Improving communication and teamwork during labor: A feasibility, acceptability, and safety study.

BACKGROUND: TeamBirth was designed to promote best practices in shared decision making (SDM) among care teams for people giving birth. Although leading health organizations recommend SDM to address gaps in quality of care, these recommendations are not consistently implemented in labor and delivery. METHODS: We conducted a mixed-methods trial of TeamBirth among eligible laboring patients and all clinicians (nurses, midwives, and obstetricians) at four high-volume hospitals during April 2018 to September 2019. We used patient and clinician surveys, abstracted clinical data, and administrative claims to evaluate the feasibility, acceptability, and safety of TeamBirth. RESULTS: A total of 2,669 patients (approximately 28% of eligible delivery volume) and 375 clinicians (78% response rate) responded to surveys on their experiences with TeamBirth. Among patients surveyed, 89% reported experiencing at least one structured full care team conversation ("huddle") during labor and 77% reported experiencing multiple huddles. There was a significant relationship between the number of reported huddles and patient acceptability (P < 0.001), suggestive of a dose response. Among clinicians surveyed, 90% would recommend TeamBirth for use in other labor and delivery units. There were no significant changes in maternal and newborn safety measures. CONCLUSIONS: Implementing a care process that aims to improve communication and teamwork during labor with high fidelity is feasible. The process is acceptable to patients and clinicians and shows no negative effects on patient safety. Future work should evaluate the effectiveness of TeamBirth in improving care experience and health outcomes.

The design of "TeamBirth": A care process to improve communication and teamwork during labor.

BACKGROUND: Despite evidence that communication and teamwork are critical to patient safety, few care processes have been intentionally designed for this purpose in labor and delivery. The purpose of this project was to design an intrapartum care process that aims to improve communication and teamwork between clinicians and patients. METHODS: We followed the "Double-Diamond" design method with four sequential steps: Discover, Define, Develop, and Deliver. In Discover, we searched professional guidelines and peer-reviewed literature to delineate the challenges to quality of intrapartum care and to uncover options for solutions. In Define, we convened an interdisciplinary group of experts to focus the problem scope and prioritize solution features. In Develop, we created initial prototype solutions. In Deliver, we engaged clinicians and patients in rapid cycle testing to iteratively produce a care process called "TeamBirth" that aims to improve team communication. RESULTS: We designed TeamBirth, an intrapartum care process composed of brief team meetings ("huddles") between clinicians and patients. Huddles are navigated by a shared planning board placed in the labor and delivery room in view of the patient and their care team. The board promotes transparent and reliable communication and contains four areas to be acknowledged or discussed: (a) the names of the team members, starting with the patient; (b) the patient's preferences; (c) the care plan for the patient, baby, and labor progress; and (d) when the next team huddle is anticipated. DISCUSSION: We identified an opportunity to improve the safety and dignity of childbirth care through an intrapartum care process that promotes reliable and structured communication and teamwork. Future work should evaluate the acceptability and feasibility of implementation and potential impact on safety and experience of care.

Cesarean Delivery Rates and Costs of Childbirth in a State Medicaid Program After Implementation of a Blended Payment Policy.

BACKGROUND: Nearly half of US births are financed by Medicaid, and one-third of births occur by cesarean delivery, at double the cost of vaginal delivery. With the goal of reducing unnecessary cesarean use and improving value, in 2009 Minnesota's Medicaid program introduced a blended payment rate for uncomplicated births (ie, a single facility or professional services payment regardless of delivery mode). OBJECTIVE: We evaluated the effect of the blended payment policy on cesarean use and costs for Medicaid fee-for-service births. METHODS: We identified births in Medicaid Analytic Extract files from 3 years before and after the 2009 payment change in Minnesota and in 6 control states. We used a quarterly interrupted time series approach to assess policy-related changes in study outcomes, comparing Minnesota to control states. Outcomes included cesarean delivery, childbirth hospitalization costs, and maternal morbidity. RESULTS: Minnesota's prepolicy cesarean rate (22.8%) decreased 0.27 percentage points per quarter after the policy for a total decrease of 3.24 percentage points, compared with control states (P=0.01). The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time of the policy. Postpolicy, childbirth hospitalization costs continued to decrease in Minnesota relative to prepolicy by $95.04 per quarter, and declined more than control states (P<0.001). There were no significant policy effects on maternal morbidity. CONCLUSIONS: Implementation of a single, blended payment to facilities and clinicians for uncomplicated births mitigated trends toward greater use of cesarean and rising costs of childbirth hospitalization, without adverse effects on maternal morbidity.

