Search

BackgroundQuality improvement (QI) projects comprise the majority of University of Maryland School of Nursing (UMSON) Doctor of Nursing Practice (DNP) projects.MethodsAn online survey was completed by 51% (n = 38) of faculty, who teach or mentor DNP students, and was analyzed using quantitative and descriptive methods.ResultsFaculty were somewhat or not familiar with developing a QI charter 68.4%, human error theory and error proofing 63.2%, driver diagrams 60.5%, characteristics of high-reliability organizations 60.5%, and Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines 55.3%. The faculty were most interested in learning more about (n = 97 responses) were human error theory and error proofing (28.9%), SQUIRE guidelines (26.3%), statistical process control (21.1%), and implementation strategies and tactics (21.1%). The most commonly identified challenges included identifying QI projects (24%), project time constraints (16%), keeping up-to-date on QI concepts, methods, and tools (12%), and balancing professional workload (10%).ConclusionsGaps in self-reported QI knowledge indicate there is a need for further development of DNP and PhD prepared faculty at the UMSON.

BACKGROUND A final culminating project that is derived from a practice immersion experience is a critical part of a doctor of nursing practice (DNP) program. PROBLEM Many schools use well-designed quality improvement (QI) projects to meet this requirement, but there is no consensus on which QI methods and tools are the most effective for DNP students to demonstrate before graduation. APPROACH One Mid-Atlantic public university began using QI process models, one of which was a logic model, to guide their DNP projects. This led to subsequent changes in the curriculum, faculty preparation, and practice partner responsibilities. OUTCOME Many benefits and challenges were identified during the logic model implementation that may benefit other schools seeking to increase consistency and rigor. Although the learning process for students and faculty may be challenging, the outcomes included improved project conceptualization, clarity, concision, and feasibility of goal attainment. CONCLUSIONS Use of logic models expands DNP students' skills to develop and implement a successful project and supports clinical scholarship.

A key component of the DNP project rigor is the collection and analysis of data or measurement. A Steering Committee at the University of Maryland formed to improve the quality of DNP projects established a workgroup to evaluate the current measurement content in four DNP core courses with the goal of establishing DNP project measurement criteria across the curriculum. The steps included: Step 1: Identify QI Measurement Methods and Tools. Identify the essential QI measurement methods and tools recommended by national organizations. Step 2: Create a DNP Measurement Grid. Define main data methods topics with subtopics. Step 3: Map the DNP core courses. Using the DNP Measurement Grid criteria determine the measurement content included in each course and student mastery level. The level of mastery was ranked from introduced (awareness), to reinforced (knowledge), to demonstrated (application). Step 4: Evaluate and Refine the DNP Measurement Grid Criteria. Adjustments were made in the DNP curriculum to include topics and subtopics at the desired mastery level. The rigor of data measurement and analysis will be evaluated in future DNP projects. The workgroup's four-step process provides a path that facilitated improving curriculum measurement content. This process may provide guidance for others undertaking similar work.

There is currently a lack of consensus on the best format for Doctor of Nursing Practice project deliverables. In this article the project course history, current format, and evaluation methods are described for a Doctor of Nursing Practice program during the transition from a sole post-master's option to one that also admitted post-baccalaureate students. The project course format shifted focus from one in which students independently implemented multiple types of projects under the direction of a chairperson and committee to one in which students carried out projects utilizing quality improvement methods and tools under the mentorship of a project faculty advisor and clinical site representative. The integration of quality improvement models is exemplified through course objectives and assignments. Lessons learned through this transition are provided in the hope that the work may benefit other nursing schools with similar programs.

