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ABSTRACT: To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff.
Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life support pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring.
Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017).
Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.
American journal of obstetrics and gynecology 09/2011; 205(3):239.e1-5. · 3.28 Impact Factor
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ABSTRACT: To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education.
Statified by year, residents (n = 38) were randomly assigned to 3 educational intervention groups: Simulation→Lecture, Simulation, and Lecture. Postintervention simulations were performed for all and scored using standardized lists. Maternal, fetal, eclampsia management, and magnesium toxcity scores were assigned. Mann-Whitney U, Wilcoxon rank sum and χ(2) tests were used for analysis.
Postintervention maternal (16 and 15 vs 12; P < .05) and eclampsia (19 vs 16; P < .05) scores were significantly better in simulation based compared with lecture groups. Postintervention magnesium toxcitiy and fetal scores were not different among groups. Lecture added to simulation did not lead to incremental benefit when eclampsia scores were compared between Simulation→Lecture and Simulation (19 vs 19; P = nonsignificant).
Simulation training is superior to traditional lecture alone for teaching crucial skills for the optimal management of both eclampsia and magnesium toxicity, 2 life-threatening obstetric emergencies.
American journal of obstetrics and gynecology 10/2010; 203(4):379.e1-5. · 3.28 Impact Factor
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ABSTRACT: The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC.
This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program.
Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively.
Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.
American journal of obstetrics and gynecology 09/2010; 203(3):238.e1-7. · 3.28 Impact Factor
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ABSTRACT: The previous century was characterized by tremendous advances in reducing maternal mortality and morbidity, as well as dramatic improvements in perinatal outcomes for fetus and newborn. However, there has now developed a plateauing or even a worsening in some of the commonly tracked indicators of reproductive health. In this section, leading policy experts focus on redefining how the health system approaches the task of continuing to improve the reproductive outcomes of women and their offspring. They analyze key underlying fundamentals and offer their individual suggestions for new initiatives to reverse these disturbing negative trends.
Journal of Women s Health 02/2010; 19(3):555-60. · 1.57 Impact Factor
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ABSTRACT: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience.
Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations.
Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25-63 years (mean+/-standard deviation 37.0+/-9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5+/-8.1). Documentation scores were significantly improved after training. Attendings' baseline documentation scores were 8.5+/-2.2 and improved to 9.4+/-2.3, P=.03. Residents' documentation scores also improved (9.0+/-2.1 compared with 10.6+/-2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores).
Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation.
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Obstetrics and Gynecology 01/2009; 112(6):1284-7. · 4.73 Impact Factor
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ABSTRACT: The objective of the study was to determine whether a simulation-based educational program would improve residents' and attending physicians' performance in a simulated shoulder dystocia.
Seventy-one obstetricians participated in an unanticipated simulated shoulder dystocia, an educational debriefing session, and a subsequent shoulder dystocia simulation. Each simulation was scored, based on standardized checklists for 4 technical maneuvers and 6 communication tasks, by 2 physician observers. Paired Student t tests were used for analysis.
Forty-three attendings and 28 residents participated. Residents showed significant improvement in mean maneuver (3.3 +/- 0.9 vs 3.9 +/- 0.4, P = .001) and communication (3.5 +/- 1.2 vs 4.9 +/- 1.0, P < .0001) scores after simulation training. Attending physicians' communication (3.6 +/- 1.6 vs 4.9 +/- 1.1, P < .0001) scores were significantly improved after training.
Our program improved physician performance in the management of simulated shoulder dystocia deliveries. Obstetric emergency simulation training can improve physicians' communication skills, at all levels of training, and should be incorporated into labor and delivery quality improvement measures.
American journal of obstetrics and gynecology 09/2008; 199(3):294.e1-5. · 3.28 Impact Factor
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ABSTRACT: In 2002 the Institute of Medicine called for implementation of information technologies in health care settings to improve quality of care and reduce the incidence of medical errors. Nowhere is this need more critical than in obstetrics. In recent years numerous electronic prenatal medical records have become available. To date there has been little literature to identify what constitutes the important features in these systems, nor research into whether these systems actually improve the quality of care or the outcome of pregnancies. In this article we will elucidate some of the features that we feel are critical if we are to achieve these goals. Some of these features are: (1) availability across a computer network so that providers can access the record in a variety of settings, (2) simplicity of the user interface to ensure provider compliance with the system, (3) an intelligent system to encourage completeness of documentation in the medical record, (4) a problem-oriented obstetric chart so that no issue is overlooked and each is adequately addressed, and (5) administrative features to allow evaluation to ensure improved quality of care. These features together, we believe, will help to minimize medical errors, improve patient outcomes and reduce liability exposure.
