28 Feb

Recently Published

PeriNews, PeriGen's take on what matters in obstetricsPeriGen assists Medstar in improving key labor & delivery outcome indicators

Becker’s Hospital Review, a health system management publication, recently published the results of a study done by Sam Smith, MD and Lynette Philips RN of Medstar as well as a team of PeriGen clinical researchers that highlights the impact of process improvement on obstetric outcomes.

The study examined ten years of data on 78,459 births at Medstar, a health system serving Maryland. Data on cesarean rates, NICU transfers, and the use of fetal resuscitation was examined before and after the introduction of a large-scale process improvement program that included the introduction of PeriGen’s decision support software tools.

Medstar results show decline in NICU transfers, fetal resuscitationKey results included:

  • A 54% reduction in the use of cardiopulmonary resuscitation, assisted ventilation, or intubation.
  • NICU transfers which had risen steadily prior to the program declined by 52%.
  • Cesarean rates stabilized after the introduction of the software despite continuously rising rates of obesity, diabetes and hypertension.

Read more

Reference:

Samuel Smith MD, Lynette Philip RN, Adi Zmiri MD, Emily Hamilton MD, Thomas Garite MD. HIT and clinical synergy: A decade of decreasing NICU admissions & stabilizing cesarean rates, Becker’s Hospital Review, 2016 Dec 20.

27 Feb

MEWS…MEWT…MEOWS

PeriNews, PeriGen's take on what matters in obstetrics
The “cat’s whiskers” behind a

key concept of obstetrical safety

by Emily Hamilton, MD CM

No, we have not taken to caring for cats or declining Latin verbs. Yes, we are “over the top” on the concepts behind these acronyms and their contributions to obstetrical safety. MEWS1,MEWT2, MEOWS3 refer to examples of Maternal Early Warning Systems that operate in addition to usual clinical care. They have been proposed to facilitate timely recognition, diagnosis and treatment of patients developing critical illness. This assistance is relevant today because delayed recognition and intervention remain contributory factors in about half of births with maternal deaths or neonatal encephalopathy.4, 5

MEWS, MEWT and MEOWS are scoring systems based on a short checklist of key criteria, Maternal Early Warning Systemprimarily vital signs. Some variants add factors such as persistence, level of consciousness, urine output, lab tests or fetal condition. Some use color coding or weighting for different levels of abnormality. Important characteristics of successful warning systems are:

  1. Assessments are routine and repeated periodically, e.g. on admission and at frequent intervals
  2. Specific scores are tied to specific actions e.g. physician assessment, calling a rapid response team or initiating a specific investigation or therapy.

In obstetrics, early warning scores on ICU admission were strongly related to maternal mortality.6 A large “Before and After” study in the US found very significant reductions in severe maternal morbidity in the group where an early warning system was implemented and no changes in these rates in the control group without a warning system.7 A survey of 130 maternity units in 2013 in the UK indicated that 100% had implemented a formal early warning system, up from 19% in 2007.8

We are still learning the impact of Early Warning Systems in obstetrics and how to optimize them to improve efficiency. Nursing effort and alarm fatigue are important considerations.

But wait…. software could reduce that nursing effort by using information already recorded in the electronic medical record. In addition it could track how often and how early a particular trigger appears. We could use statistical techniques to determine exactly what clusters of parameters are most useful.

Stay tuned … the best is yet to come. Look for more information on this topic later this year.

References
1 Mhyre JM, DʼOria R, Hameed AB, Lappen JR, Holley SL, Hunter SK, Jones RL, King JC, DʼAlton ME. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol. 2014 Oct;124(4):782-6.

2 Hedriana HL, Wiesner S, Downs BG, Pelletreau B, Shields LE.
Baseline assessment of a hospital-specific early warning trigger system for reducing maternal morbidity. Int J Gynaecol Obstet. 2016 Mar;132(3):337-41.

3 Singh S , McGlennan A, England A, Simons R. A validation study of the CEMACH recommended modified early obstetric warning system (MEOWS). Anaesthesia. 2012 Jan;67(1):12-8.

4 Main EK, McCain CL, Morton CH, Holtby S, Lawton ES. Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstet Gynecol. 2015 Apr;125(4):938-47.

5 Sadler LC, Farquhar CM, Masson VL, Battin MR. Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia. Am J Obstet Gynecol. 2016 Jun;214(6):747.e1-8.

6 Carle C, Alexander P, Columb M, Johal J. Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia. 2013 Apr;68(4):354-67.