BACKGROUND Admission in early labor is associated with increased likelihood of cesarean birth, but the context in which this occurs is unclear. Previous research has explored the relationship between dilatation at admission and the use of single intrapartum interventions; however, the majority of women in the United States receive multiple intrapartum interventions. The objective of this study was to examine the associations among cervical dilatation at admission, intrapartum care, and birth mode in low-risk, nulliparous women with spontaneous onset of labor. METHODS This was a cross-sectional, observational study of 21 858 nulliparous, singleton, term vertex births that occurred from 2002 to 2007 across nine hospitals in the Consortium on Safe Labor. Outcome measures included the individual and combined use of intrapartum interventions (amniotomy, epidural anesthesia, oxytocin augmentation) and birth mode. RESULTS In this sample, 92.0% of women received at least one intrapartum intervention and 22.7% received all three interventions. After propensity score adjustment, women were more than twice as likely to receive the combination of amniotomy-epidural-oxytocin when admitted at 0-3 cm (RR 2.83 [95% CI 2.45-3.27]) and 4-5 cm (2.49 [2.15-2.89]) compared to 6-10 cm. Adjusted likelihood of cesarean birth was five times greater for women admitted at 0-3 cm (5.26 [4.36-6.34]) and two times greater for women admitted at 4-5 cm (2.27 [1.86-2.77]) compared to 6-10 cm. CONCLUSIONS To promote normal physiologic birth, low-risk, nulliparous women should be engaged in shared decision-making about timing of admission after spontaneous onset of labor.

Background Input from practice leaders will improve how doctor of nursing practice (DNP) education is meeting the needs of the employer and improving patient outcomes. Purpose This article describes the expectations practice leaders have of new DNP graduates' ability to contribute to quality improvement (QI) efforts within health care organizations. Methods A survey of practice leaders and QI experts investigated the importance and use of QI knowledge and skills. Practice leaders were also asked about the expectations of DNP graduates at the time of hire. Results The results of this study support the need for nurses pursuing a DNP in advanced nursing practice to have education and training beyond their area of specialization, specifically in QI methods and tools. Conclusions Faculty need to provide DNP students education that includes concepts in QI and leadership to meet the expectations of future employers and the needs of a complex and changing health care system.

PURPOSE The purpose of this study was to assess postpartum nurses' knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications. STUDY DESIGN & METHODS Registered nurses (RNs) who care for women during postpartum (N = 372) completed an electronic survey. Descriptive statistics and bivariate analyses were used for data analysis. RESULTS Fifty-four percent of nurse participants were aware of the rising rates of maternal mortality in the United States and 12% accurately reported the correct percentage of deaths that occurred during the postpartum period. Ninety-three percent of nurses were more likely to identify hemorrhage as a leading cause of maternal mortality. On the day of discharge, 67% of RNs spent less than 10 minutes focusing on potential warning signs. Ninety-five percent of RNs reported a correlation between postpartum education and mortality; however, only 72% strongly agreed it was their responsibility to provide this education. Nurse respondents who were over the age of 40 were significantly more likely to report feeling very competent when providing education on all of the postpartum complication variables measured (p values

Maternal morbidity and mortality rates remain high in the United States compared with other developed countries. Of particular concern is the rise in postpartum deaths, because many of the risk factors for complications associated with maternal morbidity and mortality may not be clearly identified before a woman's discharge after birth. Although nurses provide some form of postpartum discharge education to all women who give birth, the information women receive on common potential complications is not always consistent or evidence based. By improving postpartum education, nurses may be better poised to teach women how to recognize and respond to warning signs. This article describes a project intended to increase women's access to predischarge education about the risks for postbirth complications.

Rates of maternal morbidity and mortality in the United States have increased since 1990. Registered nurses are members of the health care work force who provide essential care to women during pregnancy, during birth, and after birth. Tools are needed to more effectively measure and track the effect of nursing care on maternal health outcomes. The Association of Women's Health, Obstetric and Neonatal Nurses and the Association of Maternal & Child Health Programs co-convened an expert panel to develop a set of tools for use by public health and clinical leaders to support this effort.

