Improvement of Team Based Communication for Electronic Fetal Monitoring Interpretation and Interventions in Labor and Delivery

Background Team-based education has been shown to improve outcomes in many different fields of medicine. There have been very few studies done on team based education on a Labor and Delivery Unit and the improvements that can be seen. Objectives To compare the rates of optimal care vs suboptimal care provided to patients before and after the implementation of team-based education focused on communication. Data collection and analysis Data for this study was collected through case review of 50 pre-intervention cases and 50 post-intervention cases. Inclusion criteria for the cases included: singleton deliveries, term gestation, and at least one of the following: arterial PH <7.20 or BE>12, 5 min APGAR <7, Operative delivery (C/S or assisted vaginal delivery), and/or unexpected admission to the NICU. Independent events were identified in each case that was reviewed and it was determined whether all or some of optimal care components were implemented. Optimal care was defined as correct: documentation/interpretation, intervention, and communication. Events were compared using Student's t-test and Fischer's Exact test to determine rates of optimal care. Main results There was no significant difference between total optimal care before and after the intervention. Pre-interventions optimal care rate was 35% (out of 170 events) while post-intervention optimal care rate was 31% (out of 129 events). Although total optimal care did not differ between groups based on event type, there were significant improvements in some of the individual components: Communication was significantly better before the intervention in cases of Prolonged deceleration (90% vs 61%). Communication was significantly better after the intervention for recurrent variable decelerations (76% vs 94%). Identification and documentation significantly improved after the intervention for recurrent late decelerations (52% vs 90%). Author's conclusion Optimal care did not improve with the one time use of pilot classes focused on communication. Further pilot classes and further case reviews are needed to be able to show if optimal care will improve as further education and practice are implemented.

Running head: TEAM BASED COMMUNICATION FOR EFM 1 Improvement of Team Based Communication for Electronic Fetal Monitoring Interpretation and Interventions in Labor and Delivery Cherysh Stock, Sean Esplin, and Jocelyn Yale The University of Utah College of Nursing TEAM BASED COMMUNICATION FOR EFM 2 Abstract Background Team-based education has been shown to improve outcomes in many different fields of medicine. There have been very few studies done on team based education on a Labor and Delivery Unit and the improvements that can be seen. Objectives To compare the rates of optimal care vs suboptimal care provided to patients before and after the implementation of team-based education focused on communication. Data collection and analysis Data for this study was collected through case review of 50 pre-intervention cases and 50 post-intervention cases. Inclusion criteria for the cases included: singleton deliveries, term gestation, and at least one of the following: arterial PH <7.20 or BE>12, 5 min APGAR <7, Operative delivery (C/S or assisted vaginal delivery), and/or unexpected admission to the NICU. Independent events were identified in each case that was reviewed and it was determined whether all or some of optimal care components were implemented. Optimal care was defined as correct: documentation/interpretation, intervention, and communication. Events were compared using Student's t-test and Fischer's Exact test to determine rates of optimal care. Main results There was no significant difference between total optimal care before and after the intervention. Pre-interventions optimal care rate was 35% (out of 170 events) while postintervention optimal care rate was 31% (out of 129 events). Although total optimal care did not differ between groups based on event type, there were significant improvements in some of the individual components: Communication was significantly better before the intervention in cases TEAM BASED COMMUNICATION FOR EFM 3 of Prolonged deceleration (90% vs 61%). Communication was significantly better after the intervention for recurrent variable decelerations (76% vs 94%). Identification and documentation significantly improved after the intervention for recurrent late decelerations (52% vs 90%). Author's conclusion Optimal care did not improve with the one time use of pilot classes focused on communication. Further pilot classes and further case reviews are needed to be able to show if optimal care will improve as further education and practice are implemented. TEAM BASED COMMUNICATION FOR EFM 4 Introduction Problem Description Maternal morbidity and mortality are currently on an upward trend. In the past two decades, maternal deaths in modern obstetrical units has increased