Measuring supply-side service disruption: a systematic review of the methods for measuring disruption in the context of maternal and newborn health services in low and middle-income settings.

OBJECTIVES: During the COVID-19 pandemic, most essential services experienced some level of disruption. Disruption in LMICs was more severe than in HICs. Early reports suggested that services for maternal and newborn health were disproportionately affected, raising concerns about health equity. Most disruption indicators measure demand-side disruption, or they conflate demand-side and supply-side disruption. There is currently no published guidance on measuring supply-side disruption. The primary objective of this review was to identify methods and approaches used to measure supply-side service disruptions to maternal and newborn health services in the context of COVID-19. DESIGN: We carried out a systematic review and have created a typology of measurement methods and approaches using narrative synthesis. DATA SOURCES: We searched MEDLINE, EMBASE and Global Health in January 2023. We also searched the grey literature. ELIGIBILITY CRITERIA: We included empirical studies describing the measurement of supply-side service disruption of maternal and newborn health services in LMICs in the context of COVID-19. DATA EXTRACTION AND SYNTHESIS: We extracted the aim, method(s), setting, and study outcome(s) from included studies. We synthesised findings by type of measure (ie, provision or quality of services) and methodological approach (ie, qualitative or quantitative). RESULTS: We identified 28 studies describing 5 approaches to measuring supply-side disruption: (1) cross-sectional surveys of the nature and experience of supply-side disruption, (2) surveys to measure temporal changes in service provision or quality, (3) surveys to create composite disruption scores, (4) surveys of service users to measure receipt of services, and (5) clinical observation of the provision and quality of services. CONCLUSION: Our review identified methods and approaches for measuring supply-side service disruption of maternal and newborn health services. These indicators provide important information about the causes and extent of supply-side disruption and provide a useful starting point for developing specific guidance on the measurement of service disruption in LMICs.

Interventions for addressing trauma among people with HIV: a narrative review.

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

Strengthening Health Systems in Humanitarian Settings: Multi-Stakeholder Insights on Contraception and Postabortion Care Programs in the Democratic Republic of Congo and Somalia.

Background: In humanitarian settings, strengthening health systems while responding to the health needs of crisis-affected populations is challenging and marked with evidence gaps. Drawing from a decade of family planning and postabortion care programming in humanitarian settings, this paper aims to identify strategic components that contribute to health system strengthening in such contexts. Materials and Methods: A diverse range of key informants from North Kivu (Democratic Republic of Congo, DRC) and Puntland (Somalia), including female and male community members, adolescents and adults, healthcare providers, government and community leaders, participated in qualitative interviews, which applied the World Health Organization health system building blocks framework. Data were thematically analyzed according to this framework. Results: Findings from the focus group discussions (11 in DRC, 7 in Somalia) and key informant interviews (seven in DRC, four in Somalia) involving in total 54 female and 72 male participants across both countries indicate that health programs in humanitarian settings, such as Save the Children's initiative on family planning and postabortion care, could contribute to strengthening health systems by positively influencing national policies and guidance, strengthening local coordination mechanisms, capacitating the healthcare workforce with competency-based training and supportive supervision (benefiting facilities supported by the project and beyond), developing the capacity of Ministry of Health staff in the effective management of the supply chain, actively and creatively mobilizing the community to raise awareness and create demand, and providing quality and affordable services. Financial sustainability is challenged by the chronically limited healthcare expenditure experienced in both humanitarian contexts. Conclusions: In humanitarian settings, carefully designed healthcare interventions, such as those that address the family planning and postabortion care needs of crisis-affected populations, have the potential not only to increase access to essential services but also contribute to strengthening several components of the health system while increasing the government capacity, ownership, and accountability.

Strengthening healthcare providers' capacity for safe abortion and post-abortion care services in humanitarian settings: lessons learned from the clinical outreach refresher training model (S-CORT) in Uganda, Nigeria, and the Democratic Republic of Congo.

