best practices in efm definition, interpretation, and ... · 5/17/2011 · best practices in efm...

BEST PRACTICES IN

EFM DEFINITION, INTERPRETATION,AND MANAGEMENTA STATEWIDE CAMPAIGN TO STANDARDIZEELECTRONIC FETAL MONITORING EDUCATION

FINAL REPORT ■ May 2011

A COLLABORATION OF

A STATEWIDE CAMPAIGN TO STANDARDIZE ELECTRONIC FETAL MONITORING EDUCATION: FINAL REPORT

A COLLABORATION OF HANYS, ACOG, AND NYSDOH | MAY 2011 1

New York State’s Obstetric Safety Initiative: Providing Excellence in Electronic Fetal Monitoring (EFM) was atwo-year quality improvement initiativewith the goal of improving fetal out-comes and reducing liability exposure inNew York State by standardizing themethods by which obstetric team mem-bers define, interpret, communicate,document, and manage fetal heart ratetracings. Improving staff competenciesin this area is of critical importance be-cause EFM can warn the obstetric team

of potential fetal complications, en-abling clinicians to take action to avertor mitigate adverse outcomes.

Through the provision of regional train-the-trainer programs and subsequentongoing education and program sup-port, multi-disciplinary obstetric teamsat the participating institutions workedto educate their obstetric staff and im-plement a standardized approach toEFM interpretation and management.

EXECUTIVE SUMMARY

■ Nearly 400 multi-disciplinary obstet-ric providers attended the Initiative’strain-the-trainer programs, whichwere effective in improving and sus-taining EFM knowledge.

■ The majority of “trainers” used theknowledge obtained to educateother staff at their institutions,achieving a mean educational pene-tration of 95% for nurses and 78%for physicians receiving standardizedEFM training at participating hospitals.

■ As a result of the Initiative, at least382 obstetric providers in New YorkState are now certified in EFM by theNational Certification Corporation(NCC).

■ At least 38% of participating hospi-tals linked EFM competency to clini-cal privileging and re-credentialingrequirements.

■ Nearly all (94%) hospitals imple-mented one or more practice im-provements as a result of theInitiative and these intermediateprocess improvements have alreadyand will continue to contribute toimproved patient outcomes.

■ The Initiative illustrated that requir-ing EFM credentialing and providingmulti-disciplinary EFM educationcan help reduce challenges associ-ated with physician engagement,and improve adoption and imple-mentation of certain practicechanges.

■ The Initiative enhanced the safetyculture in participating hospitals,which reported significant improve-ments in both team communica-tions and collaboration.

The Initiative achieved tremendous success; highlights are illustrated below:

BEST PRACTICES IN EFM DEFINITION, INTERPRETATION, AND MANAGEMENT

A COLLABORATION OF HANYS, ACOG, AND NYSDOH | MAY 20112

New York State’s Obstetric Safety Initiative: Providing Excellence in Electronic Fetal Monitoring was the firstphase of an obstetric quality improve-ment initiative that was conducted fromDecember 2008 through March 2011.This phase of the Initiative focused onEFM, providing multi-disciplinary hospi-tal obstetric teams with vital training onhow to interpret, communicate, and effectively respond to fetal heart rate(FHR) tracings. Eighty-six hospitals fromacross the state, representing large academic teaching hospitals and smallercommunity hospitals, participated inthe program.

EFM is the most common method ofintrapartum surveillance, used in ap-proximately 85% of births nationwide.Appropriate utilization and a standard-ized approach to interpretation of EFMcan warn the obstetric team of poten-tial fetal complications that may leadto injury, including brain damage ordeath.

Unfortunately, hospital obstetric teamshave not universally implemented astandardized approach to interpretingand managing EFM. Variation in the interpretation of FHR tracings and poorcommunication of FHR patterns cancontribute to adverse perinatal out-comes to the mother and baby andlead to communication, trust, and pa-tient safety issues among caregivers.

The Initiative’s goal was for obstetricproviders throughout New York Stateto use a standardized approach to EFM definition, interpretation, and

management, thereby improving fetaloutcomes and reducing liability exposure for hospitals and other organizations.

