Quality and Safety Practices Among Academic Obstetrics and Gynecology Departments.

The objective was to quantify resources devoted to quality and patient safety initiatives, to document the development and use of key performance indicator reports regarding patient outcomes and patient feedback, and to assess the culture of safety within academic obstetrics and gynecology departments. Chairs of academic obstetrics and gynecology departments were asked to complete a quality and safety assessment survey. Surveys were distributed to 138 departments, yielding 52 completed responses (37.7%). Five percent of departments reported including a patient representative on a quality committee. Most committee leaders (60.5%) and members (67.4%) received no compensation. Formal training was required in 28.8% of responding departments. Most departments monitored key performance metrics for inpatient outcomes (95.9%). Leaders scored their departments' culture of safety highly. Most departments provided no protected time to faculty devoted to quality efforts, generation of key performance indicators for inpatient activities was prevalent and integrating patient and community input remain unrealized opportunities.

Sequential compression device compliance in pregnant women requiring antepartum admission.

BACKGROUND: A quality improvement study done at the Medical College of Wisconsin between 2014 and 2016 demonstrated that, at baseline, sequential compression devices (SCD) were ordered for 46.0% of admitted antepartum women. In response, provider education and a prechecked SCD order in the electronic antepartum admission order set were implemented. OBJECTIVE: To examine the effect of these interventions on SCD compliance during antepartum admissions. STUDY DESIGN: This was a prospective observational study of antepartum women admitted for nondelivery indication for more than 24 hours, from June 2017 through March 2018, in a single tertiary center. The study was conducted a year after provider education and implementation of a prechecked order for SCD in the electronic antepartum admission order set. Women with an active venous thromboembolism (VTE) and those already receiving pharmacologic thromboprophylaxis were excluded. The primary outcome was the rate of SCD compliance, assessed both among obstetric providers and patients. SCD compliance for providers was defined as SCD order present in patient's electronic medical record and documenting the presence of SCD in patient's room. SCD compliance for patients was defined as documentation that the patient was wearing SCD that were turn on while in bed during morning study rounds. RESULTS: During the study period a total of 182 rounding encounters were documented for 76 women. SCD was ordered in 77.6% (59/76) of the admissions. Out of the 59 electronic orders for SCD, 45 orders (h 76.3%) were placed on hospital day 1 (and 42 orders had confirmation of SCD present in the room (71.2%)). SCD were in active use in 45.2% (19/42) of these women. When evaluating the daily course of the hospitalization (n = 182), SCD were ordered in 86.8% (158/182) of the encounters and present in the room in 72.2% (114/158) of the daily encounters. After excluding 10 women who were ambulatory at the time of rounding (n = 104), SCD were observed being used in 31.7% (33/104) of the nonambulatory women encounters with SCD ordered and present in the room. CONCLUSION: A prechecked antepartum order set for SCD increased the rate of provider compliance with SCD. However, this increase did not result in high patient compliance with SCD among antepartum women requiring admission for longer than 24 hours. CONDENSATION: A prechecked order for SCD did not lead to high SCD compliance among admitted antepartum women.

Building a Program of Expanded Peer Support for the Entire Health Care Team: No One Left Behind.

BACKGROUND: Medical errors can cause second victim syndrome (SVS) in caregivers. Literature describing the development of effective peer support programs is limited. This article describes the implementation of a peer support program for an entire health care system. METHODS: The research team initially trained 52 supporters representing all clinical areas throughout an urban academic quaternary care campus. Each then supported at-risk colleagues, raised awareness of SVS, and recruited others for training. Triggers for peer support expanded to include medical errors, unanticipated patient outcomes, inability to stop the progression of medical conditions, medical emergencies of colleagues, aggressive behavior by a patient/family member, and COVID-19 events. Data reporting supporters' efforts were summarized. After the initial 5-hour session, training was condensed into 2.5 hours. The effectiveness of these training sessions was assessed. The Second Victim Experience and Support Tool (SVEST) was used to assess program effectiveness three and nine months after implementation. RESULTS: By 18 months, a blended program was achieved with 149 supporters: 81 medical college and 68 hospital personnel. Providers received 46.5% of support efforts and hospital personnel 47.9%. The most common event supported was inability to stop the progression of medical conditions (24.5%). Both training sessions improved attendees' knowledge of SVS and improved their comfort with teaching others how to support a second victim. Both SVEST surveys showed that nonwork and supervisor support rated highest, followed by colleague support. Institution support rated lowest. CONCLUSION: The team successfully implemented a peer support program with trained supporters from various clinical disciplines for distressing events beyond medical errors.

Factors associated with recurrent bacterial vaginosis.