BACKGROUND: Fragile and crisis-affected countries account for most maternal deaths worldwide, with unsafe abortion being one of its leading causes. This case study aims to describe the Clinical Outreach Refresher Training strategy for sexual and reproductive health (S-CORT) designed to update health providers' competencies on uterine evacuation using both medications and manual vacuum aspiration. The paper also explores stakeholders' experiences, recommendations for improvement, and lessons learned. METHODS: Using mixed methods, we evaluated three training workshops that piloted the uterine evacuation module in 2019 in humanitarian contexts of Uganda, Nigeria, and the Democratic Republic of Congo. RESULTS: Results from the workshops converged to suggest that the module contributed to increasing participants' theoretical knowledge and possibly technical and counseling skills. Equally noteworthy were their confidence building and positive attitudinal changes promoting a rights-based, fearless, non-judgmental, and non-discriminatory approach toward clients. Participants valued the hands-on, humanistic, and competency-based training methodology, although most regretted the short training duration and lack of practice on real clients. Recommendations to improve the capacity development continuum of uterine evacuation included recruiting the appropriate health cadres for the training; sharing printed pre-reading materials to all participants; sustaining the availability of medication and supplies to offer services to clients after the training; and helping staff through supportive supervision visits to accelerate skills transfer from training to clinic settings. CONCLUSIONS: When the lack of skilled human resources is a barrier to lifesaving uterine evacuation services in humanitarian settings, the S-CORT strategy could offer a rapid hands-on refresher training opportunity for service providers needing an update in knowledge and skills. Such a capacity-building approach could be useful in humanitarian and fragile settings as well as in development settings with limited resources as part of an overall effort to strengthen other building blocks of the health system.

An analytic perspective of a mixed methods study during humanitarian crises in South Sudan: translating facility- and community-based newborn guidelines into practice.

BACKGROUND: In South Sudan, the civil war in 2016 led to mass displacement in Juba that rapidly spread to other regions of the country. Access to health care was limited because of attacks against health facilities and workers and pregnant women and newborns were among the most vulnerable. Translation of newborn guidelines into public health practice, particularly during periods of on-going violence, are not well studied during humanitarian emergencies. During 2016 to 2017, we assessed the delivery of a package of community- and facility-based newborn health interventions in displaced person camps to understand implementation outcomes. This case analysis describes the challenges encountered and mitigating strategies employed during the conduct of an original research study. DISCUSSION: Challenges unique to conducting research in South Sudan included violent attacks against humanitarian aid workers that required research partners to modify study plans on an ongoing basis to ensure staff and patient safety. South Sudan faced devastating cholera and measles outbreaks that shifted programmatic priorities. Costs associated with traveling study staff and transporting equipment kept rising due to hyperinflation and, after the July 2016 violence, the study team was unable to convene in Juba for some months to conduct refresher trainings or monitor data collection. Strategies used to address these challenges were: collaborating with non-research partners to identify operational solutions; maintaining a locally-based study team; maintaining flexible budgets and timelines; using mobile data collection to conduct timely data entry and remote quality checks; and utilizing a cascade approach for training field staff. CONCLUSIONS: The case analysis provides lessons that are applicable to other humanitarian settings including the need for flexible research methods, budgets and timelines; innovative training and supervision; and a local research team with careful consideration of sociopolitical factors that impact their access and safety. Engagement of national and local stakeholders can ensure health services and data collection continue and findings translate to public health action, even in contexts facing severe and unpredictable insecurity.

Postabortion Care in Humanitarian Emergencies: Improving Treatment and Reducing Recurrence.

