Collaborative practice model: Madigan Army Medical Center.

In 2007, Madigan Army Medical Center implemented a new maternity care delivery model, integrating obstetricians and certified nurse-midwives (CNMs) in a collaborative practice. The change was driven by multiple factors, including patient preference, changes in the resident workweek, and low provider satisfaction. This article describes the elements of successful collaboration, including the structure, effective teamwork principles, role of the CNM in resident education, and preliminary data on mode of delivery, the number of CNM-supervised resident births, and procedures, such as episiotomy and epidural use.

On the front lines of patient safety: implementation and evaluation of team training in Iraq.

BACKGROUND: Team training has been identified as a key strategy for reducing medical errors and building a culture of safety in health care. Communication and coordination skills can serve as barriers to potential errors, as in the modern deployed U.S. Military Healthcare System (MHS), which emphasizes rapid movement of critically injured patients to facilities capable of providing definitive care. A team training intervention--TeamSTEPPS--was implemented on a large scale during one of the most intense phases of the conflict in Iraq. This evaluation of the program constituted the first undertaken in a combat theater of operations. IMPLEMENTING TEAMSTEPPS IN IRAQ: The Baghdad combat support hospital (CSH) conducted continuous operations from a fixed facility for a 13-month deployment--between November 2007 and December 2008. The TeamSTEPPS implementation in Iraq began at this facility and spread throughout the combat theater of operations. Teamwork training was implemented in two primary training sessions, followed up with reinforcement of team behaviors on the unit by hospital leadership. RESULTS: A total of 153 patient safety reports were submitted during the 13 months reviewed, 94 before TeamSTEPPS implementation and 59 afterwards. After training, there were significant decreases in the rates of communication-related errors, medication and transfusion errors, and needlestick incidents. There was a significant decrease in the rate of incidents coded communication as the primary teamwork skill that could have potentially prevented the event. CONCLUSIONS: Process improvement programs such as TeamSTEPPS implementation can be conducted under the extremely austere conditions of a CSH in a combat zone. Teamwork training decreased medical errors in the CSH while deployed in the combat theater in Iraq.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility.

OBJECTIVE: To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse. METHODS: We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patient's spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status. RESULTS: A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28-32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006). CONCLUSION: Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population. LEVEL OF EVIDENCE: II.

The effect of membrane sweeping on prelabor rupture of membranes: a randomized controlled trial.

OBJECTIVE: To estimate if membrane sweeping increases the rate of prelabor rupture of membranes. METHODS: This randomized trial of term, uncomplicated pregnancies included 300 patients. Patients were randomly assigned into sweep or no-sweep groups, with patients and delivering providers blinded to group allocation. Only the examining provider in the clinic was unblinded to group allocation. Membranes were then swept or not swept at each weekly visit from 38 weeks of gestation onward, depending on the randomization. Data collected included parity, cervix examination at each visit, estimated gestational age at delivery, rupture of membranes, and maternal or fetal complications. RESULTS: A total of 162 patients were randomly assigned to the membrane sweep group and 138 to the no-sweep group. There was no difference in baseline characteristics or obstetric and neonatal outcomes between the groups. The average gestational age at delivery and induction rate were not different. The overall prelabor rupture of membranes rate was not significantly higher in the membrane sweep group (12% compared with 7%) (P=.19); however, patients with a cervix more than 1 cm dilated at time of membrane sweeping were more likely to have prelabor rupture of membranes if they were in the membrane sweep group (9.1% compared with 0%; relative risk 1.10, 95% confidence interval 1.03-1.18). CONCLUSION: No benefit in gestational age at delivery or reduction of postmaturity occurred from membrane sweeping. Although the overall prelabor rupture of membranes rates were similar, patients with membrane sweeping occurring at more than 1 cm cervical dilation may be at increased risk of prelabor rupture of membranes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00294242. LEVEL OF EVIDENCE: I.