Evaluating the impact of the laborist model of obstetric care on maternal and neonatal outcomes.

BACKGROUND: The laborist model of obstetric care represents a change in care delivery with the potential of improving maternal and neonatal outcomes. OBJECTIVE: We evaluated the effectiveness of the laborist model of care compared to the traditional model of obstetric care using specific maternal and neonatal outcome measures. STUDY DESIGN: This is a population cohort study with laborist and nonlaborist hospitals matched 1:2 on delivery volume, geography, teaching status, and neonatal intensive care unit level using data from the National Perinatal Information Center/Quality Analytic Services database. A before-and-after study design with an untreated comparison group analyzed with the method of difference-in-differences was used to examine the impact of laborists on maternal and neonatal outcome measures within the 3 years after implementing the laborist system, after adjusting for secular trends, sociodemographic factors, and maternal medical conditions. The final outcome measures evaluated included cesarean delivery, chorioamnionitis, induction of labor, preterm birth, prolonged length of stay, Apgar at 5 minutes of <7, birth asphyxia, birth injury, birth trauma, and neonatal death. RESULTS: We studied nearly 550,000 women from 24 hospitals (8 laborist and 16 nonlaborist hospitals) from 1998 through 2011. Implementation of laborists was associated with fewer labor inductions (adjusted odds ratio, 0.85; 95% confidence interval, 0.71-0.99) and decreased rate of preterm birth (adjusted odds ratio, 0.83; 95% confidence interval, 0.72-0.96) after controlling for confounders. Laborists did not impact the cesarean delivery rate, chorioamnionitis, or prolonged length of stay. CONCLUSION: Implementation of the laborist model was associated with a significant reduction in labor induction rate and preterm birth without adversely affecting other outcomes.

An alternative generic groundwater-to-indoor air attenuation factor for application in commercial, industrial, and other nonresidential settings.

The default groundwater-to-indoor air attenuation factor (AF) of 10-3 (0.001) to assess the vapor intrusion (VI) pathway and generate VI screening levels for groundwater was developed by the United States Environmental Protection Agency (EPA) based on chlorinated volatile organic compound (VOC) indoor air and groundwater data collected in residential buildings and compiled in EPA's 2012 VI database. In their VI guidance published in 2015, EPA recognized that this default AF may be overly conservative for nonresidential buildings. In 2015, the Department of Defense (DoD) began developing a first-of-its-kind VI database to assess AFs at commercial and industrial buildings at DoD installations and support the development of alternative generic AF values. This database was expanded in 2019 to include 76 buildings at 22 DoD installations across the United States and is comparable in size to the EPA VI database. The DoD database includes chlorinated VOC data from groundwater and indoor air samples collected from multiple sampling zones within these buildings. Empirical groundwater-to-indoor air AFs were calculated using similar screening methods employed by EPA, including a source strength screen, to filter out potential background source contributions unrelated to VI. Analysis of indoor air-groundwater data pairs found that there is more attenuation occurring from groundwater to indoor air in DoD commercial and industrial buildings relative to residential buildings and that the DoD buildings' AFs are one to four orders of magnitude lower than EPA's residential-based default of 10-3. The results support the use of a generic groundwater AF of 10-4 (0.0001) to support VI assessment and develop groundwater screening levels specific to large commercial and industrial buildings as an alternative to the residential default AF.Implications: The use of groundwater-to-indoor air attenuation factors (AFs) is a key component of vapor intrusion (VI) pathway assessments and VI screening-level development for groundwater. Currently, the United States Environmental Protection Agency (EPA) and many state regulatory agencies use a default groundwater AF of 10-3 (0.001) based on chlorinated volatile organic compound (VOC) data collected in residential buildings. VI assessment data collected at Department of Defense (DoD) installations indicate that there is significantly more groundwater-to-indoor air attenuation occurring at DoD commercial and industrial buildings. For that reason, the default AF of 10-3 results in groundwater screening levels that are overestimating VI-related risks in these types of building. The DoD data support the use of a generic groundwater AF of 10-4 (0.0001) for conducting VI assessment and developing groundwater screening levels at large commercial and industrial buildings.

A care coordination program for substance-exposed newborns.

