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Spotlight Monitoring Fetal Health. This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case –See the full article at

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Presentation on theme: "Spotlight Monitoring Fetal Health. This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case –See the full article at"— Presentation transcript:

1 Spotlight Monitoring Fetal Health

2 This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case –See the full article at http://webmm.ahrq.gov –CME credit is available Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuhamad, MD, Department of Obstetrics and Gynecology, Eastern Virginia Medical School –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin Hartman, MS 2 Source and Credits

3 Objectives At the conclusion of this educational activity, participants should be able to: Define fetal heart rate (FHR) monitoring Describe the evidence regarding FHR monitoring List known hazards of centralized FHR monitoring Describe impact of increasing the number of displays that need to be monitored on overall vigilance and detection of critical signals Appreciate the importance of safety culture on labor and delivery units 3

4 Case: Monitoring Fetal Health A 29-year-old woman had an uncomplicated pregnancy with a healthy fetus and presented to the hospital at term (40 weeks) in early labor. She progressed slowly over the first night. By the next morning, she had a completely dilated cervix and was ready to push. She pushed for approximately 2 hours without any difficulty or any sign of problems with the fetus. When the infant was born, he was cyanotic and flaccid with very low Apgar scores. An arterial blood gas at the time showed a pH of 6.70 (normal: 7.25–7.35), a profound acidosis. The infant required extensive resuscitation but survived and was transferred to the neonatal intensive care unit (NICU). 4

5 Case: Monitoring Fetal Health (2) The infant subsequently had multiple seizures typical of hypoxic-ischemic encephalopathy (brain injury from inadequate oxygenation during childbirth) and other problems from the complicated delivery. He spent a month in the NICU before being transferred to a neuro-rehabilitation unit. It was expected he would be severely disabled for the remainder of his life. Root cause analysis found that the mother had been appropriately monitored and had not shown any evidence of distress. The fetus had been monitored throughout labor using standard fetal heart rate (FHR) tracings, which had shown evidence of category 2 and 3 abnormalities (moderate-to- severe fetal distress) for at least 90 minutes prior to delivery. These abnormalities, which likely would have prompted an urgent Caesarean section, had not been recognized by any of the physicians or nursing staff. 5

6 Case: Monitoring Fetal Health (3) In this institution, continuous fetal heart monitoring of all of the women in labor was displayed centrally on a large 40-inch monitor at the nurses' station. On this screen, individual fetal heart monitoring strips for 16 rooms were displayed continuously in small windows. Two nurses at the nursing station were assigned to watch the monitor at the time of the concerning abnormalities. When asked about the incident, the nurses both replied that they "just didn't see the bad tracings" and commented how difficult it can be sometimes to identify abnormalities and to continuously watch all 16 small windows. The responsible obstetrician was busy throughout the period of abnormal tracings with another complicated childbirth. 6

7 Electronic Fetal Monitoring Electronic fetal monitoring was introduced in 1958 and quickly adopted It offers continuous measure of fetal heart rate (FHR) activity and was expected to reduce infant mortality Both FHR activity and maternal contractions are recorded by transducers placed on maternal abdomen Tracings can be displayed on a continuous paper strip or a computer screen Providers can monitor for deviations in the baseline activity –Deviations can be absent, minimal, moderate, or marked 7

8 Stratifying Fetal Risk The National Institute of Child Health and Human Development (NICHD) recently presented a new classification of FHR monitoring Intent is to standardize communication among health care providers and stratify fetal risk Risk is classified into 3 categories: –Category 1: normal fetus –Category 2: intermediate risk requiring close observation and monitoring –Category 3: possible fetal compromise 8

9 Remote Monitoring of FHR Traditionally, FHR monitors have been located at the patient's bedside Recent technology allows monitoring to be done remotely Often located in the nursing suite of labor and delivery units to allow monitoring of multiple patients simultaneously 9

