001.
  • Average duration of UT fell from 64 minutes to 54 minutes.
  • Total time spent in UT fell by 36.5%.

Long term trends analysis is a key component of helping humans see significant trends and to anticipate what is about to happen. In psychological parlance this ability to assess current conditions and project the most likely development is known as situational awareness. In medical behavioral studies it is one of the key skills required across all acute care settings.

Computers are masters of rapid computation and efficient data visualization. Anecdotes from nursing staff related how the displays made easy it was to see when uterine tachysystole was present or even about to occur. Continuous calculations removed the subjectivity of choosing where to count the contraction rates. Quantitative data facilitated communication because predominant patterns were clearly evident. Nurses had the authority to stop oxytocin when uterine tachysystole occurred.

There is abundant evidence today that the human brain has a fixed functional capacity and that every mental task we perform detracts from our ability to do another at the same time. 11 Computers are very consistent at number crunching, that is counting, adding, measuring or doing exactly what they are programmed to do. In contrast, humans are very good at reasoning based on deep clinical understanding Clinicians will always have to integrate EFM tracing findings with other clinical information. That said, the repetitive analytic capacity of PeriCALM Patterns and its long-term displays are useful adjuncts for clinicians. This study demonstrated the synergistic effects of this technology and dedicated clinicians. Together they achieved an impressive reduction in UT.

In summary, what lessons have we learned?

Lesson 1. It is impossible to see progress in rare conditions using small samples over short periods of time.  Rates derived from large data sets and trends over long periods are much more revealing.

Lesson #2. A substantial portion of NE arises and evolves during labor.

Lesson #3.  The incidence of intrapartum-related NE, a devastatingly serious condition, is falling.

Lesson #4.  Clinical actions matter. Oxytocin protocol compliance is associated with better neonatal condition and lower cesarean rates. Uterine tachysystole rates can be reduced.

Lesson #5.  Computers and clinicians can be highly synergistic.

No one is suggesting that technology replace clinicians. However, computerization is useful for tasks like calculations, data visualization, reminders and communication thus freeing clinicians to focus applies their energy on higher level reasoning and clinical interventions.

Maternal child health care has come a very long way. Detractors of EFM often refer to randomized clinical trials conducted more than 30 ago that showed no neonatal survival benefit with EFM, although EFM use was associated with a substantial reduction in the incidence of neonatal seizures. In the largest of these studies, deaths or seizures occurred at an astonishing rate of 1 in 225.12 Today, intrapartum fetal death is exceedingly rare and moderate and severe IP-NE are estimated to occur in approximately 1.5/1000 births among the High-Income countries and 0.6/1000 specifically in the Swedish study. This achievement did not happen by chance. Concerted efforts on many fronts have contributed. It happened in part, because most clinicians did not adopt a defeatist attitude such as believing that the origins of IP-NE were beyond our influence or that EFM held no value. Rather these clinicians continued to find better ways to fine tune the imperfect tools that are available and improve our health care systems.

Healthcare informatics has also evolved. We have seen a maturation of software for basic hospital wide electronic medical records and convergence on a few products. With this accomplishment we have seen an increasing demand for the efficient overlay of smart modules with real clinical benefits. In parallel, the PeriGen experience has confirmed our belief that the most useful smart software applications are those that harness the power of computers to do what they do best especially in areas that humans find challenging or time consuming.

As for the New Year, we will continue to apply sound analytical methods on high impact clinical issues where objective quantitative analysis helps clinicians see critical factors or developing trends and intervene in a timely fashion. We have reached a new level in medical informatics and a very exciting one indeed. Stay tuned as we work to bring these ideas to the bedside.

References

1. Lee AC, Kozuki N, Blencowe H, Vos T, Bahalim A, Darmstadt GL, Niermeyer S, Ellis M, Robertson NJ, Cousens S, Lawn JE. Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990. Pediatr Res. 2013 Dec;74 Suppl 1:50-72. doi: 10.1038/pr.2013.206.

2. Wn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ. 2005 Jun;83(6):409-17. Epub 2005 Jun 17.

3. Lawn JE, Lee AC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet. 2009 Oct;107 Suppl 1:S5-18, S19. doi: 10.1016/j.ijgo.2009.07.016

4. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997 May 17;349(9063):1436-42.

5. Jonsson M, Agren J, Nordén-Lindeberg S, Ohlin A, Hanson U. Neonatal encephalopathy and the association to asphyxia in labor. Am J Obstet Gynecol. 2014 Dec;211(6):667.e1-8. doi: 10.1016/j.ajog.2014.06.027. Epub 2014 Jun 17.

6. Clark SL, Meyers JA, Frye DK, Garthwaite T, Lee AJ, Perlin JB. Recognition and response to electronic fetal heart rate patterns – impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol. 2014 Nov 22. pii: S0002-9378(14)02249-2. doi: 10.1016/j.ajog.2014.11.019. [Epub ahead of print]

7. Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns.  Obstet Gynecol. 2008 Dec;112(6):1279-1283.
8. Berglund S, Grunewald C, Pettersson H, Cnattingius S. Severe asphyxia due to delivery-related malpractice in Sweden 1990-2005. BJOG. 2008 Feb;115(3):316-323.