The Vulnerable Infants Program of Rhode Island (VIP-RI) was established as a care coordination program to promote permanency for substance-exposed newborns in the child welfare system. Goals of VIP-RI were to optimize parents' opportunities for reunification and increase the efficacy of social service systems involved with families affected by perinatal substance use. Findings from VIP-RI's final four years show that by 12 months, 86% of substance-exposed newborns had identified permanent placements and 77% were placed with biological parents or relatives.

An alternative generic subslab soil gas-to-indoor air attenuation factor for application in commercial, industrial, and other nonresidential settings.

The default subslab soil gas (SSSG)-to-indoor air attenuation factor (AF) of 0.03 to assess the vapor intrusion (VI) pathway and generate VI screening levels for SSSG was developed by the United States Environmental Protection Agency (EPA) based on chlorinated volatile organic compound (VOC) indoor air and SSSG data collected in residential buildings and compiled in EPA's 2012 VI database. In their VI guidance published in 2015, EPA recognized that this default AF may be overly conservative for nonresidential buildings. In 2015, the Department of Defense (DoD) began developing a first-of-its-kind VI database to assess AFs at commercial and industrial buildings at DoD installations and support the development of alternative generic AF values. This database was expanded in 2019 to include 76 buildings at 22 DoD installations across the United States and is comparable in size to EPA's VI database. The DoD database includes chlorinated VOC data from SSSG and indoor air samples collected from multiple sampling zones within these buildings. Empirical SSSG-to-indoor air AFs were calculated using the same screening methods employed by EPA to filter out potential background source contributions unrelated to VI, including a source strength screen. Analysis of indoor air-SSSG data pairs found that there is substantially more attenuation occurring from SSSG to indoor air in DoD commercial and industrial buildings relative to residential buildings, and that the DoD buildings' AFs are one to three orders of magnitude lower than EPA's residential-based default of 0.03. The results support the use of a generic SSSG-to-indoor air AF of 10-3 (0.001) to support VI assessment and develop SSSG screening levels at large commercial and industrial buildings as an alternative to the residential default AF.Implications: The use of subslab soil gas (SSSG)-to-indoor air attenuation factors (AFs) is a key component of vapor intrusion (VI) pathway assessments and VI screening level development for SSSG. Currently, the United States Environmental Protection Agency (EPA) and many state regulatory agencies use a default AF of 0.03 based on chlorinated volatile organic compound (VOC) data collected in residential buildings. VI assessment data collected at Department of Defense (DoD) installations indicate that there is significantly more SSSG-to-indoor air attenuation occurring at DoD commercial and industrial buildings. For that reason, the default AF of 0.03 results in SSSG screening levels that are overestimating VI-related risks in these types of building. The DoD data support the use of a generic SSSG-to-indoor air AF of 10-3 (0.001) for conducting VI assessment and developing SSSG screening levels at large commercial and industrial buildings as an alternative to the residential default AF.

Services used by perinatal substance-users with child welfare involvement: a descriptive study.

BACKGROUND: Substance use during pregnancy often leads to involvement in the child welfare system, resulting in multiple social service systems and service providers working with families to achieve successful child welfare outcomes. The Vulnerable Infants Program of Rhode Island (VIP-RI) is a care coordination program developed to work with perinatal substance-users to optimize opportunities for reunification and promote permanency for substance-exposed infants. This paper describes services used by VIP-RI participants and child welfare outcomes. METHODS: Data collected during the first four years of VIP-RI were used to identify characteristics of program participants, services received, and child welfare outcomes: closed child welfare cases, reunification with biological mothers and identified infant permanent placements. DESCRIPTIVE RESULTS: Medical and financial services were associated with positive child welfare outcomes. Medical services included family planning, pre- and post-natal care and HIV test counseling. Financial services included assistance with obtaining entitlement benefits and receiving tangible support such as food and clothing. CONCLUSIONS: Findings from this study suggest services that address basic family needs were related to positive child welfare outcomes. The provision of basic services, such as health care and financial assistance through entitlement benefits and tangible donations, may help to establish a foundation so mothers can concentrate on recovery and parenting skills. Identification of services for perinatal substance users that are associated with more successful child welfare outcomes has implications for the child welfare system, treatment providers, courts and families.

Vulnerable infants program of Rhode Island: promoting permanency for substance-exposed infants.

