Impact of implementation of the Maternal-Fetal Triage Index on patients presenting with severe hypertension.

BACKGROUND: Severe hypertension remains one of the leading preventable causes of maternal mortality in the United States. Timeliness to response to severe hypertension in pregnancy is a crucial quality indicator tracked by state and national organizations. We hypothesized that the implementation of the Maternal-Fetal Triage Index, a validated acuity tool, would improve care performance in women with severe hypertension in an urban, inner-city hospital setting. OBJECTIVE: This study aimed to assess the impact of the Maternal-Fetal Triage Index on the management of women presenting with severe preeclampsia diagnosed by severe hypertension as measured by time to provider assessment, administration of magnesium sulfate, and immediate administration of acute antihypertensives. STUDY DESIGN: This was a prospective, observational study of pregnant women presenting to the labor and delivery triage unit with severe preeclampsia diagnosed by severe hypertension giving birth at a large urban inner-city academic facility before (epoch 1: January 1, 2019, to December 31, 2019) and after (epoch 2: March 1, 2021, to September 31, 2021) the implementation of the Maternal-Fetal Triage Index. Baseline outcomes of time to assessment, time to magnesium sulfate prophylaxis, and time to antihypertensive medication administration before the implementation of the Maternal-Fetal Triage Index were assessed. The Maternal-Fetal Triage Index tool was implemented on March 1, 2021, following standardized education in 2020 for all triage nurses, unit technicians, healthcare unit coordinators, and healthcare providers. Time to assessment, administration of magnesium sulfate prophylaxis, and time to antihypertensive administration after the implementation of the Maternal-Fetal Triage Index were compared with measures before the implementation of the Maternal-Fetal Triage Index. Statistical analysis included Wilcoxon rank-sum test with P<.05 considered significant when comparing epoch 1 with epoch 2. RESULTS: A total of 370 patients were admitted with severe hypertension in 2019 before the use of the Maternal-Fetal Triage Index, and 254 patients were admitted with severe hypertension in 2021 after the implementation of the Maternal-Fetal Triage Index. There was no difference between epochs across baseline characteristics, including age, race and ethnicity, parity, and body mass index. After the Maternal-Fetal Triage Index was implemented, the time to provider assessment was significantly improved, from a median time of 44 minutes (interquartile range, 0-65) in epoch 1 to 17 minutes (interquartile range, 0-39) in epoch 2 (P<.001). Furthermore, the time from arrival to magnesium sulfate prophylaxis was significantly faster with a median time of 161 minutes (interquartile range, 109-256) in epoch 1 vs 127 minutes (interquartile range, 85-258) in epoch 2 (P=.001). Moreover, there was a decrease in the time from arrival to antihypertensive medication administration for severe blood pressures after the implementation of the Maternal-Fetal Triage Index (101 minutes [interquartile range, 61-177] vs 66 minutes [interquartile range, 35-203]; P<.001). CONCLUSION: The implementation of the Maternal-Fetal Triage Index at a large urban inner-city hospital was associated with improved timeliness of assessment and treatment of women with severe hypertension. The Maternal-Fetal Triage Index is a viable tool to improve the efficiency in triage units, specifically in the management of severe hypertension.

Episiotomy: Evolution of a Common Obstetric Practice at a Public Hospital.