to 22,980 annually in the United States alone, current national trend table and possible causes can be found in appendix A (CDC, 2018; Sonesh, 2015). Worldwide this number is even higher with approximately 287,000 women dying annually as a result of pregnancy or childbirth (Sonesh, 2015). As mortality rates continue to rise due to pregnancy and childbirth, there are many women who also have shortand long-term complications due to pregnancy and childbirth. These complications include pregnancy related illnesses and near-miss events, which are life-threatening complications that women survive (Lassi & Haider, 2015; Lyndon, et al., 2015). The consequences of these events affect these women and their families, as they can cause slow recovery and lasting sequela (Lassi & Haider, 2015). Pregnancy related illnesses, complications, and near miss events also significantly impact neonatal morbidity and mortality rates (Lassi & Haider, 2015, Lyndon, et al., 2015)). Although neonatal morbidity and mortality rates have been decreasing, they are not decreasing as quickly as should be expected with the new technological and medical advances that are currently available (Lassi & Haider, 2015). Human error has been identified as one of the major contributors to the rise of maternal mortality and morbidity (Sonesh, 2015; Raab, Will, Richards & O'Mara, 2013). Human error has many subcategories, which can be broken down and assessed individually to help improve the maternal and neonatal mortality and morbidity rates. One of the biggest contributors to human error noted by the Joint Commission (TJC) is failure to communicate and function as a team. TJC mentions these as the root causes for maternal and neonatal sentinel events (Raab, TEAM BASED COMMUNICATION FOR EFM 5 Will, Richards, & O'Mara, 2013; Maxfield, et al., 2014). There are many interventions that can be done to cause improvement in communication and teamwork in the perinatal field. These interventions include: proper education, training programs, and emergency response training (Pehrson, Sorensen, & Amer-Wahlin; Sonesh, 2015, Maxfield, et al., 2014; Brennan & Keohane, 2016). As training programs improve and communication and teamwork improve, optimal care provided to patients will also improve. This will help to decrease maternal and neonatal mortality and morbidity. The first goal in this process is the implementation of training programs specific to maternal and neonatal outcomes, which will result in a reduction in suboptimal care provided to these types of patients (Pehrson, Sorensen, & Amer-Wahlin; Sonesh, 2015; Brennan & Keohane, 2016; Pollard, Bansback, & Bryan, 2015). Available Knowledge Although there have been very few studies done on teamwork training with electronic fetal monitoring (EFM), it is known that teamwork training in other fields significantly improves outcomes (Ratelle, et al., 2016; Sonesh, et al., 2015; McComb, et al., 2017). Research has shown that as collaboration and teamwork improve, patient satisfaction and outcomes also improve. When teamwork is a key component in training programs, there is a significant impact on behavior and safety (Pehrson, Sorensen, & Amer-Wahlin, 2011; Sonesh, 2015). With these training programs in place and occurring at least every six months, it can be expected that improvements in quality of care and patient outcomes will be seen (Pehrson, Sorensen, & AmerWahlin, 2011; Gyllencreutz, Lindquist, & Holzmann, 2017). Education in EFM and obstetrical emergency training has shown to improve safety climate, teamwork climate, and rates of optimal care provided. (Pettker, et al., 2009; Young, Hamilton, & Hodgett, 2001). With the knowledge that has been gained from previous studies, TEAM BASED COMMUNICATION FOR EFM 6 this quality improvement project has been created. Through the use of training programs optimal care should improve and suboptimal care decrease, eventually causing an improvement in infant and maternal mortality and morbidity. Rationale As mentioned above, the need for a minimum of semi-annual trainings are essential for any new or continuing process to cause an improvement in outcomes. Through the implementation of quarterly classes, each focusing on an area that has been identified for improvement, involving both nurses and providers, there should be a decrease in suboptimal care provided to patients in Labor and Delivery (Pehrson, Sorensen, & Amer-Wahlin, 2011). The goal of these classes is to provide education in the form of pathophysiology, communication, and role-play with the eventual goal of making these interactions a normal and everyday process seen on the labor and delivery unit. This study uses the normalization process theory as a guide. The normalization process theory is focused on the implementation of new interventions and ensuring these become second nature to healthcare professionals. With the use of the above-mentioned theory, it is expected that the implementation of a new fetal heart monitoring program will result in improved outcomes. Through