BACKGROUND: Unsafe abortion contributes to maternal mortality worldwide and disproportionately affects the most disadvantaged women and girls; thus, improving the treatment of complications of abortion is essential. Shifting PAC treatment from sharp dilation and curettage (D&C) to the use of aspiration techniques, notably manual vacuum aspiration (MVA), and medical treatment with misoprostol improves health outcomes. Equally critical is ensuring that women have access to voluntary contraception after an abortion to prevent future unintended pregnancies. In humanitarian settings, access to voluntary family planning to disrupt the cycle of unsafe abortion is even more critical because access to quality services cannot be guaranteed due to security risks, migration, and devastation of infrastructure. Save the Children applied a multipronged postabortion care (PAC) approach in the Democratic Republic of the Congo (DRC), Somalia, and Yemen that focused on capacity building; assurance of supplies and infrastructure; community collaboration and mobilization; and monitoring and evaluation. METHODS: Program-level data were extracted for each of the 3 countries from the inception of their program through 2017. The sources of information included monthly service delivery reports that tracked key PAC indicators as well as qualitative data from evaluations of community mobilization activities. RESULTS: The number of PAC clients increased in all countries. In the DRC in 2012, 19% of PAC clients requiring treatment received D&C; in 2017 the percentage was reduced to 3%. In 2013, 25% of all PAC clients in Yemen were treated with D&C; this percentage was reduced to 3% in 2017. The proportion of women choosing contraception after an abortion increased. In 2012, only 42% of all PAC clients in the DRC chose a contraceptive method; by 2017, the proportion had increased to 70%. Somalia had substantial increases in PAC demand, with the percentage of all PAC clients electing contraception increasing from 64% in 2012 to 82% in 2017. In Yemen, where the health system has been constrained due to severe conflict, the percentage of PAC clients choosing voluntary contraception rose from 17% in 2013 to 38% in 2017. Uptake and demand for PAC was mobilized through targeted community outreach in each context. CONCLUSION: These data demonstrate that providers can effectively shift away from D&C as treatment for PAC and that contraceptive uptake by PAC clients can increase substantially, even in settings where the use of contraception after abortion is often stigmatized.

"They Love Their Patients": Client Perceptions of Quality of Postabortion Care in North and South Kivu, the Democratic Republic of the Congo.

BACKGROUND: Postabortion care (PAC) is a lifesaving intervention that, when accessible and of good quality, can prevent the majority of abortion-related deaths. However, these services are only sporadically available and often of poor quality in humanitarian settings. CARE International, the International Rescue Committee, and Save the Children strengthened the Congolese Ministry of Health to provide PAC, including voluntary contraceptive services, in North and South Kivu, DRC. OBJECTIVE: We aimed to gain understanding of the demographic and clinical characteristics of PAC clients, the experiences of women who sought PAC at supported health facilities, and the women's perceptions of the quality of care received. We also explored how client perspectives can inform future PAC programming. METHODS: A PAC register review extracted sociodemographic and clinical data on all PAC clients during a 12-month period between 2015 and 2016 at 69 supported facilities in 6 health zones. In-depth interviews were conducted between September 2016 and April 2017 with 50 women who sought PAC in the preceding 3 months at supported health facilities. Interviews were recorded, transcribed, and translated into French for analysis. Thematic content analysis was subsequently used as the data analytic approach. RESULTS: In 12 months, 1,769 clients sought PAC at supported facilities; 85.2% were at less than 13 weeks gestation. Over 80% of PAC clients were treated for incomplete abortion, and of these, 90% were treated with manual vacuum aspiration. The majority (75.2%) of PAC clients chose voluntary postabortion contraception. All but one interview participant reported seeking PAC for a spontaneous abortion, although most also reported their pregnancy was unintended. Clients were mostly made aware that PAC was available by community health workers or other community members. Experiences at the supported facilities were mostly positive, particularly in regards to client-provider interactions. Most women received contraceptive counseling during PAC and selected a modern method of contraception immediately after treatment. However, knowledge about different methods of contraception varied. Nearly all women said that they would advise another woman experiencing abortion complications to seek PAC at a supported health facility. CONCLUSIONS: The findings demonstrate the successful implementation of good-quality, respectful PAC in North and South Kivu. Overall, they suggest that the organizations' support of health workers, including competency-based training and supportive supervision, was successful.

Lessons Learned from Applying a Modified Learning Collaborative Model to Promote Change in Regional and Statewide HIV Care Systems.

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change.

Understanding health systems to improve community and facility level newborn care among displaced populations in South Sudan: a mixed methods case study.