A collaboration of Healthcare Educational and Research Fund, Inc.,an educational affiliate of HANYS; the American Congress of Obstetriciansand Gynecologists (ACOG), District II;and New York State Department ofHealth (NYSDOH), the Initiative wasgenerously funded by the New YorkState Health Foundation. The Initiativewas also guided by a multi-disciplinary expert EFM Task Force of clinicians and hospital administrators. While the first phase of the Initiative has concluded, a second phase is under development to focus on other areas of obstetric safety.

INTRODUCTION



Train-the-Trainer Education ProgramsThrough regional train-the-trainer pro-grams held during the summer of 2009,obstetric teams from participating hos-pitals were provided with education tostandardize the definition, interpreta-tion, communication, and managementof FHR tracings within hospital obstetricunits. The education programs pro-vided in-depth training on the use oftools and related techniques, such ascrew resource management principles,to overcome implementation and com-munication barriers, and also provideda component on the legal implicationsof EFM. The programs were presentedby nationally renowned faculty in EFMeducation and legal implications, DavidMiller, M.D., F.A.C.O.G., and Lisa Miller,C.N.M., J.D. A resource kit, completewith training module slide presenta-tions, post-test questions, and researchmaterials was provided to all partici-pants as a standardized resource to beused to disseminate the training totheir obstetric colleagues.

Ongoing Support and EducationFollowing the educational sessions, theparticipants educated their hospitalpeers to use the standardized NationalInstitute of Child Health and Human Development (NICHD) EFM nomenclature.

Over the next year, HANYS worked incollaboration with ACOG and NYSDOHto help hospitals implement EFMtraining at their facilities using a multi-faceted approach that included Web-conferences designed to educate andaddress implementation issues,monthly electronic communication, in-centives to take the NCC EFM exam,and offering technical assistance fromclinical advisors.

Certification Exam in EFMThe Initiative also offered select individ-uals from each institution the opportu-nity to take the NCC EFM examinationand receive reimbursement for examregistration costs. The exam providedhospitals a tool to assess staff compe-tency on the visual interpretation ofFHR tracings. Hospitals’ experiencewith the exam helped them determineif they would pursue it as a method toassess staff competency in the future.To help obstetric staff prepare for theexam, HANYS offered three Web-basedNCC EFM review sessions presented bythe Initiative’s clinical advisors.

THE INITIATIVE’S APPROACH

www.acogny.org



Data and ReportsHospitals reported data to HANYS pertaining to their culture of safety,perinatal indicators, and in-house edu-cation programs. Utilizing these data,HANYS developed and disseminatedconfidential, blinded, hospital-specificcomparative reports to each hospitalparticipating in the Initiative. The reports served as a valuable tool, enabling participating hospitals tobenchmark themselves against theirpeers in New York State.

EFM eToolkitAt the conclusion of this phase of theInitiative, a Web-based EFM eToolkitwas developed to provide obstetricstaff with up-to-date information onevidence-based research and addi-tional resources to ensure ongoingEFM competency.

Several methods were used to analyzethe impact of this Initiative, includingevaluation of the education programs,pre- and post-tests of train-the-trainerparticipants, and a final evaluation survey.

The final evaluation survey was distrib-uted to the lead point people at eachinstitution. The response rate of 65%was representative of the various typesof participating hospitals. A small, non-monetary incentive was used toencourage institutions to respond tothe survey.

EVALUATION

Train-the-Trainer ProgramsNearly 400 obstetric providers, includ-ing physicians, nurses, and midwiveswere trained to use a standardizednomenclature for interpreting andcommunicating EFM through the sixtrain-the-trainer education programsprovided across New York State. Theprograms received outstanding re-views, with an overall satisfaction scoreof 4.91 out of a possible 5.0.

The program goal was not only toteach providers EFM interpretation andmanagement, but to give them thetools and resources needed to educateothers in their individual obstetricunits. Participants expressed a commit-ment to train their obstetric teamsand, according to a final evaluation sur-vey, the majority of trainers fulfilledthis commitment.