Surgical Education and Health Care Reform: Defining the Role and Value of Trainees in an Evolving Medical Landscape.

OBJECTIVE: Health care reform and surgical education are often separated functionally. However, especially in surgery, where resident trainees often spend twice as much time in residency and fellowship than in undergraduate medical education, one must consider their contributions to health care. SUMMARY BACKGROUND DATA: In this short commentary, we briefly review the status of health care in the United States as well as some of the recent and current changes in graduate medical education that pertain to surgical trainees. METHODS: This is a perspective piece that draws on the interests and varied background of the multiinstitutional and international group of authors. RESULTS: The authors propose 3 main areas of focus for research and practice- (1) accurately quantifying the care provided currently by trainees, (2) determining impact to trainees and hospital systems of training parameters, focusing on long-term outcomes rather than short-term outcomes, and (3) determining practice models of education that work best for both health care delivery and trainees. CONCLUSIONS: The authors propose that surgical education must align itself with rather than separate itself from overall health care reform measures and even individual hospital financial pressures. This should not be seen as additional burden of service, but rather practical education in training as to the pressures trainees will face as future employees. Rethinking the contributions and training of residents and fellows may also synergistically work to impress to hospital administrators that providing better, more focused and applicable education to residents and fellows may have long-term, strategic, positive impacts on institutions.

The role and interaction of imprinted genes in human fetal growth.

Identifying the genetic input for fetal growth will help to understand common, serious complications of pregnancy such as fetal growth restriction. Genomic imprinting is an epigenetic process that silences one parental allele, resulting in monoallelic expression. Imprinted genes are important in mammalian fetal growth and development. Evidence has emerged showing that genes that are paternally expressed promote fetal growth, whereas maternally expressed genes suppress growth. We have assessed whether the expression levels of key imprinted genes correlate with fetal growth parameters during pregnancy, either early in gestation, using chorionic villus samples (CVS), or in term placenta. We have found that the expression of paternally expressing insulin-like growth factor 2 (IGF2), its receptor IGF2R, and the IGF2/IGF1R ratio in CVS tissues significantly correlate with crown-rump length and birthweight, whereas term placenta expression shows no correlation. For the maternally expressing pleckstrin homology-like domain family A, member 2 (PHLDA2), there is no correlation early in pregnancy in CVS but a highly significant negative relationship in term placenta. Analysis of the control of imprinted expression of PHLDA2 gave rise to a maternally and compounded grand-maternally controlled genetic effect with a birthweight increase of 93/155 g, respectively, when one copy of the PHLDA2 promoter variant is inherited. Expression of the growth factor receptor-bound protein 10 (GRB10) in term placenta is significantly negatively correlated with head circumference. Analysis of the paternally expressing delta-like 1 homologue (DLK1) shows that the paternal transmission of type 1 diabetes protective G allele of rs941576 single nucleotide polymorphism (SNP) results in significantly reduced birth weight (-132 g). In conclusion, we have found that the expression of key imprinted genes show a strong correlation with fetal growth and that for both genetic and genomics data analyses, it is important not to overlook parent-of-origin effects.

Clinical leadership development in postgraduate medical education and training: policy, strategy, and delivery in the UK National Health Service.

Achieving high quality health care against a background of continual change, increasing demand, and shrinking financial resource is a major challenge. However, there is significant international evidence that when clinicians use their voices and values to engage with system delivery, operational efficiency and care outcomes are improved. In the UK National Health Service, the traditional divide between doctors and managers is being bridged, as clinical leadership is now foregrounded as an important organizational priority. There are 60,000 doctors in postgraduate training (junior doctors) in the UK who provide the majority of front-line patient care and form an "operating core" of most health care organizations. This group of doctors is therefore seen as an important resource in initiating, championing, and delivering improvement in the quality of patient care. This paper provides a brief overview of leadership theories and constructs that have been used to develop a raft of interventions to develop leadership capability among junior doctors. We explore some of the approaches used, including competency frameworks, talent management, shared learning, clinical fellowships, and quality improvement. A new paradigm is identified as necessary to make a difference at a local level, which moves learning and leadership away from developing "leaders", to a more inclusive model of developing relationships between individuals within organizations. This shifts the emphasis from the development of a "heroic" individual leader to a more distributed model, where organizations are "leader-ful" and not just "well led" and leadership is centered on a shared vision owned by whole teams working on the frontline.

Paternally expressed, imprinted insulin-like growth factor-2 in chorionic villi correlates significantly with birth weight.