Objective To explore what types of educational materials and discharge information are currently used by postpartum nurses to educate women about the warning signs of postpartum complications to determine what key messages should be presented to women after birth and before discharge. Design Exploratory qualitative. Setting Six hospitals located in New Jersey and Georgia. Participants Fifty-two nurses. Methods Six focus group discussions were conducted using a semistructured interview guide to elicit data on how and what nurses taught women about maternal post-birth warning signs. The focus group discussions were audiotaped, transcribed, coded, and clustered into categories. Results Most nurses described some of the warning signs related to maternal morbidity and mortality to the women; however, these elements were not the primary focus of the education throughout the hospital stay and were most often discussed on the day of discharge. Nurses also did not consistently describe the same signs and symptoms of the warning signs with each and every woman. The primary mechanism for education consisted of individualized instruction with booklets or folders of information. Conclusion These data indicate that improvements may be needed in how nurses educate women who just gave birth about the most common post-birth warning signs before they are discharged from the hospital. These findings also suggest that nurses need more information and guidance on how to teach all women about the post-birth warning signs.

Use of skin-to-skin contact after birth supports a newborn's physiologic transition from intra- to extrauterine life, mother-infant bonding, and the initiation of breastfeeding. Nursing Care Quality Measures 3 and 4 (Skin-to-Skin is Initiated Immediately Following Birth and Duration of Uninterrupted Skin-to-Skin Contact) from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) were developed to support quality improvement efforts to increase skin-to-skin contact. AWHONN's nursing care quality measures were found to be feasible in hospitals in which medical records were configured to document the start and stop times of skin-to-skin contact. Electronic health records can be modified so that more accurate quality improvement data on immediate and continuous skin-to-skin contact are available. More accurate data will support validity testing.

Introduction Cesarean birth rates vary widely across hospitals in the United States, even among women who are considered low-risk for the procedure. This variation has been attributed to differences in health care provider practice, but few studies have explored patterns of labor management in relation to cesarean birth. Methods This was a retrospective observational study of 26,259 nulliparous, term, singleton gestation, vertex presentation births following spontaneous onset of labor. Births occurred from 2002 to 2007 in 11 hospitals in the Consortium on Safe Labor. Generalized linear mixed modeling was used to examine the relationship between intrapartum interventions (amniotomy, epidural analgesia, oxytocin augmentation) used individually and in combination and the outcome of cesarean birth. Results More than 90% of the women in this low-risk sample received at least one intervention regardless of mode of birth. Epidural analgesia was the most frequently applied intervention, both when used as a single intervention (18.7%) and in combination with other interventions (79.9%). The strongest associations between these interventions and cesarean birth were observed when 2 or 3 interventions were applied during labor. Compared with women who received no interventions, the strongest association was observed among women who received amniotomy-oxytocin augmentation (adjusted odds ratio [aOR], 1.89; 95% CI, 1.36-2.62). The use of all 3 interventions (amniotomy-epidural analgesia-oxytocin augmentation) showed a similar positive association with cesarean birth (aOR 1.83; 95% CI, 1.50-2.21). Discussion Findings show that the combined use of amniotomy, epidural analgesia, and oxytocin augmentation is positively associated with cesarean birth. Additional research is needed to examine the timing and sequence of interventions as well as whether a causal relationship exists between combinations of interventions and cesarean birth in low-risk nulliparous women.

Objective To identify the presence or absence of 38 postpartum hemorrhage preparedness elements in hospitals in New Jersey and Georgia as a component of the Postpartum Hemorrhage Project of the Association of Women's Health, Obstetric and Neonatal Nurses. Design Quality improvement baseline assessment survey. Setting Hospitals ( N = 95) in New Jersey and Georgia. Participants Key informants were clinicians who were members of their hospitals' obstetric teams and were recognized as knowledgeable about their hospitals' postpartum hemorrhage policies. Methods An electronic survey was sent by e-mail to each identified hospital's key informant. Results The mean number of elements present was 23.1 ( SD = 5.2; range = 12–34). Volume of births, students, magnet status, and other hospital characteristics did not predict preparedness. None of the hospitals had all of the 38 preparedness elements available. Less than 50% of the hospitals had massive hemorrhage protocols, performed risk assessments and drills, or measured blood loss. For every 10% increase in the total percentage of African American women who gave birth, there was a decrease of one preparedness element. Conclusion Objective measures of preparedness are needed, because perceptions of preparedness were inconsistent with the number of preparedness elements reported.