RESULTS

HIGHLIGHTS AND LESSONS LEARNED■ Train-the-trainer programs

can be an effective methodto broadly disseminate education when the trainersare comprised of multi-disciplinary providers andwhen their institutions pri-oritize EFM training.

■ The vast majority of surveyrespondents (89%) statedthat attendees of the train-the-trainer programs educated staff at their institutions.

■ Respondents reported thatan average of 95% of nursesand 78% of physicians attheir facilities receivedstandardized EFM training.

■ All survey respondentsagreed the Initiative pro-vided them with valuabletools necessary to trainstaff in standardized EFMinterpretation and management.

■ All survey respondentsagreed that the trainingwas directly applicable totheir clinical duties.

5A COLLABORATION OF HANYS, ACOG, AND NYSDOH | MAY 2011




FIGURE 1:

Methods of EducationOffered classes on EFM

Presented at nursing staff meetings

Presented at OB department meetings

Distributed Initiative Resource Packet for self-education

Required nurses take General Electric online course

Required nurses take Advance Practice Strategies online course

Required physicians take General Electric online course

Presented through grand rounds

Other

Required physicians take Advance Practice Strategies online course

Education TechniquesThe Initiative emphasized that hospi-tals should use a multi-faceted ap-proach to educate obstetric staff, andthe survey results indicate that hospi-tals followed that approach. Seventy-five percent of respondents indicatedthat they offered focused classes onEFM (see Figure 1).

Another method to ensure providersare educated and competent in stan-dardized EFM interpretation and man-agement is to link EFM competency toprivileging and re-credentialing forphysicians and midwives. As part of theInitiative, HANYS and ACOG promotedthe development of organization-specific education and competency re-quirements in EFM, which may includeprivileging and credentialing criteria.

Throughout the Initiative, the value ofinter-disciplinary education was

promoted by encouraging hospitals totrain nurses and physicians together.Our final evaluation indicated that 56%of respondents did, in fact, conductinter-disciplinary EFM training.

As a result of efforts by HANYS, ACOG,and NYSDOH, more than 38% of hospi-tals in the Initiative made EFM educa-tion and competency a requirement forclinical privileging and re-credentialing.This is an increase from the interimevaluation conducted in April 2010,which placed this requirement at 23%.

Hospitals employed a variety of ap-proaches to implement the credential-ing requirement, including requiring anannual EFM post-test, certification viathe NCC EFM exam, or completion ofan online EFM education course, whichthe Initiative promoted as anothermethod to educate obstetric staff.

HIGHLIGHTS AND LESSONS LEARNED■ Hospitals used a multi-

pronged approach to edu-cate staff on EFM interpre-tation and management.

■ Slightly more than half(56%) of survey respon-dents conducted a multi-disciplinary approach toEFM education involvingphysicians and nurses. Ben-efits of multi-disciplinaryeducation are numerous,and it is hoped more hospi-tals follow this approach inthe future.

■ There is a growing trend inNew York State to link EFMcompetency to privilegingand re-credentialing: 78%of survey respondents saidthe Initiative made theirhospital consider makingEFM competency part ofcredentialing and privileg-ing; and at least 38% imple-mented this requirement.



Education Implementation Challenges The EFM education was successfullyimplemented, as measured by changesin test scores and the percentage ofstaff who passed the NCC exam.

However, hospitals still faced barriersin their efforts to standardize practice,including lack of physician engagementand leadership, and lack of profes-sional time available to disseminatethe education (see Figure 2).

FIGURE 2:

Education ImplementationChallenges Physician engagement

Time constraints

Staffing shortages

Financial restraints/cost of training

Nurse engagement

Room/technology constraints

Gap in leadership

No one to provide the education

Other

None

In analyzing the final evaluation re-sults, the project team found thatwhen nurses and physicians train together or when hospitals requireEFM competency for credentialing,hospitals’ challenges associated withphysician engagement can be reduced (see Figure 3).