7 Shields LE, Wiesner S, Klein C, Pelletreau B, Hedriana HL. Use of Maternal Early Warning Trigger tool reduces maternal morbidity. Am J Obstet Gynecol. 2016 Apr;214(4):527.e1-6.

8 Isaacs, RA, Wee MYK, Bick DE, et al. (2015) A national survey of obstetric early warning surveys in the United Kingdom: five years on. Anaesthesia2014;69:687-9

08 Feb

Reserve C-Section / NICU Research

cesarean research

Pick up your copy at
AWHONN CA Convention

PeriGen is proud to be supporting this year’s AWHONN California Section Conference, scheduled for February 17th and 18th at the DoubleTree by Hilton at the Berkeley Marina. Rebecca Cypher, PeriGen’s CNO, will be launching the pre-conference with a presentation on “Advanced Monitoring Concepts for Clinical Practice” and also greeting attendees at the PeriGen table.

We’re also offering a limited number of copies of our clinical research team’s latest work, published by Becker’s Hospital Management, “HIT & Clinical Synergy: A decade of decreasing NICU admissions & stabilizing cesarean rates.” This research summary outlines how one system combined leadership commitment, process improvement strategies and advanced technology to lower NICU rates and extraordinary resuscitation and control c-section rates. The work serves as a blueprint for those systems looking to achieve similar results.

To reserve your copy, for pick up at the PeriGen exhibitor table, please complete the form below:

About the research

“HIT & Clinical Synergy: A decade of decreasing NICU admissions & stabilizing cesarean rates” is co-authored by PeriGen’s Clinical Research leader Emily Hamilton. It appeared in Becker’s Hospital Management earlier this year.

The research uses retrospective analysis of 78,000 singleton births from a health system serving Maryland. The research uses a before-and-after comparison to identify factors leading to a statistically significant reduction in three metrics: NICU admissions, the use of newborn resuscitation, and the rate of cesareans.

04 Jan

Words to live by when leading change

Advice from leading IT transformation and change managers

Five key thoughts for those leading changeFive key thoughts for those leading system change

“People who have low psychological ownership in a system and who vigorously resist its implementation can bring a ‘technically best’ system to its knees.”

Nancy M. Lorenzi, PhD & Robert T. Riley, PhD
Managing Change: An Overview
Journal of the Medical Informatics Association

Practical implications of a study on IS change management: “…management should aim to increase the perceived value of change and organizational support for change to reduce user resistance.”

Hee-Woong Kim & Atreyi Kankanhalli
Investigating User Resistance to Information System Implementation: A Status Quo Bias Perspective
MIS Quarterly, Vol. 33, No 3, Sept 2009

“Lead your organization to a successful outcome, and speed up the process by treating your staff as customers first.”

Claire McCarthy, MA & Douglas Eastman, PhD
Change Management Strategies for an
Effective EMR Implementation

“In his article, “Leading Change: Why Transformation Fails,” John Kotter of Harvard Business School lists the major reasons for the failure of large-scale change initiatives (such as HIT systems): lack of a sense of urgency, no strong coalition, lack of a clear vision, missing frequent, clear communication, dis-empowerment of staff, no creation of short-term ‘wins’ to build momentum, and lack of ‘anchors’ for a change culture.”

Gloria L. Austin, Stephen Klasko, MD & William B. Leaver
The Art of Health IT Transformation

“In other words, recognize that you are not done at go-live; you’ve just started achieving technology adoption and changing behavior to get value from your investment.”

David E. Garets, FHIMSS
Change Management Strategies for an
Effective EMR Implementation

21 Dec

Why EFM trends are important

The importance of longer EFM views

Inventor of PeriGen advanced fetal monitoringby Emily Hamilton, MD CM
Senior Vice President, Clinical Research

Labor and delivery clinicians use EFM to identify fetal intolerance to labor to guide intervention and prevent hypoxic fetal injury. This task requires not only assessing the past and current degree of tracing abnormality and but projecting what is likely to happen in the near future. There is good evidence that tracing abnormalities generally evolve over hours (1-3). In addition, intervention guidelines usually recommend evaluating fetal response to supportive interventions over 30 to 60 minutes before resorting to cesarean delivery (4, 5). Thus long term assessments are essential. Standard computerized displays provide views of only 8 -10 minutes of tracing. Short term “snapshot” views can contribute to a failure to appreciate duration of tracing abnormality and the likely evolution.