OBJECTIVE: To determine whether menstrual abnormalities, multiple personal behaviors and some contraceptive methods, all of which have been described as potential causes of single episodes of bacterial vaginosis (BV), are associated with recurrent bacterial vaginosis (RBV). STUDY DESIGN: This was a retrospective, case-controlled study performed in an urban setting. Women with RBV and matched controls were mailed a survey that included multiple questions about potential risk factors for BV. Four-to-one matching of age groups was performed, with 28 RBV cases matched to 112 controls. RESULTS: Among multiple possible predisposing factors, only African American ethnicity (p < 0.001) and > 1 male sex partner in the previous 2 years (p = 0.007) were strongly associated with RBV. Abnormal uterine bleeding, frequent intercourse without a condom or withdrawal, anal intercourse, menstrual hygiene product use, tub baths, back-to-front wiping after using the toilet, smoking, choice of contraceptive method (including condoms, the combination oral contraceptive, injectable medroxyprogesterone acetate or an intrauterine device) and douching were not associated with RBV. CONCLUSION: Providers should counsel women with RBV to minimize their number of male sex partners. There are few data to support the recommendation of other behavioral changes.

Safety of peripherally inserted central catheters during pregnancy: a retrospective study.

PURPOSE: We investigated the incidence of complications associated with peripherally inserted central line catheters, inserted using a standardized technique, during pregnancy and the postpartum period. MATERIALS AND METHODS: A retrospective case series was performed that included all pregnant and postpartum women who received peripherally inserted central catheters (PICCs) at a single institution between 2006 and 2014. Patient demographics and data on infectious, mechanical and thrombotic complications were collected. Some patients required more than one line insertion during the same pregnancy. In these instances, only the first line placement for each subject was included in the analysis of complications. RESULTS: One hundred and forty-six catheters were inserted in 112 pregnant and postpartum patients. The total incidence of complications was 17% (19/112). Specific complications included infection (n = 4, 3.6%), mechanical (n = 5, 4.4%), deep venous thrombosis (n = 2, 1.8%) and other (n = 8, 7.1%). Demographics of the complication and no complication groups were similar. CONCLUSIONS: In contrast with previous studies, we report a complication rate associated with peripheral line use in pregnant and postpartum women that appears similar to that in non-pregnant populations.

Normal fetus with a twin presenting as both a complete hydatidiform mole and placenta previa.

BACKGROUND: A twin gestation comprising a complete hydatidiform mole and a coexisting normal fetus is a rare and high-risk condition. Only a few such gestations have resulted in live infants. We report a case with a very large molar component presenting as a placenta previa. CASE: A live infant was delivered by cesarean at 31 weeks of gestation. The delivery incorporated prophylactic temporary balloon occlusion of the internal iliac arteries. The patient did not develop persistent gestational trophoblastic disease. CONCLUSION: We recommend that intra-arterial balloon catheters be considered before cesarean delivery in cases of complete hydatidiform mole with a coexisting normal fetus if the molar pregnancy presents as a previa. The size of the molar gestation is not an independent risk factor for persistent or metastatic disease.

Effect of a best-practice alert on the rate of influenza vaccination of pregnant women.

OBJECTIVE: To estimate the effect of a best-practice alert, a reminder within the electronic medical record on the rate of vaccination of pregnant women against influenza. METHODS: Beginning on October 1, 2008, at the Medical College of Wisconsin Obstetrics and Gynecology Clinic, we added a best-practice alert to our electronic prenatal record. The best-practice alert let the health care provider know at each prenatal visit if the patient had not yet either received vaccination against influenza or voiced an informed refusal. We then compared our 2008-2009 vaccination rate with our 2007-2008 rate. If a patient went unvaccinated, we reviewed her record to determine whether a discussion regarding vaccination was held and, if so, the reason she went unvaccinated. RESULTS: Our 2008-2009 vaccination rate exceeded our 2007-2008 rate, 61% compared with 42%, respectively (P<.001; confidence interval [CI] for the difference in proportions 0.14-0.25). Health care providers documented a higher rate of discussions regarding influenza vaccination in 2008-2009 compared with 2007-2008, 89.5% compared with 49.5%, respectively (P<.001, CI for the difference in proportions 0.35-0.45). In 2008-2009, the most common reason for going without vaccination was an informed refusal. In 2007-2008, most of the medical records of unvaccinated women contained no documented discussion. In 2008-2009, 68.1% of the women whose health care providers documented a discussion accepted vaccination. CONCLUSION: Both our rate of vaccination of pregnant women against influenza and the rate of a documented discussion regarding vaccination increased after implementation of the best-practice alert. We recommend that users of electronic medical records add a best-practice alert to improve influenza vaccination rates. LEVEL OF EVIDENCE: II.