OBJECTIVE: This study aimed to evaluate the rate and impact of episiotomy on maternal and newborn outcomes before and after restricted use of episiotomy. STUDY DESIGN: This population-based observational study used an obstetric database of all deliveries since 1990 that has been maintained with quality checks. Inclusion criteria were vaginal deliveries at ≥37 weeks. Exclusion criteria included fetal malformations, multifetal gestations, or fetal deaths known on arrival to Labor and Delivery. The primary outcomes of interest were episiotomy, perineal lacerations, and newborn outcomes. To evaluate the impact of restrictive episiotomy, data from 1990 to 1997 (35% overall episiotomy rate) were compared with data from 2010 to 2017 (2.5% overall episiotomy rate). Univariable analysis of maternal and infant outcomes were performed comparing the two-time epochs with the Pearson's Chi-squared test. RESULTS: Overall, 268,415 women met inclusion criteria and 49,089 (18.2%) had an episiotomy. The rate of episiotomy decreased from 37% of deliveries in 1990 to 2% in 2017. A total of 82,082 deliveries occurred in the 1990 to 1997 epoch and 57,183 in 2010 to 2017. Indicated use of episiotomy was associated with a significant decrease in third and fourth degree lacerations. Immediate newborn condition (5-minute Apgar's score ≤3 and umbilical artery pH <7.1) and neonatal outcomes (intraventricular hemorrhage [IVH] grade 3/4, positive culture sepsis, neonatal seizures, and neonatal demise) were not significantly different. CONCLUSION: Selective, indicated use of episiotomy compared with routine was associated with lower rates of third/fourth-degree lacerations with no change in neonatal outcomes. The common obstetric practice of routinely performing episiotomy, presumably to prevent perineal trauma, proved untrue when analyzed over almost three decades. KEY POINTS: · Episiotomy use decreased overtime at our institution.. · Decreased episiotomy use was associated with significant improvement in maternal outcomes.. · Neonatal outcomes were unchanged suggesting no deleterious effects with restricted episiotomy..

Synchronization transitions in a hyperchaotic SQUID trimer.

The phenomena of intermittent and complete synchronization between two out of three identical, magnetically coupled Superconducting QUantum Interference Devices (SQUIDs) are investigated numerically. SQUIDs are highly nonlinear superconducting oscillators/devices that exhibit strong resonant and tunable response to applied magnetic field(s). Single SQUIDs and SQUID arrays are technologically important solid-state devices, and they also serve as a testbed for exploring numerous complex dynamical phenomena. In SQUID oligomers, the dynamic complexity increases considerably with the number of SQUIDs. The SQUID trimer, considered here in a linear geometrical configuration using a realistic model with experimentally accessible control parameters, exhibits chaotic and hyperchaotic behavior in wide parameter regions. Complete chaos synchronization as well as intermittent chaos synchronization between two SQUIDs of the trimer is identified and characterized using the complete Lyapunov spectrum of the system and appropriate measures. The passage from complete to intermittent synchronization seems to be related to chaos-hyperchaos transitions as has been conjectured in the early days of chaos synchronization.

Does simulation improve clinical performance in management of postpartum hemorrhage?

BACKGROUND: Although simulation is now widely used to improve teamwork and communication, data demonstrating improvement in clinical outcomes are limited. OBJECTIVE: This study aimed to examine the clinical performance and outcomes associated with postpartum hemorrhage because of uterine atony following the implementation of a multidisciplinary simulation program. STUDY DESIGN: This was a prospective observational study of response to postpartum hemorrhage because of uterine atony in an academic medical center before (epoch 1: July 2017-June 2018) and after (epoch 2: July 2019-June 2020) implementing a multidisciplinary simulation program. A total of 22 postpartum hemorrhage simulations were performed from July 2018 to June 2019 involving more than 300 nursing, obstetrical, and anesthesia providers. The simulation program focused on managing postpartum hemorrhage events and improving teamwork and communication of the multidisciplinary teams. To evaluate the clinical effectiveness of the simulation program, the primary outcome was response to postpartum hemorrhage defined as the time from the administration of uterotonic medications to transfusion of the first unit of blood in the first 12 hours following delivery, comparing epoch 2 to epoch 1 following the implementation of a simulation program. Statistical analysis included the use of the Pearson chi-square test, Wilcoxon rank-sum test, Hodges-Lehmann statistic for differences, and bootstrap methods with a P value of <.05 considered significant. RESULTS: Between July 1, 2017, and June 30, 2018, there were 12,305 patients who delivered, of which 495 patients (4%) required transfusion. Between July 1, 2019, and June 30, 2020, there were 12,414 patients who delivered, of which 480 patients (4%) required transfusion. When isolating cases of postpartum hemorrhage because of uterine atony in both transfused groups, there were 157 women in the presimulation group (epoch 1) and 165 women in the postsimulation group (epoch 2), respectively. There was no difference in age, race, parity, or perinatal outcomes between the 2 epochs. Women in epoch 2 began receiving blood products significantly earlier in the first 12 hours following delivery compared with women in epoch 1 (51 [range, 28-125] minutes vs 102 [range, 32-320] minutes; P=.005). In addition, there was a significantly decreased variation in the time from the administration of uterotonic medications to transfusion of blood in epoch 2 (P=.035). Furthermore, women in epoch 2 had significantly lower estimated blood loss than women in epoch 1 (1250 [range, 1000-1750] mL vs 1500 [range, 1000-2000] mL; P=.032). CONCLUSION: The implementation of a multidisciplinary simulation program at a large academic center focusing on the management of postpartum hemorrhage was associated with an improved clinical response. Specifically, there were significantly faster times from the administration of uterotonic medications to transfusion of blood, decreased variance in the time from the administration of uterotonic medications to transfusion of blood, and lower estimated blood loss following the implementation of a simulation program. Because delay in treatment is a major cause of preventable maternal death in obstetrical hemorrhage, the results in our study provided clinical evidence that a simulation program may improve patient outcomes in such emergencies.

