by Rebecca Cypher, MSN, PNNP
I wanted to share with you a white paper that PeriGen asked me to prepare on how today’s healthcare technologies can help us in perinatal nursing. Since the paper is lengthy and few of us have time to read such articles in one sitting, I’ve split the paper into three parts and will deliver it to you via email and PeriGen’s social media platforms (Facebook, LinkedIn, Twitter) over the next several weeks. If, by chance, you would like the full article, click here for access to the PDF
Let’s start with a look back at where we’ve come from:
Humans have a long history of inventing tools to survive and achieve goals more efficiently.1 Some tools survive the test of time and evolve while others are abandoned. Healthcare is no different. Monitoring devices and healthcare information technologies (HIT) are key tools used in modern healthcare and time will tell how well they advance as healthcare changes.
Perinatal nursing is just one example of where HIT has had a significant influence on integrating technology with a nursing process framework. 3 Monitoring technology, information technology and clinical acumen can be thought of as an interdependent hierarchy. (See Figure 1 above ). For example, at the most basic level, electronic fetal monitor (EFM) sensors measure fetal heart rates (FHR) and uterine activity. At an intermediate level, HIT consolidates and analyzes the monitoring data for clinicians. At the highest level, nurses decide what the data means, what is likely to happen next and implement the most beneficial interventions. Each level depends, in part, upon the former. Historically, nurses did everything including auscultating FHRs with a fetoscope, palpating uterine activity, recording data in a paper record, and made FHR decisions based on what could be heard and recorded. Now EFM and software accomplish several of these tasks. For some nurses, these new technologies evoked insecurity, a feeling that professional value and roles would be diminished. For others, new technology provided a release from endless listening, counting and transcribing and consequently freeing time to focus on clinical judgment and hands on patient care. In fact, while fetal monitors did reduce the counting tasks they also elevated the expectation for medical reasoning or tracing interpretation.
The purpose of this document is to broadly outline the evolution in each of the three levels of data collection via monitors, interpretation and clinical intervention. In addition, we will discuss relative strengths and weakness of clinicians and HIT in the context of modern perinatal care and how they complement each other.
Clarity on this subject is important to:
- Emphasize that clinical acumen for diagnostic and therapeutic decisions and compassionate care is paramount
- Determine where and why technology can be a help or a hindrance for nurses
- Provide guidance for designers of new technology to meet a nurse’s greatest clinical need
By 2004, 89% of births in the United States were monitored electronically. 4 In view of the high and stable rate of electronic monitoring Vital Statistics ceased reporting EFM utilization rates in annual birth-related reports. Monitoring sensors and signal processing have evolved to provide excellent measurement of FHR, uterine activity and maternal vital signs. 5 Fetal monitors can indicate signal coincidence when two sources of heart rate measurement are the same. On the other hand, monitoring faces new physical challenges. Obesity impedes monitoring by Doppler ultrasound based external sensor technology.
Given the imprecise relationship between FHR and fetal brain oxygenation or acid- base status, a considerable effort has been devoted to finding other physiological measures that would be more discriminating. Unfortunately, prospective clinical trials show no clinical benefit in using EFM with additional sensors that measure fetal oxygen saturation or fetal ST segments of the fetal ECG compared to using EFM alone. 6, 7 Thus, for the near future, the obstetrical world remains dependent upon standard EFM.
Healthcare Information Technology
HIT has evolved considerably in contrast, to the relative stagnation of the monitoring devices. Early electronic medical records allowed clinicians to collect, display and store information in a legible fashion, but at considerable inefficiency. Data entry was often arduous, time-consuming and error -prone. “Cut and paste” shortcuts led to nonsense entries with costly legal repercussions. Lack of interoperability wasted time with redundant documentation.
Perinatal nurses have played an important role in this evolution. Working alongside HIT experts, nurses have been vital members of multidisciplinary teams in which integrating, implementing, and maintaining fetal surveillance technologies with clinical practice has become a priority in patient centered care and safety. This is especially apparent in organizations that promote high reliability units.
There has been considerable industry consolidation on a few types of hospital-wide electronic medical records boosting interoperability. IT networks, smartphones and cloud-based computing give nurses unprecedented and speedy access to information and human expertise. The computational power and reliability of basic computers and networks means very complex analytical methods can be available in real-time at the bedside. 8, 9 Computerized analyses can now be applied to EFM tracings or evaluate labor progression to bring consistent interpretation, reducing clinical variation.
Psychological testing has underlined the importance of simplicity and clarity of information displayed on computer screens. Overcrowded or confusing displays can lead to medical error. Better graphical designs mean critical information is consolidated for efficient review by clinicians. High rates of false alarms lead to frustration and disregard of the device. Truly discriminating alerts based on better evidence-based algorithms alleviate this alarm fatigue.