these new programs, working as a team to interpret fetal heart tracings will become second nature to the healthcare workers in a labor and delivery unit within the intermountain west (Sutton, et al., 2018). Specific Aims Specific aims of this study are focused on the instances of optimal vs suboptimal care given before and after the implementation of pilot classes. It is the hope that a decrease in suboptimal care and an increase in optimal care will be seen after the implementation of pilot classes. The goal of improving the rates of optimal care provided will be accomplished through TEAM BASED COMMUNICATION FOR EFM 7 pilot classes that focus specifically on team-based interventions and communication. Nurses and providers will participate in these classes through learning the pathophysiology of EFM, correct interpretation of EFM, and how to use team-based thought process and interventions. It is expected that these interventions will lead to improved communication between nurses and providers resulting in decreased rates of suboptimal care. Through the decreasing of suboptimal care and the increasing of optimal care will eventually lead to decreased rates of maternal and neonatal mortality and morbidity. Methods Context This intervention will be done in a high-risk Labor and Delivery unit in an urban intermountain region. The unit has 18 labor rooms, three triage rooms, and three operating rooms. In this unit, there are 73 bedside nurses, 16 certified nurse midwives, 20 obstetrical generalists and 15 maternal fetal medicine physicians. Previously, nurses were required to attend one class every quarter about EFM. Providers did not have any requirement or classes provided to them for continuing education in EFM. This intervention invited all nurses and providers to participate in the pilot classes provided. These pilot classes will include both providers and nurses in a discussion based training versus a lecture based class. Intervention(s) The purpose of this quality improvement project is to improve the rate of optimal care and decrease the rate of suboptimal care with the hope that maternal and neonatal mortality and morbidity rates can eventually be improved. Optimal care is defined during this study as follows: Correct interpretation and documentation of changes, appropriate interventions attempted with resolution of changes, documented communication with care provider when TEAM BASED COMMUNICATION FOR EFM 8 indicated, and initiation of chain of command when indicated. The chain of command established on the labor and delivery unit is as follows: 1. The nurse recognizes a problem and notifies the primary provider. 2. If an agreement cannot be reached after discussion and reasonable compromise, the charge nurse will then be invited to join the conversation. 3. If a solution still cannot be reached, then the on-floor laborist will be consulted. The on-floor laborist is a physician with a specialty in maternal fetal medicine, who has been trained and asked to fulfill this role. A laborist is to be available in person to support the unit at all times. With the addition of teamwork as a key component to these perinatal specific trainings, it can be expected that optimal care will increase. With an increase of optimal care given a decrease in neonatal and maternal morbidity and mortality can also be expected. A small pilot set of eight classes were done where a minimum of five nurses and two providers attended. Each class was previously recorded by a maternal fetal medicine physician with expertise in EFM. At each class a facilitator is present who was previously selected and trained to help direct conversation and education during classes. During the class, a previously recorded video was played, and questions were frequently asked to the group regarding the content. Role-play of communication also occurred between nurses and providers during these classes. The same video and content are used for each of the ten classes that were offered during that quarter. Nurses completed a nurse-physician relationship survey before and after implementation of classes to evaluate the level of teamwork in the unit. All who attended classes were asked to take an additional survey after each class answering questions specific to the class. Each class was sixty minutes in length. Included in each class was the review of a fetal heart strip, outcomes, and care provided. Each person in the class was asked to participate in discussions involving pathophysiology, interventions, and why certain outcomes occurred. TEAM BASED COMMUNICATION FOR EFM 9 There was further discussion about communication between nurses and providers and how this could change to improve outcomes and care that was provided in each of these cases. Study of the Intervention(s) The approach chosen for assessing the impact of the interventions was to use change statistics to measure the rates of suboptimal vs optimal care before and after the implementation of pilot classes. Optimal vs suboptimal care will be determined