How personality affects teamwork: a study in multidisciplinary obstetrical simulation.

BACKGROUND: Multidisciplinary simulation has been shown to improve teamwork in the obstetrical literature by providing a safe, but realistic, environment for participants to learn. However, the impact of team members' personality traits on how the team performs during an obstetrical emergency has not been studied in medicine. OBJECTIVE: Our objective was to evaluate teamwork and communication of simulation participants in association with personality traits within a multidisciplinary obstetrical simulation program. STUDY DESIGN: This was a prospective observational study of postpartum hemorrhage simulations involving participants from Obstetrics, Nursing, Midwifery, and Anesthesia. Before simulation, individual personality testing was performed on participants using the Big Five Inventory. Each team was scored using the Clinical Teamwork Scale after simulation. Communication and teamwork scores were evaluated for association, and personality traits were analyzed for association with teamwork and communication. For each personality trait, an interaction model was tested for 3 of the team scores: teamwork, communication, and situational awareness. Analysis of variance with 2 level interactions was used in this effort. RESULTS: From July 2018 to June 2019, 22 obstetrical simulations were performed with a total of 270 staff. Overall, teamwork was significantly associated with communication for each team. When examining individual personality scores, neuroticism was negatively associated with teamwork when coupled with communication. That is, increased neuroticism was significantly associated with increased communication that was detrimental to the overall teamwork. Other personality traits were not significantly associated with teamwork and communication (P=.03). CONCLUSION: In a multidisciplinary simulation, communication was positively associated with teamwork, and specific personality traits negatively affected team performance.

Multi-branched resonances, chaos through quasiperiodicity, and asymmetric states in a superconducting dimer.

A system of two identical superconducting quantum interference devices (SQUIDs) symmetrically coupled through their mutual inductance and driven by a sinusoidal field is investigated numerically with respect to dynamical properties such as its multibranched resonance curve, its bifurcation structure and transition to chaos as well as its synchronization behavior. The SQUID dimer is found to exhibit a hysteretic resonance curve with a bubble connected to it through Neimark-Sacker (torus) bifurcations, along with coexisting chaotic branches in their vicinity. Interestingly, the transition of the SQUID dimer to chaos occurs through a torus-doubling cascade of a two-dimensional torus (quasiperiodicity-to-chaos transition). Periodic, quasiperiodic, and chaotic states are identified through the calculated Lyapunov spectrum and illustrated using Lyapunov charts on the parameter plane of the coupling strength and the frequency of the driving field. The basins of attraction for chaotic and non-chaotic states are determined. Bifurcation diagrams are constructed on the parameter plane of the coupling strength and the frequency of the driving field, and they are superposed to maps of the three largest Lyapunov exponents on the same plane. Furthermore, the route of the system to chaos through torus-doubling bifurcations and the emergence of Hénon-like chaotic attractors are demonstrated in stroboscopic diagrams obtained with varying driving frequency. Moreover, asymmetric states that resemble localized synchronization have been detected using the correlation function between the fluxes threading the loop of the SQUIDs.

Turbulent chimeras in large semiconductor laser arrays.