Objective To describe the development and content validity testing of the Maternal Fetal Triage Index (MFTI), a standardized tool for obstetric triage. Design Online survey. Participants Participants included 15 registered nurses, 15 certified nurse-midwives, and 15 physicians from across the United States who provided maternity care. Methods A convenience sample of experienced clinicians was used as content validators for the MFTI. An item content validity index (I-CVI) was computed for the tool's items and a scale content validity index (S-CVI) was computed for the tool's scale based on the responses submitted via the online survey. Two rounds of content validation occurred. Results In the first round of testing, a total of 12 of 61 items in the MFTI did not meet the I-CVI threshold of greater than 0.78 because of disagreement about clinical condition (75%) or priority level placement (25%). In the second round of testing, all but 3 of the 69 content items in the revised version of the MFTI had I-CVI thresholds greater than 0.78. These 3 items were related to vital sign values. The overall S-CVI score calculated for Round 2 only was 0.95, whichwas greater than the threshold of 0.90. Conclusion The results of the content validity testing of multidisciplinary validators suggest that the MFTI is a valid tool for use in obstetric triage and evaluation settings.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

Objective To describe the structures and processes implemented during the Association of Women's Health, Obstetric, and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project. Design An 18-month, multiregion, multihospital quality improvement project. Setting/Local Problem Fifty-eight hospitals located in Washington, DC; Georgia; and New Jersey. Participants Volunteer registered nurse hospital leaders implemented the AWHONN PPH bundle, which consisted of structure and process improvements. Intervention/Measurements The process and effectiveness of the implementation of the interventions were measured and compared between baseline and after implementation. Results All structures and processes showed improvement but were not fully implemented at all sites. Registered nurse participation in drills increased from 0% to 92%, quantification of blood loss increased from 5% to 45%, hemorrhage risk assessment increased from 10% to 70%, prebirth risk assessment increased from 2% to 52%, postbirth risk assessment increased from 2% to 57%, and debriefing increased from 1% to 13%. No statistically significant differences were found in the pre- and postimplementation outcomes measured (maternal deaths, blood products transfused, women with massive transfusions, peripartum hysterectomies during the birth admission, and ICU admissions for women who gave birth and/or had a postpartum hemorrhage). Participants' self-assessments of their monthly implementation efforts (leader intensity) were not correlated with implementation fidelity (the degree to which the intervention was provided as proposed). Conclusion None of the 58 hospitals were able to implement all of the structure and process changes before the end of the 18-month implementation phase. This suggests that an 18-month implementation phase may be too short.

Objective To measure whether implementation of a comprehensive, 18-month, multihospital, multiregion postpartum hemorrhage (PPH) project influenced intrapartum clinicians’ perceptions of patient safety. Design Pre- and post-survey design. Setting Survey results from eight hospitals in Georgia, New Jersey, and Washington that participated in the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) PPH Project were included in the final analysis. The number of annual births at the hospitals ranged from 1,290 to 3,567. Participants There were 473 respondents for the pre-implementation survey: 50.5% (239) were registered nurses, 27.1% (128) were physicians, and 22.4% (106) were other intrapartum clinicians. The post-implementation survey included 426 respondents: 62.9% (268) registered nurses, 18.5% (79) physicians, and 18.6% (79) other intrapartum clinicians. Intervention/Measurements A paired t test was used to compare Safety Attitudes Questionnaire (SAQ) domain scores. Pearson’s chi-square test was used to analyze perceptions before and after the intervention. Results Baseline SAQ scores were high in all six domains. Improvements were noted in five of the six domains measured; none reached statistical significance. A significant improvement was found in reported perception of the quality of nursing care after implementation of the PPH Project. Conclusion SAQ scores remained high and showed some improvement among participating hospitals. Participation in the PPH Project increased overall perceptions of safety among the clinicians at these hospitals.