The Vulnerable Infants Program of Rhode Island is a care coordination program to promote permanency for substance-exposed infants by addressing parental needs and increasing collaboration among social service agencies. Over the first four years of the program, there was a decrease in time spent in the newborn nursery beyond medical necessity and identification of permanent placements by 12 months for 84% of infants, with the majority of infants (78%) placed with biological parents or relatives.

Impact of the Agency for Healthcare Research and Quality's Safety Program for Perinatal Care.

BACKGROUND: The Safety Program for Perinatal Care (SPPC) seeks to improve safety on labor and delivery (L&D) units through three mutually reinforcing components: (1) fostering a culture of teamwork and communication, (2) applying safety science principles to care processes; and (3) in situ simulation. The objective of this study was to describe the SPPC implementation experience and evaluate the short-term impact on unit patient safety culture, processes, and adverse events. METHODS: We supported SPPC implementation by L&D units with a program toolkit, trainings, and technical assistance. We evaluated the program using a pre-post, mixed-methods design. Implementing units reported uptake of program components, submitted hospital discharge data on maternal and neonatal adverse events, and participated in semi-structured interviews. We measured changes in safety and quality using the Modified Adverse Outcome Index (MAOI) and other perinatal care indicators. RESULTS: Forty-three L&D units submitted data representing 97,740 deliveries over 10 months of follow-up. Twenty-six units implemented all three program components. L&D staff reported improvements in teamwork, communication, and unit safety culture that facilitated applying safety science principles to clinical care. The MAOI decreased from 5.03% to 4.65% (absolute change -0.38% [95% CI, -0.88% to 0.12%]). Statistically significant decreases in indicators for obstetric trauma without instruments and primary cesarean delivery were observed. A statistically significant increase in neonatal birth trauma was observed, but the overall rate of unexpected newborn complications was unchanged. CONCLUSIONS: The SPPC had a favorable impact on unit patient safety culture and processes, but short-term impact on maternal and neonatal adverse events was mixed.

Obstructive sleep apnea in pregnancy is associated with adverse maternal outcomes: a national cohort.

OBJECTIVE: Pregnancy and the obesity epidemic impacting women of reproductive age appear to predispose women to obstructive sleep apnea (OSA) in pregnancy. The aim of this study is to examine the association between OSA and adverse maternal outcomes in a national cohort. METHODS: The National Perinatal Information Center in the US was used to identify women with a delivery discharge diagnosis of OSA from 2010 to 2014. We used the International Classification of Diseases, ninth Revision to classify OSA diagnosis and maternal outcomes. MEASUREMENTS: The sample consisted of 1,577,632 gravidas with a rate of OSA of 0.12% (N = 1963). There was a significant association between OSA and preeclampsia (adjusted odds ratio (aOR) 2.22, 95% confidence interval (CI) 1.94-2.54), eclampsia (aOR 2.95, 1.08-8.02), and gestational diabetes (aOR 1.51, 1.34-1.72) after adjusting for a comprehensive list of covariates which includes maternal obesity. OSA status was also associated with a 2.5-3.5-fold increase in risk of severe complications such as cardiomyopathy, congestive heart failure, and hysterectomy. Length of hospital stay was significantly longer (5.1 + 5.6 vs 3.0 + 3.0 days, p < 0.001) and odds of an admission to an intensive care unit higher (aOR 2.74, 2.36-3.18) in women with OSA. CONCLUSIONS: Compared to pregnant women without OSA, pregnant women with OSA have a significantly higher risk of pregnancy-specific complications such as gestational hypertensive conditions and gestational diabetes, and rare medical and surgical complications such as cardiomyopathy, pulmonary edema, congestive heart failure, and hysterectomy. OSA diagnosis was also associated with a longer hospital stay and significantly increased odds for admission to the intensive care unit.

Relationship Between Labor and Delivery Unit Management Practices and Maternal Outcomes.