Jonsson M, Nordén SL, Hanson U. Analysis of malpractice claims with a focus on oxytocin use in labour. Acta Obstet Gynecol Scand. 2007;86(3):315-319.

10. Smith S, Bunting K, Hamilton E. Using Intelligent Electronic Fetal Monitoring Software to Reduce Iatrogenic Complications of Childbirth: A Case Study.J Healthc Inf Manag, in press

10. Rock D., Your Brain at Work: Strategies for Overcoming Distraction, Regaining Focus, and Working Smarter All Day Long Harper Business. Harper Collins, New York, NY.

12. MacDonald D, Grant A, Sheridan-Pereira M, Boylan P, Chalmers I. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol. 1985 Jul 1;152(5):524-39

01 Jun

Decision Support and Patient Safety: The Time Has Come

Publication: American Journal of Obstetrics & Gynecology
Date: June 2011
Author: Steve K. Hasley, MD

Abstract:
Decision support (DS) may help to improve patient safety by helping clinicians improve the evaluation, assessment, and treatment of patients. By providing best practice guidelines at critical decision points, errors can be prevented. Location of these decision points varies in different care environments, therefore DS must be customizable. Being able to customize the design, functionality, and clinical context of how a DS rule behaves may help each unique clinical environment improve performance. The ability to review aggregate data on the behavior of both the DS system and the providers will be necessary to further adapt the DS rule to the setting. A robust tool set and ongoing institutional engagement are critical elements for a successful DS implementation.

Full Article

01 Jul

Patient Education to Reduce Elective Labor Inductions

Publication: American Journal of Maternal/Child Nursing
Date: 7/1/2010
Author: Simpson, Kathleen Rice PhD, RNC, FAAN; Newman, Gloria MSN, RNC; Chirino, Octavio R. MD, FACOG, FACS

Abstract:
Purpose: To reduce elective inductions among nulliparous women in a community hospital by adding standardized education regarding induction risks to prepared childbirth classes.

Study Design and Methods: Elective induction rates were compared between class attendees and nonattendees before and after the standardized content was added to prepared childbirth classes. A survey of nulliparous women’s decisions regarding elective induction was conducted.

Results: Elective induction rates of 3,337 nulliparous women were evaluated over a 14-month period (n = 1,694, 7 months before adding content to classes; n = 1,643, 7 months after). Rates did not differ between class attendees (35.2%, n = 301) and nonattendees (37.2%, n = 312, p = .37) before the content was included. However, after standardized education was added, class attendees were less likely to have elective induction (27.9%, n = 239) than nonattendees (37%, n = 292, p < .00). Sixty-three percent of women who attended the classes and did not have elective induction indicated that the classes were influential in their decision. Physicians offered the option of elective induction to 69.5% (n = 937) of survey participants. This was a factor in women’s decisions; 43.2% (n = 404) of those offered the option had elective induction, whereas 90.8% (n = 374) of those not offered the option did not have elective induction.

Clinical Implications: Education regarding elective induction offered during prepared childbirth classes was associated with a decreased rate among nulliparous women who attended classes when compared to those who did not attend. Patient education may be beneficial in reducing elective inductions.

Full Article

20 Apr

How often is a low Apgar score the result of substandard care during labour?

Publication: BJOG: An International Journal of Obstetrics & Gynaecology
Date: 4/20/2010
Author: S Berglund, H Pettersson, S Cnattingius, C Grunewald

Abstract: The authors have determined, in this study done in Sweden, that “there was substandard care during labour of two thirds of infants with a low Apgar score.  The main reasons for substandard care were related to misinterpretation of CTG, not acting on an abnormal CTG in a timely fashion, and incautious use of oxytocin.”

Full article

12 Mar

Deadly Delivery: Health is a Human Right

Publication: Amnesty International
Date: 3/12/2010
Author: Amnesty International

Abstract: As put forth by this Amnesty International review, “In 2009, the new US Administration and Congress focused on the need to reform the health care system, in particular on improving access to care and reducing the growth in health care spending. Although the proposals under debate would reduce the number of uninsured individuals, no legislation currently under consideration would realize the human rights standards of making health care available, accessible, acceptable, and of good quality to all, without discrimination. It is estimated that the proposed reforms would still leave between 18 and 24 million people without insurance, and for many health care costs would remain unaffordable. In addition, as reform is primarily focused around health care coverage, it would leave largely unaddressed the issues identified in the report regarding discrimination, systemic failures and accountability. As efforts to reform the US health care system are developed and implemented, it is imperative that human rights standards are applied, so that all have equal access to affordable, quality health care, including maternal health care. Maternal deaths and injuries are stark reminders of what is at stake when the government fails to put in place a health care system that respects, protects and fulfills the human right to health without discrimination. The consequences are evident every step of the way. Women have inadequate access to family planning, enter pregnancy in less than optimal health, receive late or inadequate prenatal care, are given inadequate or inappropriate care during delivery and have limited access to post-natal care. It is essential that the debate about health care in the USA goes beyond health care coverage and addresses access to quality health care for all on the basis of equality and non-discrimination. Maternal health care services must be improved for all women, and particularly for those most affected by current disparities in health care and outcomes. For over 20 years the US authorities have failed to improve the outcomes and disparities in maternal health care. This report shows the human cost of this failure and highlights the urgent steps needed to reduce maternal mortality and morbidity rates in the USA.”
01 Mar