by reviewing charts of patients who had adverse outcomes the two months (July-August 2018) prior to pilot classes. Following the pilot classes, further cases were reviewed for the two months following the pilot classes (December - February 2019). Through measuring the rate at which optimal care was provided, it will be noted whether these classes were effective or not. It was also noted the number of nurses and providers attending each individual class was noted. It is then determined what percentage of providers and nurses who are employed by the hospital attended the pilot classes. These numbers are attained by taking attendance at every class and then asking each individual to complete the Participation Survey (found in Appendix B) and marking whether they are a provider or a nurse. Further evaluation will be accomplished by using change statistics to measure the differences in responses to the Nurse-Physician Collaboration survey (found in Appendix C). This survey was completed by the nurses on the unit the month before (September, 2018) the pilot classes, and the month following the pilot classes (January, 2019). This showed if the classes created a change in culture on the unit through education of team-based interpretation and interventions that are taught in the pilot classes. Measures TEAM BASED COMMUNICATION FOR EFM 10 The above intervention is being evaluated through multiple measures. The first is through the nurse-physician collaboration surveys and participant surveys. Both surveys are validated tools. The second evaluation will be the rate at which suboptimal vs optimal care is provided pre and post pilot classes. A nurse-physician collaboration survey was completed by 46 nurses before pilot classes. The nurses were asked again to complete the same survey after the implementation of classes. 8 of the original 46 nurses completed the post survey. The survey was provided to the nurses through both physical copies and through email allowing multiple ways to complete the survey to allow for highest rates of participation as possible. The survey was completed anonymously but each nurse only completed one survey. The survey can be found in Appendix B. The second survey that was provided was the participation survey provided after each pilot class. This survey was completed by both nurses and providers. It consisted of 12 questions that were to be rated as follows: agree strongly, agree, disagree, and disagree strongly. A 13th question was provided allowing for comments to help improve the course provided. There were 103 participants in classes including both providers and nurses and 84 surveys were completed. The survey was provided in a physical form. Each individual was asked to complete the survey before leaving the class. The surveys were then placed in a pile allowing for anonymity for those completing the survey. Each individual was asked to mark whether they were a provider or a nurse and the date they attended the class. The survey can be found in Appendix C (Kroushev, Beaves, Jenkins, & Wallace, 2009). The rate of suboptimal vs optimal care will be evaluated from reviewing cases from June -August 2018 before the classes were implemented and then cases in December 2018-February 2019 after the conclusion of the classes. Through this evaluation it is expected to see a decrease TEAM BASED COMMUNICATION FOR EFM 11 in suboptimal care and an increase in optimal care being provided by both nurses and providers. These will be shown by looking at each definition of optimal care and the change in percentages pre-and post-pilot classes. The overall goal of improving maternal and infant mortality and morbidity cannot be measured as further research and longer time periods are necessary to show this desired effect. Analysis Change statistics were calculated looking at a pre-and post-survey evaluating the effectiveness of the classes that were provided. To determine the rate of optimal versus suboptimal care the following statistical analysis was used. Continuous variables were compared using Student's t-test, categorical variables were compared using Fischer's Exact test. Ethical Considerations No direct patient contact was made during the process of this study. Project was submitted to Intermountain Healthcare and University of Utah IRB. IRB approval was exempt, as this is a quality improvement project. Results In part one of the study nurses on at an urban, high-risk obstetrical unit were asked to complete a pre- and post-survey concerning the relationship between the nursing staff and the providers. The pre-survey showed that nurses overall felt that the nurse-provider relationship was good and that the providers listened and trusted them as part of the care team. The postsurvey was not completed by enough staff to be included in the results of this study. In part two of the study a post-class survey was given to all that attended the pilot classes about improving nurse-provider relationship. This survey showed that the majority of providers approved of