The Journal of reproductive medicine 12/2007; 52(11):987-93. · 0.87 Impact Factor
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Siobhan M Dolan,
Susan J Gross, Irwin R Merkatz,
Vincent Faber,
Lisa M Sullivan,
Fergal D Malone,
T Flint Porter,
David A Nyberg,
Christine H Comstock,
Gary D V Hankins,
Keith Eddleman,
Lorraine Dugoff,
Sabrina D Craigo,
Ilan Timor-Tritsch,
Stephen R Carr,
Honor M Wolfe,
Diana W Bianchi,
Mary E D'Alton
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ABSTRACT: To assess the impact of birth defects on preterm birth and low birth weight.
Data from a large, prospective multi-center trial, the First and Second Trimester Evaluation of Risk (FASTER) Trial, were examined. All live births at more than 24 weeks of gestation with data on outcome and confounders were divided into two comparison groups: 1) those with a chromosomal or structural abnormality (birth defect) and 2) those with no abnormality detected in chromosomes or anatomy. Propensity scores were used to balance the groups, account for confounding, and reduce the bias of a large number of potential confounding factors in the assessment of the impact of a birth defect on outcome. Multiple logistic regression analysis was applied.
A singleton liveborn infant with a birth defect was 2.7 times more likely to be delivered preterm before 37 weeks of gestation (95% confidence interval [CI] 2.3-3.2), 7.0 times more likely to be delivered preterm before 34 weeks (95% CI 5.5-8.9), and 11.5 times more likely to be delivered very preterm before 32 weeks (95% CI 8.7-15.2). A singleton liveborn with a birth defect was 3.6 times more likely to have low birth weight at less than 2,500 g (95% CI 3.0-4.3) and 11.3 times more likely to be very low birth weight at less than 1,500 g (95% CI 8.5-15.1).
Birth defects are associated with preterm birth and low birth weight after controlling for multiple confounding factors, including shared risk factors and pregnancy complications, using propensity scoring adjustment in multivariable regression analysis. The independent effects of risk factors on perinatal outcomes such as preterm birth and low birth weight, usually complicated by numerous confounding factors, may benefit from the application of this methodology, which can be used to minimize bias and account for confounding. Furthermore, this suggests that clinical and public health interventions aimed at preventing birth defects may have added benefits in preventing preterm birth and low birth weight.
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Obstetrics and Gynecology 09/2007; 110(2 Pt 1):318-24. · 4.73 Impact Factor
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ABSTRACT: To assist in predicting future leadership needs, this longitudinal study examines turnover and net retention rates among chairs at university obstetrics and gynecology departments between 1981 and 2005.
A database of appointment dates and tenure of chairs at each of 125 Association of American Medical Colleges-approved United States medical schools was collated using membership listings from the Association of Professors of Gynecology and Obstetrics and from the Council of University Chairs in Obstetrics and Gynecology. Complete data from 118 departments were confirmed by selective correspondence at individual departments and further review by the investigators.
A total of 260 individuals (232 men, 28 women) became new chairs between 1981 and 2005. The annual turnover rate increased gradually from 6.0% to 12.7%. Five-year net retention rates remained steady between 1982 and 1997 but dropped after 1997 (85.6% compared with 63.2%; P=.03). A chair's tenure ranged widely (1 to 23 years; median 8 years), regardless of gender or school type, size, or location. Approximately one half of interim chairs became permanent chairs, usually at their own institution. The number of new women chairs increased from none in 1981 to 17 (15.2% of total chairs) in 2005.
Academic chair positions in obstetrics and gynecology experienced a doubling in annual turnover rates, while retention rates declined. The proportion of chairs occupied by women increased progressively.
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Obstetrics and Gynecology 12/2006; 108(5):1217-21. · 4.73 Impact Factor
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ABSTRACT: Preterm birth (PTB) is a common, serious, and costly health problem affecting nearly 1 in 8 births in the United States. Burdens from PTB are especially severe for the very preterm infant (<32 weeks' gestation), comprising 2% of all US births. Successful prevention needs to include newly focused and adequately funded research, incorporating new technologies and recognition that genetic, environmental, social, and behavioral factors interact in complex pathogeneses and multiple pathways leading to PTB. The March of Dimes Scientific Advisory Committee created this prioritized research agenda, which is aimed at garnering serious attention and expanding resources to make major inroads into the prevention of PTB, targeting six major, overlapping categories: epidemiology, genetics, disparities, inflammation, biologic stress, and clinical trials. Analogous to other common, complex disorders, progress in prevention will require incorporating multipronged risk reduction strategies that are based on sound scientific discovery, as well as on effective translation into clinical care.
