Implementation of an electronic genomic and family health history tool in primary prenatal care.

"The Pregnancy and Health Profile," (PHP) is a free genetic risk assessment software tool for primary prenatal providers that collects patient-entered family (FHH), personal, and obstetrical health history, performs risk assessment, and presents the provider with clinical decision support during the prenatal encounter. The tool is freely available for download at www.hughesriskapps.net. We evaluated the implementation of PHP in four geographically diverse clinical sites. Retrospective chart reviews were conducted for patients seen prior to the study period and for patients who used the PHP to collect data on documentation of FHH, discussion of cystic fibrosis (CF) and hemoglobinopathy (HB) carrier screening, and CF and HB interventions (tests, referrals). Five hundred pre-implementation phase and 618 implementation phase charts were reviewed. Documentation of a 3-generation FHH or pedigree improved at three sites; patient race/ethnicity at three sites, father of the baby (FOB) race/ethnicity at all sites, and ancestry for the patient and FOB at three sites (P < 0.001-0001). CF counseling improved for implementation phase patients at one site (8% vs. 48%, P < 0.0001) and CF screening/referrals at two (2% vs. 14%, P < 0.0001; 6% vs. 14%; P = 0.05). Counseling and intervention rates did not increase for HB. This preliminary study suggests that the PHP can improve documentation of FHH, race, and ancestry, as well as the compliance with current CF counseling and intervention guidelines in some prenatal clinics. Future evaluation of the PHP should include testing in a larger number of clinical environments, assessment of additional performance measures, and evaluation of the system's overall clinical utility.

Evaluation of a novel electronic genetic screening and clinical decision support tool in prenatal clinical settings.

"The Pregnancy and Health Profile" (PHP) is a free prenatal genetic screening and clinical decision support (CDS) software tool for prenatal providers. PHP collects family health history (FHH) during intake and provides point-of-care risk assessment for providers and education for patients. This pilot study evaluated patient and provider responses to PHP and effects of using PHP in practice. PHP was implemented in four clinics. Surveys assessed provider confidence and knowledge and patient and provider satisfaction with PHP. Data on the implementation process were obtained through semi-structured interviews with administrators. Quantitative survey data were analyzed using Chi square test, Fisher's exact test, paired t tests, and multivariate logistic regression. Open-ended survey questions and interviews were analyzed using qualitative thematic analysis. Of the 83% (513/618) of patients that provided feedback, 97% felt PHP was easy to use and 98% easy to understand. Thirty percent (21/71) of participating physicians completed both pre- and post-implementation feedback surveys [13 obstetricians (OBs) and 8 family medicine physicians (FPs)]. Confidence in managing genetic risks significantly improved for OBs on 2/6 measures (p values ≤0.001) but not for FPs. Physician knowledge did not significantly change. Providers reported value in added patient engagement and reported mixed feedback about the CDS report. We identified key steps, resources, and staff support required to implement PHP in a clinical setting. To our knowledge, this study is the first to report on the integration of patient-completed, electronically captured and CDS-enabled FHH software into primary prenatal practice. PHP is acceptable to patients and providers. Key to successful implementation in the future will be customization options and interoperability with electronic health records.

Resident training for eclampsia and magnesium toxicity management: simulation or traditional lecture?

OBJECTIVE: To compare eclampsia and magnesium toxicity management among residents randomly assigned to lecture or simulation-based education. STUDY DESIGN: 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. RESULTS: 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). CONCLUSION: 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.

A Low-Cost Trainer for the Surgical Management of Postpartum Hemorrhage.

INTRODUCTION: Simulation-based training to manage surgical postpartum hemorrhage allows for improved preparation for these rarely needed life-saving procedures. Our objectives were to design a low-tech simulation model for use in training and evaluation of surgical techniques for the management of postpartum hemorrhage and to present evidence of its validity in assessment and training. METHODS: Fifty-two obstetrics and gynecology residents and 25 attending physicians from an academic hospital were video recorded while performing the O'Leary and B-Lynch techniques on the low-tech model. Performance was evaluated using a Technical Skills Checklist, for B-Lynch and O'Leary techniques, and the Reznick's Global Rating Scale. Interrater reliability was computed to assess the consistency of the ratings between 2 raters. Average scores were determined and compared between incoming residents, junior residents, senior residents, and attending physicians to show construct validity. RESULTS: For the B-Lynch, Technical Skills Checklist scores (maximum 17 points) of attendings (15.04) and senior residents (15.12) were higher than those of junior residents (5.63) and new residents (3.38). Global Rating Scale scores (maximum 25 points) on the B-Lynch reflected the same increase (22.38, 19.35 vs. 8.85, 6.75, respectively). For the O'Leary stitch, the scores of attendings, senior, junior, and incoming residents were as follows: 15.20, 13.65, 11.54, and 2.83, respectively (maximum 19 points). This supports the construct validity of the model. The model was considered realistic and useful for improving surgical skills in 71.4% of participants. CONCLUSIONS: This low-cost, easily constructed model is a useful tool for training these surgical skills.

Improving shoulder dystocia management among resident and attending physicians using simulations.

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSION: 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.

Does a surgical simulator improve resident operative performance of laparoscopic tubal ligation?

OBJECTIVE: The purpose of this study was to assess whether a surgical skills simulator laboratory improves resident knowledge and operative performance of laparoscopic tubal ligation. STUDY DESIGN: Twenty postgraduate year 1 residents were assigned randomly to either a surgical simulator laboratory on laparoscopic tubal ligation together with apprenticeship teaching in the operating room or to apprenticeship teaching alone. Tests that were given before and after the training assessed basic knowledge. Attending physicians who were blinded to resident randomization status evaluated postgraduate year 1 performance on a laparoscopic tubal ligation in the operating room with 3 validated tools: a task-specific checklist, global rating scale, and pass/fail grade. RESULTS: Postgraduate year 1 residents who were assigned randomly to the surgical simulator laboratory performed significantly better than control subjects on all 3 surgical assessment tools (the checklist, the global score, and the pass/fail analysis) and scored significantly better on the knowledge posttest (all P < .0005). CONCLUSION: Compared with apprenticeship teaching alone, a surgical simulator laboratory on laparoscopic tubal ligation improved resident knowledge and performance in the operating room.

A surgical skills laboratory improves residents' knowledge and performance of episiotomy repair.

OBJECTIVE: This study was undertaken to assess whether a surgical skills laboratory improves residents' knowledge and performance of episiotomy repair. STUDY DESIGN: Twenty-four first- and second-year residents were randomly assigned to either a surgical skills laboratory on episiotomy repair or traditional teaching alone. Pre- and posttests assessed basic knowledge. Blinded attending physicians assessed performance, evaluating residents on second-degree laceration/episiotomy repairs in the clinical setting with 3 validated tools: a task-specific checklist, global rating scale, and a pass-fail grade. RESULTS: Postgraduate year 1 (PGY-1) residents participating in the laboratory scored significantly better on all 3 surgical assessment tools: the checklist, the global score, and the pass/fail analysis. All the residents who had the teaching laboratory demonstrated significant improvements on knowledge and the skills checklist. PGY-2 residents did not benefit as much as PGY-1 residents. CONCLUSION: A surgical skills laboratory improved residents' knowledge and performance in the clinical setting. Improvement was greatest for PGY-1 residents.