OBJECTIVE: To define, measure, and characterize key competencies of managing labor and delivery units in the United States and assess the associations between unit management and maternal outcomes. METHODS: We developed and administered a management measurement instrument using structured telephone interviews with both the primary nurse and physician managers at 53 diverse hospitals across the United States. A trained interviewer scored the managers' interview responses based on management practices that ranged from most reactive (lowest scores) to most proactive (highest scores). We established instrument validity by conducting site visits among a subsample of 11 hospitals and established reliability using interrater comparison. Using a factor analysis, we identified three themes of management competencies: management of unit culture, patient flow, and nursing. We constructed patient-level regressions to assess the independent association between these management themes and maternal outcomes. RESULTS: Proactive management of unit culture and nursing was associated with a significantly higher risk of primary cesarean delivery in low-risk patients (relative risk [RR] 1.30, 95% CI 1.02-1.66 and RR 1.47, 95% CI 1.13-1.92, respectively). Proactive management of unit culture was also associated with a significantly higher risk of prolonged length of stay (RR 4.13, 95% CI 1.98-8.64), postpartum hemorrhage (RR 2.57, 95% CI 1.58-4.18), and blood transfusion (RR 1.87, 95% CI 1.12-3.13). Proactive management of patient flow and nursing was associated with a significantly lower risk of prolonged length of stay (RR 0.23, 95% CI 0.12-0.46 and RR 0.27, 95% CI 0.11-0.62, respectively). CONCLUSION: Labor and delivery unit management varies dramatically across and within hospitals in the United States. Some proactive management practices may be associated with increased risk of primary cesarean delivery and maternal morbidity. Other proactive management practices may be associated with decreased risk of prolonged length of stay, indicating a potential opportunity to safely improve labor and delivery unit efficiency.

Hospital differences in special care nursery use for newborns of gestational diabetic mothers.

OBJECTIVE: Relatively healthy newborns of mothers with gestational diabetes mellitus (GDM) sometimes receive unwarranted surveillance. We studied the relationship between hospital characteristics and special care nursery use and total length of stay among GDM deliveries. METHODS: We identified GDM deliveries at 44 USA member hospitals of the National Perinatal Information Center from 2007 to 2011. To study low risk, relatively healthy newborns with presumed discretion in special care nursery use, we analyzed 43 444 singleton newborns with only minor or moderate complications and WHO were not preterm or low birthweight. RESULTS: Among eligible newborns, 6% received special care, but this ranged from 1% to 16% across 44 hospitals studied. Unadjusted associations suggested special care nursery use was highest in academic teaching hospitals, the Midwest, hospitals with ≥40% Medicaid births, and hospitals with a high supply of special care nursery beds. However, after controlling for clustering within hospitals, there were no significant associations between hospital characteristics and special care nursery use or length of stay. CONCLUSIONS: Hospital-level variation in special care nursery use and length of stay of relatively healthy newborns of mothers with GDM is unexplained by hospital characteristics and suggests other operational or management factors impacting utilization of newborn care resources.

Multiple myeloma.

OBJECTIVES: After completing this article, readers should be able to: Recognize the signs and symptoms of multiple myeloma. Discuss the process used to confirm a multiple myeloma diagnosis. Identify imaging modalities used to diagnose the disease. Describe the appearance of multiple myeloma on radiographic images. Explain the use of computed tomography, magnetic resonance and positron emission tomography in imaging of multiple myeloma. List traditional and newer multiple myeloma treatment options.

Laborist model of care: who is using it?

OBJECTIVE: Utilization of the laborist model in the provision of obstetric (OB) care appears to be growing. In collaboration with the National Perinatal Information Center/Quality Analytic Services (NPIC/QAS), we assessed the utilization of this model of care delivery and hospital-level characteristics associated with its use. METHODS: A cross-sectional electronic survey of all NPIC/QAS member hospitals (26 states) was performed in February 2010. Questions assessed staffing and clinical capabilities and utilization of laborists. The association between laborists and hospital-level characteristics were calculated using chi-square analyses or Fisher's exact tests for categorical variables and t tests for continuous variables. RESULTS: Ninety-three percent of hospitals (69/74) responded and only those that provide OB services were analyzed (N = 68). Nearly 40% (25/68) of hospitals responded that they are utilizing laborists. Delivery volume is significantly associated with implementation of laborists whereas OB level, presence of residents and fellows, and geography were not. CONCLUSION: Laborists are being introduced into the OB care delivery model rapidly. This is the first assessment of their use in a large sample of US hospitals. Given the millions of women who deliver each year, it is imperative to evaluate the impact of this model on patient safety and outcomes.

Chiari malformations.

Chiari malformations can be serious conditions and their diagnosis often confounds clinicians. When patients present with Chiari malformations, they may have no symptoms or a range of symptoms, many of which can be confused with other neurological conditions. Imaging, and particularly magnetic resonance, plays an important role in diagnosing and treating Chiari malformations.