American Journal of Obstetrics and Gynecology 10/2005; 193(3 Pt 1):626-35. · 3.47 Impact Factor
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Lorraine Dugoff,
John C Hobbins,
Fergal D Malone,
John Vidaver,
Lisa Sullivan,
Jacob A Canick,
Geralyn M Lambert-Messerlian,
T Flint Porter,
David A Luthy,
Christine H Comstock,
George Saade,
Keith Eddleman, Irwin R Merkatz,
Sabrina D Craigo,
Ilan E Timor-Tritsch,
Stephen R Carr,
Honor M Wolfe,
Mary E D'Alton
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ABSTRACT: To estimate the effect of second-trimester levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), unconjugated estriol (uE3), and inhibin A (the quad screen) on obstetric complications by using a large, prospectively collected database (the FASTER database).
The FASTER trial was a multicenter study that evaluated first- and second-trimester screening programs for aneuploidy in women with singleton pregnancies. As part of this trial, patients had a quad screen drawn at 15-18 6/7 weeks. We analyzed the data to identify associations between the quad screen markers and preterm birth, intrauterine growth restriction, preeclampsia, and fetal loss. Our analysis was performed by evaluating the performance characteristics of quad screen markers individually and in combination. Crude and adjusted effects were estimated by multivariable logistic regression analysis. Patients with fetal anomalies were excluded from the analysis.
We analyzed data from 33,145 pregnancies. We identified numerous associations between the markers and the adverse outcomes. There was a relatively low, but often significant, risk of having an adverse pregnancy complication if a patient had a single abnormal marker. However, the risk of having an adverse outcome increased significantly if a patient had 2 or more abnormal markers. The sensitivity and positive predictive values using combinations of markers is relatively low, although superior to using individual markers.
These data suggest that components of the quad screen may prove useful in predicting adverse obstetric outcomes. We also showed that the total number and specific combinations of abnormal markers are most useful in predicting the risk of adverse perinatal outcome.
Obstetrics and Gynecology 09/2005; 106(2):260-7. · 4.73 Impact Factor
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ABSTRACT: In 2002, the Institute of Medicine called for the introduction of information technologies in health care settings to improve quality of care. We conducted a review of hospital charts of women who delivered before and after the implementation of an intranet-based computerized prenatal record in an inner-city practice. Our objective was to assess whether the use of this record improved communication among the outpatient office, the ultrasonography unit, and the labor floor.
The charts of patients who delivered in August 2002 and August 2003 and received their prenatal care at the Comprehensive Family Care Center at Montefiore Medical Center were analyzed. Data collected included the presence of a copy of the prenatal record in the hospital chart, the date of the last documented prenatal visit, and documentation of any prenatal ultrasonograms performed.
Forty-three charts in each group were available for review. The prenatal chart was absent in 16% of the charts of patients from August 2002 compared with only 2% in August 2003 charts (P < .05). Among charts with prenatal records available, the median length of time between the last documented prenatal visit and delivery was significantly longer for August 2002 patients compared with August 2003 patients (36 compared with 4 days, respectively, P < .001). All patients received prenatal ultrasonograms, but documentation of the ultrasonogram was missing from 16% of the August 2002 charts compared with none of the August 2003 charts (P = .01).
The use of a paperless, hospital intranet-based prenatal chart significantly improves communication among providers.
Obstetrics and Gynecology 04/2005; 105(3):607-12. · 4.73 Impact Factor
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ABSTRACT: The purpose of this study was to compare alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol levels in women who take protease inhibitors and those women who do not.
This retrospective review from August 2000 to May 2003 was performed for maternal serum screen results, medication use, pregnancy, and perinatal outcomes.
Thirty-nine women met study criteria. Sixteen women were treated with protease inhibitors, and 23 women were not treated with protease inhibitors. There was no difference in initial viral load or initial CD4 count between the groups. No difference was found for human chorionic gonadotropin and estriol levels; significantly lower alpha-fetoprotein multiples of the median were found for the women who were treated with protease inhibitors compared with the women who were not (0.97 +/- 0.32 [SD] MoM vs 1.2 +/- 0.4 MoM, respectively; P = .04). Six of 39 women (15%) had positive maternal serum screens. All the babies were normal at birth, and there were no cases of perinatal transmission of human immunodeficiency virus.
Protease inhibitors are associated with lower alpha-fetoprotein levels in women who are infected with human immunodeficiency virus.