the new process. Most that attended that class felt that it provided new knowledge TEAM BASED COMMUNICATION FOR EFM 12 and helped them better care for patients through better communication with the nurses. The improvements that were suggested by those that attended the classes where, "could be longer to allow for more discussion", "please continue to have these classes to allow both providers and nurses to learn to communicate better". In part three of this study, there were 50 before cases and 50 after cases reviewed preand post-pilot classes. The pre- and post-cases had the inclusion criteria of singleton deliveries, term gestation, and at least one of the following: Art PH <7.20 or BE >12, 5 min APGAR <7, Operative delivery (C/S or Assisted vaginal delivery), or unexpected admission to NICU. Exclusion criteria included: multiple gestation, and gestational age < 37 weeks. The following indicates why the following 50 before cases were pulled: Art pH <7.20/BE >-12 (N=15), C/S for NRFHT (N=30), Assisted vaginal delivery for NRFHT (N=13), unexpected admission to NICU (N=6), and 5-minute APGAR <7 (N=6). 170 independent events occurred in all of the patients combine (the minimum number was 1 event; the maximum number was 12). All cases had at least one event. The average number of events was 3.84 per case. The following indicates why the following 50 after cases were pulled: Art pH <7.20 or BE>-12 (N=31), C/S for NRFHT (N=22), Assisted vaginal delivery for NRFHT (N=4), Unexpected NICU admission/neonatal death (N=4), and 5-minute APGAR <7 (N=7). There was a total of 129 independent events occurred in all the patients combined post-interventions (the minimum number was 0 events; the maximum number was 8). The average number of events was 2.58 per case. The review of these before cases had the overall goal of looking at rate of optimal care provided before and after the pilot classes that were provided. The rate of optimal care is measured by looking at four areas which include: interpretation/documentation, interventions, TEAM BASED COMMUNICATION FOR EFM 13 communication, use of chain of command. The rates of optimal care provided in each definition are as follows: interpretation/documentation (96/170 events: 56%), Interventions (96/170 events: 56%), communication (142/170 events: 84%), and use of chain of command (1/2 events: 50%). Total optimal care, which was determined by looking at the rate at which optimal care was provided for each individual event, was provided 35% of the time (60/170). The review of these after cases had the overall goal of looking at rate of optimal care provided before and after the pilot classes that were provided. The rate of optimal care is measured by looking at four areas which include: interpretation/documentation, interventions, communication, use of chain of command. The rates of optimal care provided in each definition are as follows: interpretation/documentation (90/129 events: 70%), Interventions (64/129 events: 50%), communication (98/129 events: 76%), and use of chain of command (0/0: 0%). Total optimal care that was provided 31% of the time (40/129). Each type of event was placed in the different categories of why each case was pulled (i.e. Arterial pH <7.20 or BE >-12.0, 5 minute APGARS <7, unexpected NICU admission/neonatal death, cesarean section for non-reassuring fetal heart tracing (NRFHT), and assisted vaginal delivery for NRFHT), each of these categories were individually analyzed for optimal care. These tables can be found in appendix E. Final analysis of the pre- and post-cases looks at each individual event and the rate at which optimal care was provided for each event. The events can be described as the following: bradycardia, prolonged deceleration, recurrent late deceleration, recurrent variable decelerations, minimal/absent variability, marked variability, fetal tachycardia, and undetermined decelerations. The analysis of optimal care provided for each individual case can be found in appendix F. Discussion TEAM BASED COMMUNICATION FOR EFM 14 Summary During this study, 100 cases were reviewed looking at rates of optimal care vs suboptimal care. This information shows that there was no significant difference between total optimal care before and after the intervention. Interpretation Although total optimal care decreased between groups based on event type, there were significant improvements in some of the individual components. Communication was significantly better before the intervention in the cases of prolonged deceleration. Communication was significantly better after the intervention for recurrent variable decelerations. Identification and documentation significantly improved after the intervention for recurrent late decelerations. Post-intervention cases noted many compounding factors that may have caused a decrease in the rate of optimal care that was provided. During the time period that the pilot classes were administered there were nine nurses hired to the labor and delivery unit that the cases were pulled