CONTEXT: Fetal growth involves highly complex molecular pathways. IGF2 is a key paternally expressed growth hormone that is critical for in utero growth in mice. Its role in human fetal growth has remained ambiguous, as it has only been studied in term tissues. Conversely the maternally expressed growth suppressor, PHLDA2, has a significant negative correlation between its term placental expression and birth weight. OBJECTIVE: The aim of this study is to address the role in early gestation of expression of IGF1, IGF2, their receptors IGF1R and IGF2R, and PHLDA2 on term birth weight. DESIGN: Real-time quantitative PCR was used to investigate mRNA expression of IGF1, IGF2, IGF1R, IGF2R and PHLDA2 in chorionic villus samples (CVS) (n = 260) collected at 11-13 weeks' gestation. Expression was correlated with term birth weight using statistical package R including correction for several confounding factors. RESULTS: Transcript levels of IGF2 and IGF2R revealed a significant positive correlation with birth weight (0.009 and 0.04, respectively). No effect was observed for IGF1, IGF1R or PHLDA2 and birth weight. Critically, small for gestational age (SGA) neonates had significantly lower IGF2 levels than appropriate for gestational age neonates (p = 3.6 × 10(-7)). INTERPRETATION: Our findings show that IGF2 mRNA levels at 12 weeks gestation could provide a useful predictor of future fetal growth to term, potentially predicting SGA babies. SGA babies are known to be at a higher risk for type 2 diabetes. This research reveals an imprinted, parentally driven rheostat for in utero growth.

Case report of tc-99m sulfur colloid single-photon emission computed tomography/computed tomography study differentiating tumor from accessory spleen.

We present a case report where Tc-99m sulfur colloid single-photon emission computed tomography (SPECT)/computed tomography (CT) scan was useful in characterizing a soft tissue abdominal mass and helped with patient management. A 63-year-old male with no previous history of trauma had an incidental finding of a soft tissue nodule adjacent to the splenic hilum, unchanged in size over 4 months and with similar enhancing features as the spleen. A Tc-99m sulfur colloid SPECT/CT scan was performed to determine the nature of the nodule. It showed no uptake of tracer within this mass, therefore excluding splenic tissue. This prompted subsequent investigations and this tissue was found to represent a pancreatic neuroendocrine tumor, which was excised.

Using prescribing indicators to measure the quality of prescribing to elderly medical in-patients.

OBJECTIVES: to evaluate the performance of hospitals using eight indicators designed to assess prescribing practice in medical in-patients aged > or =65 years. DESIGN: local coalition teams were invited to collect cross-sectional prescribing and clinical data on 100 consecutive medical in-patients aged > or =65 years during a specific week in April 1999. SETTING: 102 hospitals across England. PARTICIPANTS: all NHS Trust hospitals in Wales and England were invited to participate in the study. MAIN OUTCOME MEASURES: the performance and inter-hospital variation of hospitals in eight indicators of prescribing. Also, the age-related appropriate use of anti-thrombotic stroke prophylaxis in atrial fibrillation, of aspirin in angina and of benzodiazepines. RESULTS: data were collected on 9,979 patients prescribed 70,458 medications. The number of hospitals achieving the prescribing goal for the indicators varied between 0 and 70. Frequency of administration instructions with 'as required' prescriptions were documented on 60% (10,403/17,258) of occasions. Generic (or acceptable proprietary) names were used for 84% (58,953/70,458) medications, 50% (4,870/9,778) of patients had documentation of allergy status on the drug chart and 23% (1,380/6,060) of patients had the potential risk of exceeding the maximum recommended dosage (4 g/24 h) of paracetamol. Long-acting hypoglycaemic drugs were prescribed to 50 patients. Anti-thrombotic stroke prophylaxis in atrial fibrillation were used appropriately for 53% (805/1,518) of patients, aspirin was used appropriately in angina for 90% (952/1,052) of patients and benzodiazepines were used appropriately for 49% (824/1,689) of patients. For the latter three indicators, the appropriate use of medications declined from 60% to 44%, 95% to 85% and 53% to 44% in patients aged >/=85 years compared with those aged 65-74 years. CONCLUSIONS: prescribing indicators were effective in evaluating the performance of 102 hospitals on prescribing practice to medical in-patients aged >/=65 years. Prescribing to elderly medical in-patients is sub-optimal but targets were achieved by some hospitals. This should inspire those hospitals not achieving high standards to improve their performance. The higher level of inappropriate prescribing with increasing age is unacceptable.