PeriCALM Checklist analyzes EFM tracings in a consistent fashion. Its displays show long term trends over several hours, color coding regions of abnormality according to the criteria set by the institution. Such displays help clinicians see if a problem is intermittent or persistent, improving or deteriorating, stable or changing rapidly. A view of EFM trends may assist with situational awareness and helps clinicians in acute care settings more accurately project what is likely to happen and institute appropriate care. Checklist techniques and methods are especially pertinent in acute care settings during night time work when large amounts of data must be processed by the care givers over many hours. (6,7)

1. Vintzileos AM, Smulian JC. Decelerations, tachycardia, and decreased variability: have we overlooked the significance of longitudinal fetal heart rate changes for detecting intrapartum fetal hypoxia? Am J Obstet Gynecol. 2016 Sep;215(3):261-4.
2. Elliott C, Warrick PA, Graham E, Hamilton EF. Graded classification of fetal heart rate tracings: association with neonatal metabolic acidosis and neurologic morbidity. Am J Obstet Gynecol. 2010 Mar;202(3):258.
3. Clark SL, Hamilton EF, Garite TJ, Timmins A, Warrick PA, Smith S. The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. Am J Obstet Gynecol. 2016 Oct 14. pii: S0002-9378(16)30872-9. doi: 10.1016/j.ajog.2016.10.009. [Epub ahead of print]
4. Clark SL, Nageotte MP, Garite TJ, Freeman RK, Miller DA, Simpson KR, Belfort MA, Dildy GA, Parer JT, Berkowitz RL, D’Alton M, Rouse DJ, Gilstrap LC, Vintzileos AM, van Dorsten JP, Boehm FH, Miller LA, Hankins GD. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol. 2013 Aug;209(2):89-97.
5. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol. 2009 Jul;114(1):192-202.
6. Chapter 46. Fatigue, Sleepiness, and Medical Errors. AHRQ. (accessed December 2, 2016) https://archive.ahrq.gov/clinic/ptsafety/chap46a.htm
7. Fioratou E, Flin R, Glavin R, Patey R. Beyond monitoring: distributed situation awareness in anaesthesia. Br J Anaesth. 2010;105:83-90.

20 Dec

How one health system used HIT to control rate of Cesareans


Cesareans stabilized, NICU admissions and resuscitation decline after implementation of PeriCALM® Patterns™

Becker’s Hospital Review just released the results of 10-year study on the impact of process improvement and the use of PeriCALM on the rate of cesareans, NICU admissions and CPR/ventillation/intubation.

The study, authored by Sam Smith MD and Lynette Philip RN of MedStar and Adi Zmiri MD, Emily Hamilton MD CM, and Thomas Garite MD of PeriGen, looked at data for 78,459 births for Cesarean rates, NICU admissions, and the use of extraordinary fetal resuscitation procedures before and after the introduction of a management focus on care processes and staff training combined with the use of PeriCALM Patterns.

Following is a summary of the results published by Becker’s:

  • Despite an increase in factors associated with rates of cesarean sections, the rate of cesareans remained stable after the introduction of PeriCALM and advanced management strategies.
  • NICU admissions declined by more than half after PeriCALM and the process improvement steps were introduced.
  • The number of babies requiring unusual resuscitation measures in the delivery room decreased from 5.2% to 2.4%.

Click to access the Becker’s article providing full results and details

13 Dec

Build-a-Bike Challenge Trivia Quiz

A few of the trivia questions asked

during last week’s PeriGen team-building event

Here are a few of the questions we asked the PeriGen team as part of last week’s ‘Build-a-Bike Challenge.’  Teams that answered them correctly were awarded a point each and received a part of the bike they were building.

To see the answers, simply click on the questions. And, please, let us know how you do!