Greenlight Issues for the CFO: Investing in Patient Safety

Publication: Journal of Patient Safety
Date: 3/1/2010
Authors: Charles R. Denham, MD

Abstract: As opined by the author, “Fairly or unfairly reflecting reality, many in the quality and patient safety leadership positions bemoan that the role of the CFO has been to say ‘No’ to spending on performance improvement. Yet, changes in health care will mandate new coalitions and new partnerships between players who are often on opposing sides of budget debates. The next generation of great hospital leaders may come from the ranks of our finance leaders, who can help translate core values into bottom line performance by educating themselves in the financial impact of performance improvement. There are a number of issues with great potential for performance improvement, which include performance envelopes, chasing zero infections, impact scenarios, legal myths, quality teams and financial know-how, changing revenue assumptions, readmission red-ink revenue, coding issues, evidence-based point estimates, delegated purchasing risk, vendor risk, cost of technology adoption, cost of leadership failure, and purchaser gain sharing. It is our belief that the next generation of great leaders may come from the ranks of our CFOs and finance leaders who help translate core values into bottom-line performance.”

Full Article

01 Feb

The legal effects of fetal monitoring guidelines

Publication: International Journal of Gynecology & Obstetrics
Date: 2/1/2010
Authors: Dickens BM, Cook RJ
Abstract: The new American College of Obstetricians and Gynecologists’ (ACOG) monitoring guidelines introduce a new category of interpretation of fetal heart rate tracings between reassuring and nonreassuring, namely intermediate. The purpose is to reduce unnecessary cesarean deliveries. The legal role of medical guidelines is ambivalent. Providers are expected to be familiar with such guidelines, but also to exercise clinical judgment in their patients’ interests. Practice departing from guidelines requires justification, but simple compliance without regard to patients’ circumstances may constitute negligence. Some courts defer to medical professional guidelines, but others hold that professional standards are set as a matter of law, not by the profession itself. Unlike conclusions in medical science, which are open to continuing review, courts determine facts in a case only once, at trial. Litigation to compel patients’ compliance with medical advice based on guidelines may fail, as may prosecutions, more common in the US, of patients who defy such advice.
25 Jan

Sentinel Event Alert #44 – Preventing Maternal Death

Publication: The Joint Commission Sentinel Event Alert
Date: 1/25/2010
Authors: The Joint Commission

Abstract: The goal of all labor and delivery units is a safe birth for both the newborn and mother. As a previous Alert reviewed the causes of death and injury among newborns with normal birth weight and suggested risk reduction strategies, this Alert addresses the loss of mothers. Unfortunately, current trends and evidence suggest that maternal mortality rates may be increasing in the U.S., despite the rarity of the incidence of maternal death: deaths that occur within 42 days of birth or termination of pregnancy. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission’s sentinel event database, with the largest numbers of events reported in2004, 2005 and 2006. According to the National Center for Health Statistics of the Centers for Disease Control and Prevention, in 2006, the national maternal mortality rate was 13.3 deaths per 100,000 live births.

Full Article

01 Jan

Quality and Safety in Women’s Health Care (Second Edition)

Date: 2010
Authors: American College of Obstetricians and Gynecologists, Women’s Health Care Physicians
Abstract: As stated in the introduction, “Quality and Safety in Women’s Health Care, Second Edition, is intended to serve as a primer for obstetricians and gynecologists starting or managing quality improvement programs within their hospital departments or ambulatory practices by focusing on the following practices:
  • Quality and safety in the inpatient setting
  • Clinical competence
  • Quality and safety in the outpatient setting
  • Data analysis tools

The manual is presented in five parts. Part 1 provides background information on the evolution of health care quality improvement efforts. Part 2 provides an overview of quality and safety in the inpatient setting, including quality measurement, disclosure of adverse events, hospital leadership roles in community hospitals and residency programs, and patient safety initiatives. Some information may be adapted for use in the ambulatory setting. Part 3 addresses the issues of assessing clinical competence, one of the key elements of any quality improvement program and certainly a major responsibility for chairpersons of obstetrics and gynecology departments. Part 4 addresses quality and patient safety issues in the outpatient setting. Part 5 covers tools that can be used to analyze data or study management issues.  Provided in the appendices are resources that include the 2009 Report of the Presidential Task Force on Patient Safety in the Office Setting and the World Health Organization’s Surgical Safety Checklist.”

Full Article