Objective To describe the barriers and facilitators to implementing the Association of Women's Health, Obstetric and Neonatal Nurses Postpartum Hemorrhage (AWHONN PPH) Project experienced by hospital leaders, project champions, and staff. Design Qualitative descriptive study with a grounded theory approach. Setting Hospital leaders, champions, and staff from hospitals in New Jersey and Georgia. Participants A total of 21 nurses and physicians who worked at six hospitals shared their experiences with regard to implementation of the AWHONN PPH Project. Methods Interviews were recorded and transcribed verbatim. Analysis included open, selective, and theoretical coding with a constant comparative method of grounded theory. Analysis was complete when a central process emerged. Results Successful implementation of most or all of the program elements was facilitated by support from administrators, positive attitudes, active nurse and physician champions, and an existing culture of safety. When these elements were in place, respondents reported that they believed they made a difference. Barriers to implementation included negative attitudes, lack of champions, poor staff buy in, lack of resources, and lack of support from administrators. When barriers were encountered, respondents felt discouraged and disappointed. Conclusion Although the road to full participation and implementation was difficult for some, lessons were learned by all. Suggestions for future projects include a step-by-step approach that begins with education, the creation and celebration of milestones, and the formation of teams to facilitate buy in and empowerment.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. The safety bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and "Potential Best Practices" to assist with implementation.

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have a role in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) created the Perinatal Staffing Data Collaborative in response to the release of its Guidelines for Professional Registered Nurse Staffing for Perinatal Units. In total, 183 surveys were submitted from 175 birthing hospitals in the United States. These findings represent the largest set of data available to describe current patterns in perinatal registered nurse (RN) staffing. In this article we summarize the findings of the AWHONN Perinatal Staffing Data Collaborative from 2011 through 2012.

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.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.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).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.

Objective To describe the neonatal health risks (hypothermia, hypoglycemia, hyperbilirubinemia, respiratory distress, the need for a septic workup, and feeding difficulties) experienced by late preterm infants (LPIs) from a large multisite study and determine how these risks were affected by gestational age at birth. Design Descriptive analysis of prospective data obtained as part of the AWHONN Late Preterm Infant Research‐Based Practice Project. Setting Fourteen hospitals located through the United States and Canada. Participants Late preterm infants (802) born at gestational ages between 34 0/7 and 36 6/7 weeks. Methods Nurses at each site obtained consent from the mother of the infant. The data about the infant were gathered from the infant's medical record. Results Thirty‐six percent of LPIs were initially cared for in a special care nursery; approximately one half of these infants were eventually transferred to a well‐baby nursery. Of the 64% of LPIs initially cared for in a routine nursery, 10% were transferred to a special care unit or neonatal intensive care unit (NICU). More than one half of LPIs experienced hypothermia, hypoglycemia, feeding difficulties, hyperbilirubinemia, and respiratory distress and/or needed a septic workup. The risk for these problems was higher in infants of younger gestational ages. Thirty‐two percent of the infants were bathed during the first 2 hours of life, and by 4 hours, more than two thirds had had their first bath. Fifty‐two percent received kangaroo care during the first 48 hours of life. Conclusion These findings support those of smaller studies indicating that LPIs are at high risk for developing health problems during their neonatal hospitalization. Nurses may be able to ameliorate some of these health problems through early identification of problems and simple, inexpensive interventions such as avoiding early bathing and promoting kangaroo care.

Obstetric hemorrhage is an emergency situation in which clinicians can make errors that cause women to suffer preventable maternal morbidity and mortality. Scrutinizing commonly occurring obstetric hemorrhage-related practice errors by applying the generic errors modeling system, a research-based framework, to quality improvement efforts facilitates the identification of error specific reduction strategies. The common types of errors are skill-based, rule-based, and knowledge-based active and latent errors.

Nursing Care Women and Babies Deserve describes the core habits of character, also called virtues, that nurses can strive to incorporate into their care of women and newborns. This commentary provides background on the development of Nursing Care Women and Babies Deserve, as well as inspiring examples of how nurses incorporate these virtues into their nursing practice.