FIGURE 3:

Implementation Challengeby Credentialing Requirements

Hospitals reporting physician engagement challengeby credentialing requirements



FIGURE 4:

Implementation Challenges by Training Approach

However, providing multi-disciplinaryeducation can result in additional chal-lenges in some areas compared withtraining providers separately. These include additional time constraints,higher training costs, and challengesassociated with nurse engagement (see Figure 4).

HIGHLIGHTS AND LESSONS LEARNED■ Physician engagement challenges and time constraints were the most

common challenges in implementing EFM education at the participatinginstitutions. More work needs to be done to elicit physician support andprioritize EFM education and training.

■ EFM credentialing and multi-disciplinary education can improve physi-cian engagement; however, those methods alone are not enough.

■ Multi-disciplinary education can be more challenging to implement;however, as noted in later results, the benefits can be significant.



FIGURE 5:

EFM Pre-Test and Post-TestMean Percent of CorrectResponses

HIGHLIGHTS AND LESSONS LEARNED■ The education programs

were effective in improvingEFM knowledge as evi-denced by improvement in test results.

■ While the post-testsshowed improvement, con-tinued reinforcement andrepetition of the NICHD ter-minology and definitions isneeded to sustain knowl-edge over time.

EFM Pre- and Post-Tests To assess the trainers’ knowledge andretention following the train-the-trainer EFM education programs, theproject team administered a test be-fore the start of the training program,followed by a test at the end of thetraining program—the post-test wasoffered again at six and 18 months fol-lowing the pre-test.

The pre-test demonstrated a notewor-thy gap in knowledge among partici-pants and demonstrated a significantneed for education and training in astandardized approach to EFM defini-tion, interpretaton, and management

(see Figure 5). The average percent ofcorrect responses for the pre-test wasonly 49%.

The Initiative team observed substan-tial improvements in post-test results,indicating that the education was highlyeffective in improving knowledge. Moreimportantly, the knowledge was re-tained as a result of clinicians using thestandardized nomenclature. Comparingthe pre-test to the post-test adminis-tered in December 2010, more than ayear later, the average percent changeincrease in correct responses was a re-markable 104%.

Pre-test(June/July 2009)

Post-test(June/July 2009)

Post-test(Dec. 2009)

Post-test(Dec. 2010)



NCC EFM Exam ResultsSelect individuals from each institutionwere given the opportunity to take theNCC EFM exam and receive reimburse-ment for the exam registration costs.While HANYS reimbursed 169 individu-als for the cost of the exam, at least510 providers, including nurses, physi-cians, and midwives took the examsince the summer of 2009. Of theseproviders, 382 (75%) passed, which isconsistent with the national average.

Moreover, 76% of survey respondentsagree that participation in the Initiativewas instrumental in encouraging someof their obstetric staff to take the NCCEFM exam, accomplishing one of themajor objectives of the Initiative.

Building a Culture of SafetyOne of the objectives of this Initiativewas to encourage a culture of safetywithin each obstetric department andunit. The regional train-the-trainer ed-ucation programs provided hospitalswith tools to assist in improving theirpatient safety culture, including incor-porating crew resource managementprinciples.

Importantly, the Initiative also enabledhospitals to distribute the nationally

recognized and validated Agency forHealthcare Research and Quality(AHRQ) Hospital Survey to multi-disciplinary obstetric staff via an on-line, Web-based tool. The AHRQ Hospital Survey provides hospital lead-ers with the basic knowledge neededto conduct an effective safety cultureassessment. It can be used to trackchanges in patient safety over time andto evaluate the impact of patient safetyinterventions, such as EFM educationand training.

The AHRQ Hospital Survey was offeredtwice during the Initiative; while partic-ipation was voluntary, 60 hospitalschose to respond. The project teamwas pleased with this response ratebecause a number of hospitals were already conducting a culture of safetysurvey and were thus unable to partici-pate in another survey through this Initiative.

While the timeframe for this Initiativewas insufficient to decipher trends andchanges in the AHRQ Hospital Surveyresults, according to the final evalua-tion, a remarkable 96% of respondentsagreed that the Initiative helped im-prove their culture of safety.