from. These nurses were not certified in interpretation of electronic fetal monitoring and did not have the trusted relationship that exists between the providers and nurses. Due to this it was noted that these nurses were part of a large number of the cases that were pulled. Through further implementation of quarterly classes that include these nurses, all providers and nurses on the unit will be educated with the same information and interventions. Limitations The nurse-physician collaboration pre-survey was completed by 46 nurses, when the same survey was provided post-intervention the survey was only completed by 5 nurses. Due to this limitation, it was not included in the study. TEAM BASED COMMUNICATION FOR EFM 15 The number of some cases were very small and our power may be limited to detect a difference. With larger numbers a difference may be detectable. Conclusions There was no difference in the total optimal care or independent components of optimal care based on the indication for inclusion in the study. Our first intervention was a case study that focused on communication and we did see some improvement in communication in certain areas. Future interventions should focus on identification/documentation of abnormalities in interventions. We anticipate that the number of cases with total optimal care will improve after additional directed interventions. We plan to repeat case evaluation after additional interventions to demonstrate continued improvement. With changing the inclusion in the study to a random selection this may show a larger or smaller different in optimal care that was provided. Acknowledgements We would like to thank the nurses, providers, and management of the labor and delivery unit at Intermountain Medical Center in Salt Lake City, for participating in the pilot classes, completing surveys, and helping in the evaluation of care provided. TEAM BASED COMMUNICATION FOR EFM 16 References CDC (2018, August 7). Pregnancy mortality surveillance. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortalitysurveillancesystem.htm?CDC_AA_refVal=https://www.cdc.gov/reproductivehealth/maternalinfanthe alth/pmss.html Brennan, R. A, & Keohane, C. A. (2016). How communication among members of the health care team affects maternal morbidity and mortality. Journal of Obstetric, Gynecology, and Neonatal Nursing, 45(6), 878-884. Doi.10.1016/j.jogb.2016.03.142 Gyllencreutz, E., Varli, I. H., Lindquist, P. G., & Holzmann, M. (2017). Reliability in cardiotocography interpretation-impact of extended on-site education in addition to webbased learning: An observational stud. Acta Obstetricia Et Gynecologica Sandinavica, 96 (4), 496-502 Kroushev, A., Beaves, M., Jenkins, V., & Wallace, E. M. (2009). Participant evaluation of the RANZCOG fetal surveillance education program. Australian and New Zealand Journal of Obstetrics and Gynaecology, 49I(3), 268-273. Doi:10.1111/j.1479-828x.2009.00988.x Lassi, Z. S., & Haider, B. A. (2015). Community-based intervention packages for reducing maternal morbidity and mortality and improving neonatal outcomes. Cochrane Library, (3). Doi:10.23846/sr1014 Lyndon, Al., Johynson, M. C., Bingham, D., Napolitano, P. G., Joseph, G., Maxfield, D. G., & O'keeffe, D. F. (2015). Transforming communication and safety culture in intrapartum care. Obstetrics & Gynecology, 125(5), 1049-1055. Doi:10.1097/aog.000000000000793 Maxfield, D., Lyndon, A., Kennedy, H., O'Keefe, D., & Zlatnik, M. (2014). Confronting safety gaps across labor and delivery teams. Obstetric Anesthesia Digest, 34(4), 200-201. Doi:10.1097/01.aoa.0000455569.41706.12 Pehrson, C., Sorensen, J., & Amer-Wahlin, I. (2011). Evaluation and impact of cardiotocography training programs: A systematic review. BJOG: An International Journal of Obstetrics & Gynecology, 118(8), 926-935. Doi:10.1111/j.1471-0528.2011.03021.c Pettker, C. M., Thung, S. F., Norwitz, E. R., Buhimschi, C. S., Raab, C. A., Copel, J. A., . . . Funai, E. F. (2009). Impact of a comprehensive patient safety strategy on obstetric adverse events. American Journal of Obstetrics and Gynecology, 200(5), 492. Pollard, S., Bansback, N., & Bryan, S. (2015). Physician attitudes toward shared decision making: a systematic review. Patient Education and Counseling, 98(9), 1046-1057. Doi:10.1016/j.pec.2015.05.004 Raab, C. A., Will, S. E., Richards, S. L., & O'mara, E. (2013). The effect of collaboration on obstetric patient safety in three academic facilities. Journal of Obstetric, Gynecologic & Neonatal Nursing, 42(5), 606-616. Doi:10.1111/1552-6909.12234 Ratelle, J., Henkin, S., Chon, T., Christopherson, M., Halvorsen, A., & Worden, L. (2016). Improving nurse-physician teamwork through interprofessional bedside rounding. Journal of Multidisciplinary Healthcare, 201. Doi:10.2147/jmdh.s106644 Sonesh, S. C., Gregory, M. E., Hughes, A. M., Feitosa, J., Benishek, L. E., Verhoeven, D., . . . Gonzalez, L. (2015). Team training in obstetrics: A multilevel evaluation. Families, System, & Health, 33(3), 250-261. Doi:10.1037/fsh0000148 