Purpose The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project design and approach In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project description The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical implications In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

Purpose of review Quality-improvement activities affect every obstetrician and every birthing service in the country. This review will serve to introduce the obstetric practitioner to the latest evidence of effective quality-improvement methods and provide an understanding of the different roles of the various organizations involved. Recent findings Maternity quality improvement is an interrelated process with quality-improvement activities that occur at the hospital (e.g. protocols, checklists, drills, simulations, data collection and feedback and rapid-cycle quality-improvement projects), quality-improvement activities that occur at the level of a multihospital system or region (e.g. development of materials to support the hospital, development of quality-improvement leaders, provide pressure for change, benchmark outcomes), quality-improvement activities that occur within public agencies (e.g. public education campaigns) and still others that occur at governmental levels (e.g. selecting measures and targets, setting incentives and regulations, collecting administrative data). Quality collaboratives are relatively new, but can serve to jumpstart and coordinate the quality-improvement process among all the institutions involved. Summary This review helps hospital leaders identify the quality-improvement activities that will be most effective for their needs.

Objective To conduct interrater reliability testing of the Maternal Fetal Triage Index (MFTI), a standardized tool forobstetric triage. Design Observational study of a convenience sample of nurses' triage assessments of hospital-based obstetricpatients. Setting: A birth unit of a suburban hospital located in a large metropolitan region with approximately 5,200 birthsannually. Participants Ten registered nurses provided triage assessments of 211 pregnant women. Methods: Using blinded paired triage assessments, we assessed the reproducibility of the triage priority levels assignedusing the MFTI. Results: Priority levels assigned by the MFTI research nurse and the study nurses were in agreement for 154 of the211 (72.9%) triage assessments. The strength of agreement was classified as good based upon the weighted kappascore of 0.65. There was no statistically significant difference in the accuracy of assigning priority levels between theday and night shifts Conclusion: The interrater reliability of the MFTI met the minimum strength of agreement threshold goal of 0.60 whenused by nurses in a large birth unit to assign priority for evaluation. Based on this finding, the MFTI can be recommendedfor use in obstetric triage settings. Additional testing should be done to measure how this standardized tool improvescare processes and outcomes.

Nurse staffing decisions are high-cost decisions. Having too few nurses may cause more mistakes or more episodes of missed care resulting in worse outcomes, increased pain, and additional suffering and health care costs. Having too many nurses increases health care costs. The Organizing Frameworks for Calculating Nurse Staffing and for Evaluating Nurse Staffing Decisions presented in this article build on the American Nurses' Association's principle-based staffing models and Donabedian's framework for evaluating the quality of health care.

As the director of patient-care services for maternal-child health and clinical practice at two large, metropolitan hospitals, the author of this article outlines ways in which childbirth educators can empower women to receive the birth experience they want. Techniques include offering a special prepregnancy class, helping expectant women to formulate questions for their care providers, and encouraging women to express their perceptions of their birth experience by responding to their hospital's patient-satisfaction survey, writing letters, or nominating mother- and baby-friendly nurses for special recognition.

Don’t Rush Me . . . Go the Full 40 is a grassroots public health campaign from the Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) that educates women about the physiologic benefits of full-term pregnancy for themselves and their babies. GoTheFull40.com seeks to increase the percentage of women who complete at least 40 weeks of pregnancy, decrease the percentage of women who choose elective induction or elective cesarean surgery, and increase nurses’ and other pregnancy-care providers’ effectiveness in reducing the number of elective inductions and cesarean surgeries. Childbirth educators and other pregnancy providers are asked to share the campaign with women in preconception and prenatal settings to encourage waiting for spontaneous labor leading to full-term births when all is healthy and well with the mother and fetus.

Lamaze International is pleased to launch the newly revised and updated (as of May 2007) six care practice papers that synthesize best practices that promote, support, and protect normal birth, bonding, and breastfeeding for pregnant women and their support teams. The updated six care practice papers are available as resource materials to start and support conversations of change. Childbirth educators are encouraged to be change champions and to incorporate the six care practices into the maternity care that women receive in their communities.