American Journal of Obstetrics and Gynecology 10/2004; 191(3):1004-8. · 3.47 Impact Factor
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ABSTRACT: Montefiore Medical Center increased the collections of the Department of Obstetrics & Gynecology and Women's Health by $1.2 million without cutting costs or increasing its charges. Instead, the organization appointed a billing director to take charge of revenue-cycle performance and redesign its billing processes by: Implementing standard processes organizationwide Involving physicians in data collection to ensure accurate claims Collecting copayments at the front end.
Healthcare financial management: journal of the Healthcare Financial Management Association 03/2004; 58(3):82-8.
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ABSTRACT: Objective: To evaluate whether ACOG's patient education pamphlets comply with the recommended readability level for health education materials intended for the general public.
Methods: All 100 English-language pamphlets available during 1997 (created or revised between 1988 and 1997) were evaluated using four standard readability formulas.
Results: Mean readability levels of ACOG's pamphlets were between grade 7.0 to grade 9.3, depending on the formula used. Analysis of readability over the 10 years showed a trend toward lower readability levels. Analysis by category of pamphlet found that the lowest readability levels were in Especially for teens pamphlets.
Conclusion: Our data suggested that most of ACOG's patient education pamphlets currently available are written at a higher readability level than recommended for the general public. The readability of those pamphlets improved in the 10 years since the organization published its first pamphlet, but the goal of sixth-grade readability level has not been reached.
A major component of primary health care for women, including prenatal and preconceptional care, is effective patient education.1 There are many methods of educating patients, but a common strategy is to give women pamphlets produced by reputable organizations that address specific topics to reinforce verbal teaching by health care providers. Many factors influence the effectiveness of written health education materials, including patients' age and education, cultural and linguistic relevance of pamphlets, layout and organization of material, illustrations used, and readability of pamphlets.2 One of the most frequently studied factors is readability, defined as the ease of reading and understanding a document. Readability was shown to be essential in appropriate use of written health educational materials by patients.2
When considering the literacy of their patients, health care providers mistakenly might assume that patient educational attainment correlates with reading ability, which has been studied frequently.2 Davis et al3 found that literacy levels in a sample of adults in primary care settings ranged from fifth to tenth grade, with 60% of patients reading at least three grade levels below their last grade attended. Miller and Bodie4 found that patients read at an average of six grade levels below their last grade completed. Similar results were found by others.5-7 The average reading level of United States citizens is eighth grade, and one in five adults reads at the fifth-grade level or below2; therefore, the general recommendation is that health education materials should be written at sixth-grade reading level to be readable to the widest audience possible.2,8
Readability is evaluated with mathematical formulas that most often measure combinations of frequency of multisyllabic words and sentence length. Certain formulas are more appropriate for specific audiences, such as children, textbook readers, or adults. It is recommended that more than one formula by used to evaluate readability, and that they match the audience intended for the document.9-12 Although different formulas produce slightly different results, Meade and Smith13 showed that results correlate highly with each other. The purpose of this study was to evaluate the readability of ACOG's patient education pamphlets, comparing their readability level with that recommended by health education experts. The last published evaluation of ACOG pamphlets was a decade ago.14
Obstetrics and Gynecology 04/1999; 93(5, Part 1):771-774. · 4.73 Impact Factor
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MARGARET COMERFORD FREDA RN, EdD, CHES, FAAN,
H. FRANK ANDERSEN MD,
PhD KARLA DAMUS RN,
IRWIN R. MERKATZ MD,
MARGARET COMERFORD FREDA,
H. FRANK ANDERSEN,
KARLA DAMUS, IRWIN R. MERKATZ
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ABSTRACT: Objective: To compare client and health-care provider perceptions concerning health topics.Design: A survey conducted at the first prenatal visit asked women to indicate levels of interest in 38 topics. Providers answered the same survey, indicating perceptions of clients' interests.Setting: A prenatal clinic and a private office, both in an inner city area.Participants:Two groups of prenatal clients (n =135 private care and n =250 public care) and their health-care providers (n =32 nurses and physicians).Results:Significant differences were found (p < .01 for four topics, p < .05 for six topics) between the clients' interests and the providers' perceptions. Women in private and public care differed significantly (p < .01) in their levels of interest. Interest was significantly affected by parity, but not maternal education.Conclusions: Nurses and other health professionals should be aware of the range of topics in which clients express interest. This study suggests that site of care and parity should be considered when developing prenatal health education.
Journal of Obstetric Gynecologic & Neonatal Nursing 04/1993; 22(3):237 - 244. · 1.03 Impact Factor