A major component contributing to aculture of safety is improved communi-cation among providers. Nearly all(95%) survey respondents agreed thatthe Initiative improved inter-disciplinarycommunication and collaboration re-lated to EFM.

HIGHLIGHTS AND LESSONS LEARNED■ At least 382 obstetric

providers in New York Stateare now certified in EFM,representing a 75% passrate for test takers. Thisnumber is consistent withthe national average.

■ The Initiative successfullyencouraged more obstetricstaff to take the NCC EFMexam.

HIGHLIGHTS AND LESSONS LEARNED■ Providing vital training on how to interpret, communicate, and effectively

respond to FHR tracings can help improve an obstetric unit’s patientsafety culture, including improved inter-disciplinary communication.

■ Ninety-six percent of survey respondents agreed that the Initiative helpedimprove their culture of safety.



Practice ImprovementsWhen surveyed, 94% of participants indicated that they implemented oneor more practice improvements as a

result of this Initiative. It is anticipatedthat such improvements will lead toimproved outcomes in the future (see Figure 6).

FIGURE 6:

Practice ImprovementsImplemented Improved staff communication

Nurse presentation to physicians using the NICHD nomenclature

Physician documentation based on NICHD nomenclature

Measurement of cord blood gas for high-risk patients

Intrapartum fetal heart rate monitoring management decision

Standardized interpretation

No change observed

Other



■ The method used to disseminateand encourage EFM educationcan impact the effectiveness ofthe program in improving practice.

■ Nearly all (94%) survey respon-dents indicated that they imple-mented one or more practice improvements.

■ Hospitals implemented a greaterpercentage of certain practiceimprovements if EFM compe-tency was tied to credentialingor they provided multi-disciplinary EFM education.

■ The overall improvement in staffcommunication was greater inhospitals that tied EFM compe-tency to credentialing and inhospitals that provided multi-disciplinary EFM education.

■ Despite the additional challengespresented by multi-disciplinaryEFM education, it appears thatovercoming those challenges can lead to better practice improvements.

Practice improvements varied depend-ing on whether a hospital linked EFMcompetency to credentialing andwhether a hospital implemented multi-disciplinary EFM training (see Figure 7).Both approaches appeared to have sig-nificant impacts on the types of prac-tice improvements implemented. Themost dramatic results can be found inthe perceived improvement in inter-disciplinary communication, with bothEFM credentialing requirements andmulti-disciplinary training yielding bet-ter results (see Figure 8, next page).

FIGURE 7:

Practice Improvements by Hospital CredentialingRequirements

HIGHLIGHTS AND LESSONS LEARNED



FIGURE 8:

Practice Improvements byTraining Approach

Perinatal IndicatorsAnalysis of perinatal outcomes for thisInitiative was a significant challenge,primarily due to a combination of thelow volume of “events” in obstetricsand the short timeframe for analyzingdata. In addition, it required severalmonths to a year for participants tofully implement and conduct the train-ing at their institutions.

Hospitals were asked to submit perina-tal indicator data over a two-year period, including baseline data. Theperinatal indicator portion of the Initiative was vital to help hospitalsbenchmark themselves against theirpeers and begin to trend their indicatorsover time. HANYS is examining methodsto continue to collect data following theconclusion of this phase of the Initiative.

HIGHLIGHTS AND LESSONS LEARNED■ While the Initiative was not

yet able to demonstrate improvements in perinataloutcomes due to the shorttimeframe, it is anticipatedthat the intermediateprocess improvements willhelp improve outcomes inthe future.



SustainabilityThis program has had many successes;however, the key to sustainability iscontinued quality improvement. Manyof the Initiative’s Webconferences fo-cused on methods to sustain ongoing

EFM education and competency. According to the final survey, 93% ofrespondents implemented initiatives to assess ongoing quality and compe-tency in EFM interpretation and management (see Figure 9).

