Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study.

BACKGROUND: In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee. AIMS: To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event. MATERIALS AND METHODS: Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens. RESULTS: Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation. CONCLUSIONS: There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia.

BACKGROUND: The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken. OBJECTIVES: The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement. STUDY DESIGN: National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement. RESULTS: Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. CONCLUSION: A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.

Validation of local review for the identification of contributory factors and potentially avoidable perinatal deaths.

BACKGROUND: Reporting on perinatal mortality commenced 2006 in New Zealand through the Perinatal and Maternal Mortality Review Committee (PMMRC). Following review of international models, a process was developed for use in local review to identify contributory factors and potentially avoidable perinatal deaths. Local review of 720 perinatal deaths in 2009 found contributory factors in 24% of deaths and 14% to be potentially avoidable. AIMS: To validate the process of local review for identification of contributory factors and potentially avoidable perinatal deaths. MATERIAL AND METHODS: Records of 48 perinatal deaths were reviewed by an independent multidisciplinary panel using the same methodology as local review to determine agreement between local and independent review for identification of contributory factors and potentially avoidable perinatal death. RESULTS: Independent review found contributory factors in 54% of deaths compared to 40% by local review. Independent review identified eight deaths and local review identified one death with contributory factors not identified by the other review. Kappa statistic for agreement for identifying contributory factors was substantial [0.63 (0.42, 0.84)]. Independent review found 42% of deaths potentially avoidable compared to 23% by local review. Independent review identified 10 deaths and local review identified one death not identified by the other review. Kappa statistic for agreement for identifying potentially avoidable deaths was moderate [0.50 (0.26, 0.73)]. CONCLUSIONS: This study provides validation of local review for identification of contributory factors in perinatal death. The higher proportion of potentially avoidable perinatal deaths identified by independent review compared to local review requires further exploration.

Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital.

OBJECTIVE: The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review. STUDY DESIGN: All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contributory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Perinatal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group. RESULTS: Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings. CONCLUSION: Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary review team; priorities were identified for improvement of local maternity services.