Sutton, E., Herbert, G., Burde, S., Lewis, S., Thomas, S., Ness, A., & Atkinson, C. (2018). Correction: using the normalization process theory to qualitatively explore sense-making TEAM BASED COMMUNICATION FOR EFM 17 in implementation of the enhances recovery after surgery programme. "its not rocket science". Plas one 13(5). Doi: 10.1371/journal.pone.0197790 Ushiro, R. (2009). Nurse-Physician Collaboration Scale: Development and psychometric testing. Journal of Advanced Nurse, 65(7), 1497-1508.doi:10.1111/j.1365-2648.2009.05011.x Young, P., Hamilton, R., & Hodgett, S. (2001). Reducing risk by improving standards of intrapartum care. Journal of the royal Society of Medicine, 94(7), 372-372. Doi:10.1177/014107680109400731 TEAM BASED COMMUNICATION FOR EFM 18 Appendix A According to the CDC there has been a continuous rise in maternal morbidity and mortality in the United States. The below tables show this increase from 1987-2014. The second table shows the causes of the pregnancy related deaths. TEAM BASED COMMUNICATION FOR EFM 19 TEAM BASED COMMUNICATION FOR EFM 20 Appendix B Participation Feedback The participation feedback survey is also a validated tool and has been used to provide feedback on EFM classes specifically. It is important for feedback to be received for any class that is being presented so that improvements can be made. Each individual will have different perceptions of the class and what can be improved Through this study the pilot classes were able to be improved through feedback given from the participants who attended the pilot classes (Kroushev, Beaves, Jenkins, & Wallace, 2009). Overall Rating of the Course 1. The course enabled me to review and update knowledge in topics presented 2. The course enabled me to enhance my understanding in the topics presented 3. Sessions featured relevant and practical case presentations 4. There was adequate time for discussion 5. The course has improved my confidence in EFM interpretation 6. Overall, the length of each session was appropriate 7. The meeting facilities provided a satisfactory environment for learning 8. The presenter's style enhanced my learning experience 9. the fetal heart rate physiology was useful 10. The fetal assessment information was helpful 11. The normal and abnormal EFM information was useful 12. The EFM workshop was helpful 13. Comments: Agree Strongly Agree Disagree Disagree Strongly TEAM BASED COMMUNICATION FOR EFM 21 Appendix C Nurse-Physician Collaboration Survey The Nurse-Physician collaboration survey is a validated tool that has been used to measure the nurse physician relationship in intensive care units. Intensive care units are floors were the providers and nurses work closely together, which creates a very unique relationship between the providers and the nurses they work with. The relationship between nurses and physicians are an essential part of this quality improvement project and therefore needed to evaluated twice during this project. Labor and Delivery units are very similar to intensive care units in that most nurses have one to two patients and work very closely with the providers that care for those patients. The survey is presented below and nurses were asked to rate each question on a scale of one to five with the following rating score: 1= disagree strongly, 2=disagree slightly, 3=neutral, 4=agree, 5=agree strongly (Ushiro, 2009). NURSE-PHYSICIAN COLLABORATION JOINT PARTICIPATION IN THE CURE/CARE DECISIONMAKING PROCESS The nurses and the physicians exchange opinions to resolve problems related to patient cure/care In the event of a disagreement about the future direction of a patient's care, the nurses and the physicians hold discussions to resolve differences of opinion The nurses and the physicians discuss whether to continue a certain treatment when the treatment is not have the expected effect. When a patient is to be discharged from the hospital, the nurses and the physicians discuss where the patient will continue to be treated and the lifestyle regimen the patient needs to follow. When confronted by a difficult patient, then nurses and the physicians discuss how to handle the situation. The nurses and the physicians discuss the problems a patient has The nurses and the physicians together consider their proposals about the future direction of patient care 1 2 3 4 5 TEAM BASED COMMUNICATION FOR EFM In the event a patient develops unexpected side effects or complications, the nurses and the physicians discuss countermeasures In the event a patient no longer trusts a staff member, the nurses and the physicians try to respond to the patient in a consistent manner to resolve the situation The future direction of a patient's care is based on a mutual exchange of opinions between the nurses and the physicians The nurses and the physicians seek agreement on signs that a patient can be discharged The nurses and the physicians discuss how to prevent medical care accidents SHARING OF PATIENT INFORMATION The nurses and physicians all know what has been explained to a patient