Semiconductor laser arrays have been investigated experimentally and theoretically from the viewpoint of temporal and spatial coherence for the past forty years. In this work, we are focusing on a rather novel complex collective behavior, namely chimera states, where synchronized clusters of emitters coexist with unsynchronized ones. For the first time, we find such states exist in large diode arrays based on quantum well gain media with nearest-neighbor interactions. The crucial parameters are the evanescent coupling strength and the relative optical frequency detuning between the emitters of the array. By employing a recently proposed figure of merit for classifying chimera states, we provide quantitative and qualitative evidence for the observed dynamics. The corresponding chimeras are identified as turbulent according to the irregular temporal behavior of the classification measure.

Multiclustered chimeras in large semiconductor laser arrays with nonlocal interactions.

The dynamics of a large array of coupled semiconductor lasers is studied numerically for a nonlocal coupling scheme. Our focus is on chimera states, a self-organized spatiotemporal pattern of coexisting coherence and incoherence. In laser systems, such states have been previously found for global and nearest-neighbor coupling, mainly in small networks. The technological advantage of large arrays has motivated us to study a system of 200 nonlocally coupled lasers with respect to the emerging collective dynamics. Moreover, the nonlocal nature of the coupling allows us to obtain robust chimera states with multiple (in)coherent domains. The crucial parameters are the coupling strength, the coupling phase and the range of the nonlocal interaction. We find that multiclustered chimera states exist in a wide region of the parameter space and we provide quantitative characterization for the obtained spatiotemporal patterns. By proposing two different experimental setups for the realization of the nonlocal coupling scheme, we are confident that our results can be confirmed in the laboratory.

Functional and anatomic comparison of 2 versus 3 suture placement for uterosacral ligament suspension: a cadaver study.

OBJECTIVE: The objective of the study was to compare the vaginal apex pullout distance using 2 vs 3 suspension sutures during transvaginal uterosacral ligament suspension (USLS) and to describe relationships to ipsilateral ureter and nerve structures. STUDY DESIGN: Eight fresh-frozen female cadavers were studied. After hysterectomy, a transvaginal USLS was performed with placement of 3 suspension sutures per side. The 2 most distal sutures on each ligament were tied. A screw-and-washer attachment was secured in the middle of the vaginal cuff and tied to a pulley system with surgical filament. Distal traction was applied with sequentially increasing weight loads. Distal migration of the vaginal apex from baseline with each weight load was recorded. The most proximal suspension suture was tied and the procedure repeated. Horizontal distances between each USLS suture to the ipsilateral ureter were measured. Three discrete points were marked on sacral nerves S1-S3, and the shortest distance between each point and each ipsilateral USLS suture was measured. Descriptive statistics and repeated-measures analysis of variance were performed. RESULTS: Application of each load resulted in greater migration distances for the 2 suture configuration when compared with 3 sutures (P < .05). Differences were greatest for the 3 kg load (mean ± SEM, 2.0 ± 0.2 vs 1.5 ± 0.1 cm, respectively). Distances to ipsilateral ureter between the 2 most cranial sutures were comparable (P > .05). The most cranial USLS suture was closest to sacral nerves S1-S3. CONCLUSION: In this cadaveric study, 3 USLS sutures provided more support to the vaginal apex than 2 sutures, although the absolute difference may not be clinically significant. The most cranial suture had the smallest distances to sacral nerves S1-S3.

Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth.

OBJECTIVE: To determine the variation in vaginal axis and posterior cul-de-sac depth when the lowest suture used to attach the sacrocolpopexy mesh to the anterior longitudinal ligament is anchored at different levels. STUDY DESIGN: At five lumbosacral mesh attachment sites, the anterior vaginal wall axis angle was measured relative to a line between the lowest border of the pubic symphysis and fourth sacral (S4) foramen in 9 unembalmed cadavers. The vertical distance from S4 to the posterior mesh was measured as a surrogate of cul-de-sac depth. RESULTS: From a mesh fixation point at the lower border of S2 to a point at the lower border of L5, there was a 3-fold increase in both vaginal axis angle (13.04 ± 3.19 vs 42.88 ± 4.16 cm) and distance from S4 to the posterior mesh (2.50 ± 0.61 vs 7.38 ± 1.30 cm) between these points. CONCLUSION: During sacrocolpopexy, progressively cephalad sacral attachment increases vaginal axis angle and cul-de-sac depth.