FIGURE 9:

Quality ImprovementMethods for EFM Periodic chart reviews

Reviewing EFM strip reviews at department meetings

Incorporation of EFM strip reviews in rounds

Incorporation of quality assurance and peer review programs

Redistribution of EFM post-test

No plan implemented

Other

It is the hope of the project team thatthe Initiative’s Web-based EFM eToolkitwill keep obstetric providers up to dateand current on the latest evidence-based research and provide them withadditional tools to sustain ongoing EFMcompetency. The toolkit, available atwww.acogny.org, includes an EFM tuto-

rial, a resource center, and various as-sessment tools to help hospitals imple-ment EFM education and training attheir institutions. The toolkit will con-tinue to be accessible on the ACOG District II Web site to all obstetricproviders, their staff, and the public inNew York State and across the country.

HIGHLIGHTS AND LESSONS LEARNED■ Ninety-three percent of re-

spondents indicated theyhave implemented at leastone method to monitor ongoing EFM competency.This demonstrates that hos-pitals are committed tomaintaining EFM compe-tency over time.



New York State’s Obstetric Safety Initiative: Providing Excellence in Electronic Fetal Monitoring was onecomponent of a broader patient safetyagenda in obstetrics. By working to-gether, HANYS, ACOG, and NYSDOHwere able to provide participating hos-pitals an opportunity to enhance staffcompetency in the interpretation, com-munication, and management of FHRtracings based on the standardizednomenclature.

Hospitals participating in this patientsafety collaborative reported improve-ments in multi-disciplinary communica-tions, clinical practice, and overall EFMknowledge, demonstrating that this

Initiative is effective in helping to en-hance the culture of safety in hospitals.

While there were several successeswith this Initiative, significant changesin practice on obstetric units take time,and ongoing education and continuedquality improvement are essential forcontinued success.

While working to improve obstetriccare in New York, this program has thepotential to serve as a model for othereducation programs around the country. HANYS, ACOG, and NYSDOHwill seek opportunities to broadly dis-seminate and publish the Initiative’sfindings.

CONCLUSION

CONTACT INFORMATION:

HEALTHCARE ASSOCIATION OF NEW YORK STATEKathleen Ciccone, R.N., M.B.A., Executive Director, HANYS Quality InstituteChrista Christakis, M.P.P., Director, Quality and Research Initiatives

AMERICAN CONGRESS OF OBSTETRICIANS AND GYNECOLOGISTS DISTRICT IIDonna Montalto, M.P.P., Executive DirectorKelly Gilchrist, Medical Education and Patient Safety Manager

NEW YORK STATE DEPARTMENT OF HEALTHJohn Morley, M.D., Medical Director, Office of Health Systems Management



Thank YouHANYS, ACOG, and NYSDOH would like to express our appreciation to all of the Initiative participants for their dedication and commitment to this quality improvement effort. In addition, we thank the following organizations and individuals:

■ New York State Health Foundation

■ EFM Task Force

■ EFM Task Force Co-chairs:

● Joel Seligman, President and Chief Executive Officer, Northern Westchester Hospital, Mount Kisco, NY

● Richard Berkowitz, M.D., F.A.C.O.G., Professor of Obstetrics and Gynecology, NewYork-Presbyterian Hospital–Columbia University Medical Center, Division of Maternal Fetal Medicine, New York, NY

■ Faculty:

● David Miller, M.D., F.A.C.O.G., Professor of Clinical Obstetrics, Gynecology and Pediatrics, Children’s Hospital, Los Angeles, CA

● Lisa Miller, C.N.M., J.D., President of Perinatal Risk Management and Education Services, Chicago, IL

■ Clinical Advisors:

● Brian Wagner, M.D., F.A.C.O.G., Jacobi Medical Center, New York, NY

● James Woods, Jr., M.D., F.A.C.O.G., Chairman, Department of Obstetrics and Gynecology, University of Rochester Medical Center,Rochester, NY

● Joanne Weinschreider, R.N., M.S., Director, Nursing Simulation Lab, Wegmans School of Nursing, St. John Fisher College, Rochester, NY

best practices in efm definition, interpretation, and ... · 5/17/2011 · best practices in efm...

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