about his/her condition or treatment The nurses and the physicians share information to verify the effects of treatment The nurses and the physicians have the same understanding of the future direction of the patient's care The nurses and the physicians identify the key person in a patient's life In the event of a change in treatment plan, the nurses and physicians have a mutual understanding of the reasons for the change The nurses and the physicians check with each other concerning whether a patient has any signs of side effects or complications The nurses and the physicians share information about a patient's reaction to explanations of his/her disease status and treatment methods. The nurses, the physicians, and the patient have the same understanding of the patient's wish for cure and care The nurses and the physicians share information about a patient's level of independence in regard to activities of daily living. COOPERATIVENESS The nurses and the physicians can easily talk about topics other than topic related to work The nurses and the physicians can freely exchange information or opinions about matters related to work The nurses and the physicians show concern for each other when they are very tired The nurses and the physicians help each other The nurses and the physicians greet each other every day. The nurses and the physicians take into account each other's schedule when making plans to treat a patient together. 22 TEAM BASED COMMUNICATION FOR EFM 23 Appendix D The first table provided below shows the number of events per patient during the 50-prepilot class review. Number of Events Number of Patients 0 0 1 13 2 8 3 11 4 6 5 4 6 1 7 3 8 1 9 1 10 0 11 1 12 1 TEAM BASED COMMUNICATION FOR EFM The second table below shows that type of events that were occurring and what type of interventions were or were not done. 24 TEAM BASED COMMUNICATION FOR EFM 25 Appendix E The follow tables show the rate of optimal care that was provided for each reason that each case of pulled for evaluation. Arterial pH <7.20 or BE >-12.0 Pre-Intervention Post-Intervention P Value Total Number of Cases 17 26 Total Optimal Care 8 (47%) 9 (35%) 0.5277 Identify/Document 10 (59%) 16 (39%) 0.999 Intervention 12 (71%) 16 (39%) 0.7448 Communication 15 (88%) 21 (81%) 0.6845 Pre-Intervention Post-Intervention P Value Total Number of Cases 7 6 Total Optimal Care 3 (43%) 5 (83%) 0.5594 Identify/Document 5 (71%) 4 (67%) 0.999 Intervention 3 (43%) 2 (33%) 0.999 Communication 5 (71%) 3 (50%) 0.5921 5 minute APGAR <7 Unexpected NICU admission/neonatal death Total Number of Cases Pre-Intervention Post-Intervention 4 4 P Value TEAM BASED COMMUNICATION FOR EFM 26 Total Optimal Care 1 (25%) 0 0.999 Identify/Document 1 (25%) 3 (75%) 0.4857 Intervention 3 (75%) 1 (25%) 0.4857 Communication 4 (100%) 2 (50%) 0.4286 Cesarean Section or Non-Reassuring Fetal Heart Tracing Pre-Intervention Post-Intervention P Value Total Number of Cases 4 4 Total Optimal Care 1 (25%) 0 0.999 Identify/Document 1 (25%) 3 (75%) 0.4857 Intervention 3 (75%) 1 (25%) 0.4857 Communication 4 (100%) 2 (50%) 0.4286 Assisted Vaginal Delivery for Non-Reassuring Fetal Heart Tracing Pre-Intervention Post-Intervention P Value Total Number of Cases 4 4 Total Optimal Care 1 (25%) 0 0.999 Identify/Document 1 (25%) 3 (75%) 0.4857 Intervention 3 (75%) 1 (25%) 0.4857 Communication 4 (100%) 2 (50%) 0.4286 TEAM BASED COMMUNICATION FOR EFM 27 Appendix F The following table shows the analysis of each individual event as it pertains to the optimal care that was provided during the events. Pre-Intervention Post-Intervention 9 0 Total Optimal Care 6 (67%) 0 0.999 Identify/Document 7 (78%) 0 0.999 Intervention 7 (78%) 0 0.999 Communication 6 (68%) 0 0.999 70 57 Total Optimal Care 27 (39%) 15 (26%) 0.1849 Identify/Document 38 (54%) 33 (58%) 0.7219 Intervention 43 (61%) 31 (54%) 0.4718 Communication 63 (90%) 35 (61%) 0.0002 31 20 Total Optimal Care 11 (35%) 10 (50%) 0.3863 Identify/Document 16 (52%) 19 (90%) 0.006 Intervention 19 (61%) 13 (65%) 0.999 Communication 28 (90%) 17 (85%) 0.668 41 37 Bradycardia (Events) Prolonged Deceleration Recurrent Lates Recurrent Variables P Value TEAM BASED COMMUNICATION FOR EFM 28 Total Optimal Care 14 (34%) 12 (32%) 0.999 Identify/Document 28 (68%) 30 (81%) 0.299 Intervention 21 (58%) 15 (41%) 0.372 Communicate 31 (76%) 35 (94%) 0.027 Minimal/Absent Variability 3 1 Total optimal care 0 0 0.999 Identify/document 1 (33%) 1 (100%) 0.999 0 0 0.999 2 (67%) 1 (100%) 0.999 1 7 Total Optimal Care 0 2 (29%) 0.999 Identify/Document 0 5 (71%) 0.375 1 (100%) 3 (43%) 0.999 0 7 (100%) 0.125 8 7 Total Optimal Care 1 (13%) 1 (14%) 0.999 Identify/Document 3 (38%) 3 (43%) 0.999 Intervention 3 (38%) 2 (29%) 0.999 Intervention Communication Marked Variability Intervention Communication Fetal Tachycardia TEAM BASED COMMUNICATION FOR EFM Communication 29 3 (38%) 3 (43%) 0.999 4 0 0.999 Total Optimal Care 1 (25%) 0 0.999 Identify/Document 2 (50%) 0 0.999 Intervention 1 (25%) 0 0.999 Communication 3 (75%) 0 0.999 Undetermined Deceleration