  • What is a DAS?
  • At what university was Patterns originally invented?
  • In what state is it illegal to kill mice without a hunting license?
  • Emily Hamilton's recent analysis of birth data indicates that cesarean rates did what since PeriCALM Patterns was installed at MedStar 10 years ago?
  • What is an example of a standard interface?
  • What were the wheels of the smallest adult bicycle made of?
  • Covered California, the state's health insurance program, indicates that they will remove hospitals based on what childbirth metric?
  • For WatchChild, what does BAM stand for?
  • In what city was Patterns first tested in a hospital?
  • Name the world's largest ocean.
  • What is the WatchChild database storage requirement?
  • What chess pieces can only move diagonally?
  • What WatchChild solution allows caregivers to monitor patients at any network-enabled location within the hospital (e.g., ED/ICU) and external locations such as physician offices?
  • How did the 17th president of the US, Andrew Johnson, start his career in Raleigh, NC ?
  • Which PeriGen client often provides Emily Hamilton with historic birth data (depersonalized) for clinical data analysis?
  • Name an EMR with which both WatchChild and PeriCALM can integrate?
  • According to a recent AJOG article co-authored by Emily Hamilton, when are ACOG first stage arrest criteria most applicable?
A store and forward device
McGill University
Ohio
Cesarean rates stayed the same despite an increase in risk factors associated with cesareans
ADT, LAB, pharmacy, outbound vitals/annotations
Silver dollars
The annual percentage of cesarean sections
Baby and Mother
Montreal
The Pacific
10MB per patient per day (uncompressed)
Bishops
Mobile Fetal Monitoring
He was a tailor’s apprentice
MedStar
Epic, Meditech, Allscripts, Cerner
After dilation has reached 6 CM
06 Dec

PeriCALM CheckList nominated for Edison Award

CheckList nominated for 2017 Edison Award for innovation

Protocol Management Tool again

recognized for innovation,

nominated for Edison Award

PeriGen announced today that their protocol management tool, PeriCALM CheckList, has been nominated for a 2017 Edison Award.  The Edison Awards recognize and honor innovation and innovators who make a positive impact in the world.

CheckList also received a Fierce Health Innovation Award earlier this year.

The Edison Awards are named after Thomas Alva Edison (1847-1931) who developed 1,093 patented new products, including the incandescent electric light and the system we still use today to generate electrical power.  His other products include the telephone transmitter, the phonograph, the first storage battery, and a motion-picture camera.

Edison Awards nominees are evaluated not only on their impact, but also the method of conceptualization, product value (advantages and differentiation), and marketing delivery.

PeriCALM CheckList, a module of the PeriCALM electronic fetal monitoring and analytics software solution, is designed to help bedside perinatal clinicians identify when patient EFM metrics match specific protocol parameters.  Although it is highly customizable, it is most often used by hospital clients to monitor oxytocin protocols.  The automation of protocol management that CheckList offers aims to save labor & delivery providers time by eliminating manual calculations and improve data accuracy.  Published research on obstetric protocols, in addition, have been shown to improve outcomes and lower cesarean section rates.

The module also includes a unique export feature, saving additional time by sending EFM data to the EHR and to annotations after review.

 

10 Nov

Impact of the laborist model on obstetric care

Research Summary:
Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes*

Inventor of PeriGen advanced fetal monitoringBy Emily Hamilton, MD CM, Senior Vice President of Clinical Research

This study, published in the August 13th issue of the American Journal of Obstetrics & Gynecology, examines outcomes before and after the introduction of a laborist model of care. Surprisingly, very few differences were noted when comparing changes over time in the hospitals with laborists to changes over the same period of time in the matched hospitals without laborists. This paper describes an interesting methodology to try and tease apart the effect of various factors on obstetrical outcomes. This is relevant because most quality improvement initiatives are studied in a before-and-after fashion and not in a prospective randomized trial.

The study is discharge summary data to NPIC between 1998 and 2011. Results from three hospitals where laborists were introduced were compared to six control hospitals matched for delivery volume, geographical area, teaching hospital status and level of neonatal nursery.

Once adjustment was made for several patient-related factors, no differences were observed in the odds ratio (OR) for any of the neonatal outcomes or for cesarean rates. The OR was reduced only for induction of labor (0.85 95%CI 0.71-0.99) and for Preterm Birth (0.83 95%CI 0.72-0.96). Although the OR for Preterm Birth was reduced this was not accompanied by a change in the OR for the birth of babies weighing

In short, the introduction of laborists was associated with a change in medical behavior (Induction of labor) and some change in actual outcome (preterm births), but not in low-birth-weight babies. A question that springs to mind immediately is the role of unmeasured factors such as policies to curtail elective induction of labor prior to 39 weeks that became common during this timeframe and were not adopted by all hospitals at the same time. Evidently the desire to improve is alive and well in many hospitals and there is no single solution for all.

Reference:
*Srinivas SK, Small DS, Macheras M, Hsu JY, Caldwell D, Lorch S. Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes. Am J Obstet Gynecol. 2016 Aug 13. https://www.ncbi.nlm.nih.gov/pubmed/27530491