10 Evidence for Central Monitoring In one 3-year study, there was no difference in clinical outcomes (Cesarean section, admissions to neonatal ICU, or low Apgar scores) with and without centralized fetal monitoring At present, there are no agreed upon standards for comparing computerized and clinical analysis of fetal heart rate The lack of a standardized method has hampered efforts to evaluate central computerized monitoring systems 10

11 Hazards in Centralized Monitoring Rationale for central monitoring is that it facilitates monitoring of all patients at once Previously, a nurse or physician had to visit bedside of each patient frequently to monitor the paper strips One clear disadvantage is that, unlike paper strips, only a portion of tracing can be visible on an electronic screen with other tracings In this case, data from 16 patients were displayed on a single 40-inch monitor—allowing for viewing only about 10 minutes of activity 11

12 Hazards in Centralized Monitoring (2) With paper strips, a clinician can quickly scan 30 minutes or more very quickly On an electronic screen, one tracing can be expanded, but this is at the cost of reducing other patients' tracings A less obvious disadvantage is that centralized monitoring creates unique attentional challenges for those required to monitor the displays The primary concern is vigilance or the ability to maintain attention and respond to stimuli over long periods of time 12

13 Monitoring Displays Over Time When monitoring displays over extended periods of time, an observer's ability to detect critical signals can decline This diminished ability to detect critical stimuli is known as vigilance decrement and has been replicated in numerous studies Monitoring displays is part of many industries: air traffic control, nuclear power plants, etc. 13

14 Vigilance Decrement Characteristics of signals themselves exert an important influence on vigilance performance –Critical signals that are infrequent, expected to occur infrequently, or are of low intensity may be missed The event rate can also affect vigilance –As event rate increases, performance can actually decrease Monitoring multiple displays or multiple sources of information within a single display also tends to harm performance In one study, observers asked to monitor multiple displays detected fewer signals and had more false alarms as the number of displays increased 14

15 Monitoring Multiple FHR Displays One research study had participants monitor one, two, or four FHR tracings and distinguish critical signals As number of tracings increased, fewer critical signals were identified In addition, correct detections decreased as time on the task progressed 15

16 Safety Culture on Labor and Delivery Units Accurate interpretation of FHR requires: –Understanding the physiology of fetal monitoring –Open and clear communication between health care teams –Common buy-in and understanding of chain of command on the unit Often when sentinel events occur on labor and delivery units, the cause is traced to lack of clear communication and a culture that does not promote openness In addition, despite central monitoring, providers may be busy with other tasks and there may be no one assigned to monitoring at any given time 16

17 Improving Detection of Events Multiple methods can be used to improve detection of critical signals and minimize vigilance decrements: –Additional training –Having multiple people monitor displays –Limiting duration of monitoring In addition, system may provide warnings based on computer analysis of FHR tracings 17

18 Computer-Based Detection May reduce vigilance failures but won't eliminate them –First, creating more sophisticated computer-based detection systems actually shifts the monitoring burden from the users to the system designers –Second, unless a computer-based detection system is completely reliable, users may lose trust in it and come to ignore it or put too much trust in it Either may leave users less able to detect anomalies when they do occur 18

19 This Case This case involved failure to detect significant abnormal FHR tracings during labor Ensuring adequate recognition and action when abnormal FHR tracings are encountered requires: –Open and transparent communication between health care teams –Ongoing education and training to help providers identify subtle fetal heart rate abnormalities –Chain-of-command protocols to allow for quick resolution of disagreement when it arises –Ongoing review of near-misses and poor outcomes is also an essential step towards building a safer system and a safety culture 19

20 Take-Home Points FHR monitoring on labor and delivery is a complex process that is often affected by staff education and training, staffing levels, and the unit safety culture Centralized monitoring introduces significant changes in the way patients are monitored. These changes are accompanied by some obvious advantages and some less obvious disadvantages Attempts to combat monitoring deficits in other high-risk domains with more sophisticated technology have reduced but not eliminated failures of attention Improving communication on the labor and delivery unit and establishing an ultrasafe and resilient culture that promotes transparency are two major components of accurate interpretation of FHR 20

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