Audrey Lyndon

Abstract

Objective:To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.Methods:This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.Results:1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI = 9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR = 1.29; ≥35 years: aOR = 1.41), had ≤high-school education (aOR = 1.63), public/no-insurance (aOR = 1.22) or a cesarean section (primary: aOR = 1.99; repeat: aOR = 1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI = 4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR = 2.09), Asian (aOR = 1.59), Hispanic (aOR = 1.42), had public/no-insurance (aOR = 1.52), delivered in hospitals with <1,000 births/year (aOR = 1.93), were primiparous (aOR = 2.03), had a multiple birth (aOR = 3.5), diabetes (aOR = 1.47), or chronic hypertension (aOR = 8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR = 3.72; aOR = 4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI = 17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI = 40.8-74.4).Conclusions:The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

Abstract

Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient's understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.

Abstract

Objective: To explore maternity nurses' perceptions of women's informed decision making during labor and birth to better understand how interdisciplinary communication challenges might affect patient safety. Design: Constructivist grounded theory. Setting: Four hospitals in the western United States. Participants: Forty-six (46) nurses and physicians practicing in maternity units. Method: Data collection strategies included individual interviews and participant observation. Data were analyzed using the constant comparative method, dimensional analysis, and situational analysis (Charmaz, ; Clarke, ; Schatzman, ). Results: The nurses' central action of holding off harm encompassed three communication strategies: persuading agreement, managing information, and coaching of mothers and physicians. These strategies were executed in a complex, hierarchical context characterized by varied practice patterns and relationships. Nurses' priorities and patient safety goals were sometimes misaligned with those of physicians, resulting in potentially unsafe communication. Conclusions: The communication strategies nurses employed resulted in intended and unintended consequences with safety implications for mothers and providers and had the potential to trap women in the middle of interprofessional conflicts and differences of opinion.

Abstract

Objective: This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants. Study Design: From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion. Results: Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders. Conclusions: Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.

Abstract

Objective: To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization. Methods: Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models. Results: The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity. Conclusions: Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

Abstract

Objective: To solicit input from registered nurse members of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) on critical considerations for review and revision of existing nurse staffing guidelines. Design: Thematic analysis of responses to a cross-sectional on-line survey question: "Please give the staffing task force your input on what they should consider in the development of recommendations for staffing of perinatal units." Participants: Members of AWHONN (N = 884). Results: Descriptions of staffing concerns that should be considered when evaluating and revising existing perinatal nurse staffing guidelines. Consistent themes identified included the need for revision of nurse staffing guidelines due to requirements for safe care, increases in patient acuity and complexity, invisibility of the fetus and newborn as separate and distinct patients, difficulties in providing comprehensive care during labor and for mother-baby couplets under current conditions, challenges in staffing small volume units, and the negative effect of inadequate staffing on nurse satisfaction and retention. Conclusion: Participants overwhelmingly indicated current nurse staffing guidelines were inadequate to meet the needs of contemporary perinatal clinical practice and required revision based on significant changes that had occurred since 1983 when the original staffing guidelines were published.

Abstract

Background: Despite widespread emphasis on promoting 'assertive communication' by care givers as essential to patient-safety-improvement efforts, little is known about when and how clinicians speak up to address safety concerns. In this cross-sectional study, the authors use a new measure of speaking up to begin exploring this issue in maternity care. Methods: The authors developed a scenario-based measure of clinician's assessment of potential harm and likelihood of speaking up in response to perceived harm. The authors embedded this scale in a survey with measures of safety climate, teamwork climate, disruptive behaviour, work stress, and personality traits of bravery and assertiveness. The survey was distributed to all registered nurses and obstetricians practising in two US Labour & Delivery units. Results: The response rate was 54% (125 of 230 potential respondents). Respondents were experienced clinicians (13.7611 years in specialty). A higher perception of harm, respondent role, specialty experience and site predicted the likelihood of speaking up when controlling for bravery and assertiveness. Physicians rated potential harm in common clinical scenarios lower than nurses did (7.5 vs 8.4 on 2-10 scale; p<0.001). Some participants (12%) indicated they were unlikely to speak up, despite perceiving a high potential for harm in certain situations. Discussion: This exploratory study found that nurses and physicians differed in their harm ratings, and harm rating was a predictor of speaking up. This may partially explain persistent discrepancies between physicians and nurses in teamwork climate scores. Differing assessments of potential harms inherent in everyday practice may be a target for teamwork intervention in maternity care.

Abstract

OBJECTIVES: To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term. METHODS: Clinical data for premature neonates born in 2005-2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors. RESULTS: Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005-2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999-2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001). CONCLUSION: A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.