BACKGROUND: Targeted clinical interventions have been associated with a decreased risk of neonatal morbidity and mortality. In conflict-affected countries such as South Sudan, however, implementation of lifesaving interventions face barriers and facilitators that are not well understood. We aimed to describe the factors that influence implementation of a package of facility- and community-based neonatal interventions in four displaced person camps in South Sudan using a health systems framework. METHODS: We used a mixed method case study design to document the implementation of neonatal interventions from June to November 2016 in one hospital, four primary health facilities, and four community health programs operated by International Medical Corps. We collected primary data using focus group discussions among health workers, in-depth interviews among program managers, and observations of health facility readiness. Secondary data were gathered from documents that were associated with the implementation of the intervention during our study period. RESULTS: Key bottlenecks for implementing interventions in our study sites were leadership and governance for comprehensive neonatal services, health workforce for skilled care, and service delivery for small and sick newborns. Program managers felt national policies failed to promote integration of key newborn interventions in donor funding and clinical training institutions, resulting in deprioritizing newborn health during humanitarian response. Participants confirmed that severe shortage of skilled care at birth was the main bottleneck for implementing quality newborn care. Solutions to this included authorizing the task-shifting of emergency newborn care to mid-level cadre, transitioning facility-based traditional birth attendants to community health workers, and scaling up institutions to upgrade community midwives into professional midwives. Additionally, ongoing supportive supervision, educational materials, and community acceptance of practices enabled community health workers to identify and refer small and sick newborns. CONCLUSIONS: Improving integration of newborn interventions into national policies, training institutions, health referral systems, and humanitarian supply chain can expand emergency care provided to women and their newborns in these contexts.

Using a quality improvement approach to improve maternal and neonatal care in North Kivu, Democratic Republic of Congo.

Providing quality health care services in humanitarian settings is challenging due to population displacement, lack of qualified staff and supervisory oversight, and disruption of supply chains. This study explored whether a participatory quality improvement (QI) intervention could be used in a protracted conflict setting to improve facility-based maternal and newborn care. A longitudinal quasi-experimental design was used to examine delivery of maternal and newborn care components at 12 health facilities in eastern Democratic Republic of Congo. Study facilities were split into two groups, with both groups receiving an initial "standard" intervention of clinical training. The "enhanced" intervention group then applied a QI methodology, which involved QI teams in each facility, supported by coaches, testing small changes to improve care. This paper presents findings on two of the study outcomes: delivery of active management of the third stage of labour (AMTSL) and essential newborn care (ENC). We measured AMTSL and ENC through exit interviews with post-partum women and matched partographs at baseline and endline over a 9-month period. Using generalised equation estimation models, the enhanced intervention group showed a greater rate of change than the control group for AMTSL (aOR 3.47, 95% CI: 1.17-10.23) and ENC (OR: 49.62, 95% CI: 2.79-888.28), and achieved 100% ENC completion at endline. This is one of the first studies where this QI methodology has been used in a protracted conflict setting. A method where health staff take ownership of improving care is of even greater value in a humanitarian context where external resources and support are scarce.

"You have to take action": changing knowledge and attitudes towards newborn care practices during crisis in South Sudan.

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers' knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre-post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers' knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

State of newborn care in South Sudan's displacement camps: a descriptive study of facility-based deliveries.

BACKGROUND: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. METHODS: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. RESULTS: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2.32]), but other practices were not statistically different. Mothers' knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). CONCLUSIONS: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries.

Developing Institutional Capacity for Reproductive Health in Humanitarian Settings: A Descriptive Study.

INTRODUCTION: Institutions play a central role in advancing the field of reproductive health in humanitarian settings (RHHS), yet little is known about organizational capacity to deliver RHHS and how this has developed over the past decade. This study aimed to document the current institutional experiences and capacities related to RHHS. MATERIALS AND METHODS: Descriptive study using an online questionnaire tool. RESULTS: Respondents represented 82 institutions from 48 countries, of which two-thirds originated from low-and middle-income countries. RHHS work was found not to be restricted to humanitarian agencies (25%), but was also embraced by development organizations (25%) and institutions with dual humanitarian and development mandates (50%). Agencies reported working with refugees (81%), internally-displaced (87%) and stateless persons (20%), in camp-based settings (78%), and in urban (83%) and rural settings (78%). Sixty-eight percent of represented institutions indicated having an RHHS-related policy, 79% an accountability mechanism including humanitarian work, and 90% formal partnerships with other institutions. Seventy-three percent reported routinely appointing RH focal points to ensure coordination of RHHS implementation. There was reported progress in RHHS-related disaster risk reduction (DRR), emergency management and coordination, delivery of the Minimum Initial Services Package (MISP) for RH, comprehensive RH services in post-crisis/recovery situations, gender mainstreaming, and community-based programming. Other reported institutional areas of work included capacity development, program delivery, advocacy/policy work, followed by research and donor activities. Except for abortion-related services, respondents cited improved efforts in advocacy, capacity development and technical support in their institutions for RHHS to address clinical services, including maternal and newborn health, sexual violence prevention and response, HIV prevention, management of sexually-transmitted infections, adolescent RH, and family planning. Approximately half of participants reported that their institutions had experienced an increase in dedicated budget and staff for RHHS, a fifth no change, and 1 in 10 a decrease. The Interagency RH Kits were reportedly the most commonly used supplies to support RHHS implementation. CONCLUSION: The results suggest overall growth in institutional capacity in RHHS over the past decade, indicating that the field has matured and expanded from crisis response to include RHHS into DRR and other elements of the emergency management cycle. It is critical to consolidate the progress to date, address gaps, and sustain momentum.

Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor.

OBJECTIVE: The objective of the study was to examine the clinical impact of specific fetal monitoring-related practices during induced labor. STUDY DESIGN: This was a prospective, nonrandomized study. RESULTS: We studied 14,398 women undergoing oxytocin induction of labor. A decrease in the infusion rate of oxytocin in the face of specified category II fetal heart rate tracings was associated with a significantly reduced rate of neonatal intensive care unit admission (3.8% vs 5.2%, P = .01) and Apgar score less than 7 at 1 and 5 minutes (4.9% vs 6.4%, P = .01, 0.6% vs 1.1%, P = .04). Compliance with an in-use checklist was associated with both a reduction in the rate of neonatal intensive care unit admission (2.9 vs 4.4, P = .00) and a reduction in the cesarean delivery rate (15.8% vs 18.8%, P = .00). CONCLUSION: Electronic fetal heart rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions. Utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes and a reduction in the cesarean delivery rate.

Association of obstetric intervention with temporal patterns of childbirth.

OBJECTIVE: To examine the gestational age at and day and time of delivery in current U.S. obstetric practice. METHODS: We examined electronic records from 72 hospitals in 16 states during a 4-month period during 2013. Day of week of delivery, time of day of delivery, and route of delivery were examined in various subpopulations delivering both with and without obstetric intervention. RESULTS: Records of 21,381 women were examined. The distribution curve for gestational age at delivery peaked at 39 weeks both for the entire group and for the subgroup entering labor spontaneously and delivering vaginally without augmentation. Statistical modeling suggests that medical intervention accounts for only a fraction of the shift in distribution peak from 40 to 39 weeks of gestation. Three temporal peaks of total and primary cesarean delivery were seen on weekdays, corresponding to immediate preclinic, lunch time, and immediate postclinic timeframes. These peaks were not seen on weekend days. The risk of nonelective primary cesarean delivery during a weekday was approximately one third higher than on a weekend (relative rate 1.36, confidence interval 1.24-1.49). CONCLUSION: The recently described shift in peak distribution of U.S. gestational age at delivery from 40 to 39 weeks of gestation may reflect an underlying physiologic change in the U.S. population and is not exclusively related to obstetric intervention. During the work week, factors other than medical necessity appear to have a marked association with both timing of delivery and rate of cesarean delivery and may affect up to one third of primary cesarean deliveries.

Implementation of standardized pediatric i.v. medication concentrations.

PURPOSE: The development and implementation of a comprehensive and standardized list of pediatric i.v. medication concentrations across a large healthcare system are described. SUMMARY: In accordance with National Patient Safety Goals, facilities affiliated with the Hospital Corporation of America system had independently standardized and limited the number of drug concentrations in use. This resulted in variation among facilities, which prevented the systemwide standardization of drug dictionaries within the computerized pharmacy and prescriber-order-entry systems, complicated the movement of providers among facilities, and contributed to inconsistency in medication prescribing. A team of experts collaborated to create a comprehensive standard list that included 119 medications and 372 concentrations for pediatric i.v. medications. Implementation of this standard list was driven through a financial incentive from the malpractice insurance provider; facilities that completed the required activities for this optional program could apply for a credit of a portion of their malpractice insurance cost. For the standardization of pediatric i.v. medications, required activities included approval of the standard medication list, incorporation of this list into facility pharmacy dictionaries, and update of all smart pump software to include only the new standard medications and concentrations. Of the 145 facilities that were eligible for the implementation of standard pediatric i.v. medication concentrations, 141 (97%) completed all requirements and received the 2% malpractice insurance cost credit. CONCLUSION: The use of a financial incentive strategy, in the form of a malpractice insurance credit, successfully motivated the implementation of standardized pediatric medication concentrations across a large healthcare system.

Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.

OBJECTIVE: The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data. STUDY DESIGN: We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data. RESULTS: Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases. CONCLUSION: Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.

Validation of the joint commission exclusion criteria for elective early-term delivery.

OBJECTIVE: To evaluate whether current Joint Commission (JC) exclusion criteria for measure PC-01, "Elective Delivery" before 39 weeks of gestation, accurately identify valid, codeable indications for planned early-term delivery. METHODS: We performed a review and critical analysis of all cases recorded as noncompliant for the measure in a large health care system during the second half of 2012. RESULTS: During the study period, of 107,145 total deliveries, 205 cases were reported as noncompliant with PC-01. Ten percent of compliance fallouts (ie, cases coded as noncompliant) resulted from valid indications for delivery identifiable by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) coding not included on the JC exclusion list; these were primarily unusual or extreme variations of these conditions. Twenty-five percent of fallouts represented valid indications not represented by an ICD-9-CM code. Eight percent of cases were reported as fallouts as a result of imprecise physician charting; only 2% represented chart abstraction errors. Fifty-five percent of cases involved stated indications for early-term delivery not generally recognized as such by the medical community. Compliance rates of 98% are achievable across a large population using the current ICD-9-CM-based metric for compliance assessment used by the JC (PC-01). The current exclusion list does not appear to be amenable to further improvement by inclusion of more or different ICD-9-CM codes. However, given the low volumes generated using the current PC-01 denominator definition, approximately 60% of facilities would have compliance rates below a 95% benchmark with even a single justified outlier if analyzed on a quarterly basis. CONCLUSION: Our data validate the current JC exclusion criteria for this measure, which identify the vast majority of valid indications for early-term delivery used by obstetrician-gynecologists and identifiable with ICD-9-CM codes. LEVEL OF EVIDENCE: III.

The clinical and economic impact of nurse to patient staffing ratios in women receiving intrapartum oxytocin.

OBJECTIVE: To examine the relationship between nurse-to-patient staffing ratios and perinatal outcomes in women receiving oxytocin during labor. STUDY DESIGN: A retrospective analysis of perinatal outcomes in women receiving oxytocin for induction or augmentation of labor during 2010. Outcomes examined were fetal distress, birth asphyxia, primary cesarean delivery, chorioamnionitis, endomyometritis, and a composite of adverse events. Frequency of 1:1 nurse-to-patient staffing was determined for each hospital. Outcomes were compared between hospitals categorized into quartiles of staffing ratios. RESULTS: In 208,033 women delivering during 2010, there was no relation between frequency of 1:1 nurse-to-patient staffing ratio and improved perinatal outcomes. Adoption of universal 1:1 staffing in the United States would result in the need for an additional 27,000 labor nurses and a cost of $1.6 billion. CONCLUSION: Available data do not support the imposition of mandatory 1:1 nurse-to-patient staffing ratios for women receiving oxytocin in all U.S. facilities.

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.

We describe a systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. Voluntary reports of near-miss events were prospectively collected during 2010 in 203,708 deliveries. These reports were analyzed according to frequency and potential severity. Near-miss events were reported in 0.69% of deliveries. Medication and patient identification errors were the most common near-miss events. However, existing barriers were found to be highly effective in preventing such errors from reaching the patient. Errors with the greatest potential for causing harm involved physician response and decision making. Fewer and less effective existing barriers between these errors and potential patient harm were identified. Use of a comprehensive system for identification of near-miss events on labor and delivery units have proven useful in allowing us to focus patient safety efforts on areas of greatest need.