Nursing for Women's Health convened a group of nurse researchers for a roundtable discussion about the relationship of research to the profession of nursing, how research drives evidence-based practice and how nurses can get involved in research and in its application to the care of women and newborns.

Obstetric hemorrhage remains the leading cause of maternal death in the United States, and 54% to 93% of these deaths may have been preventable. Leaders must honor the lives of women who die from obstetric hemorrhage by reviewing their deaths and sharing lessons learned. Shortening the current 3 to 7 year data gap will allow for timely initiation of quality improvement efforts. Designated leaders and researchers from the Association of Women's Health, Obstetric, and Neonatal Nurses are ideally positioned to lead these quality initiatives.

Debra Bingham, DrPH, RN, is the Vice President of Research, Education, and Publications for the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), Washington, DC. An assumption exists that any woman who gives birth in any hospital in the United States will have access to blood products and other, basic, life-saving therapies and that these hospitals will have an adequate number of highly skilled clinicians (nurses, doctors, midwifes) who can reliably recognize, respond, and manage an obstetric hemorrhage. However, these assumptions have been called into question by multiple researchers who studied the preventability of obstetric hemorrhage-related deaths. In these studies, researchers reported that 54% (Della Torre et al., 2011), 70% (California Department of Public Health, 2011), or even 93% (Berg et al., 2005) of the obstetric hemorrhage-related mortality cases reviewed were judged to be preventable. These researchers found that clinician error was the major factor contributing to maternal deaths. Another very troubling statistic is the overall 3-fold to 4fold racial disparity in maternal mortality. Researchers from the Centers for Disease Control and Prevention (CDC) showed that Black women were equally as likely as White women to have an obstetric hemorrhage, but in women experiencing an obstetric hemorrhage, Black women were 2 to 3 times more likely to die than White women (Tucker, Berg, Callaghan, & Hsia, 2007).

Background/Purpose: Comparisons of pediatric ANCA-associated vasculitis subtypes (AAV) are limited by the paucity of reported cases, standardized definitions, and overlapping classification criteria. Published work from ARChiVe (A Registry for Childhood Vasculitis) demonstrated modifications of validated classification algorithms applied to pediatric patients with AAV can classify each patient to mutually exclusive diagnostic categories. We compared presenting features of children with microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA) classified according to this methodology. Methods: A pediatric modification of the European Medicines Agency (EMA) algorithm for classifying AAV and polyarteritis nodosa (incorporating the EULAR/PRINTO/PRES pediatric classification criteria for GPA) was applied to patients in ARChiVe censored to April 2012. We compared characteristics of patients classified as having MPA and GPA. STATA (Statcorp, 2013) was used to calculate frequencies, percentages, and chi-squared with fisher's exact for categorical variables and means, standard deviations, and t-tests for continuous variables. Results: One hundred fifty-two of 227 children in ARChiVe met criteria for diagnosis of MPA (n = 22) or GPA (n = 130). Characteristics and presenting features are shown in Table 1. Children with MPA were younger at diagnosis (mean diff. 2.7y, p = 25% lower limit of normal 8 (89) 18 (36)

The first steps toward improving perinatal quality and safety are to identify where the problems are and develop the indicated solutions. Yet, there are a limited number of perinatal measures of quality and safety that are widely used, inhibiting opportunities for learning...

Change implementation within organizations is a complex and dynamic process that is not always successful. Tailoring the implementation strategies and tactics to address the identified barriers to change is one method that has been shown to be effective. Examples of 3 broad types of interrelated strategies used by frontline leaders when implementing quality improvement (QI) projects are (1) discourse (communication), (2) education (formal and informal), and (3) data (audit). Examples of common barriers to implementation are leaders' and clinicians' knowledge, attitudes, and practices, the QI topic characteristics, and the implementation climate. External pressures from national organizations such as the National Quality Forum, the Leapfrog Group, and The Joint Commission likely facilitate change. Knowledgeable, tenacious, and creative frontline physician and nurse leaders may have the greatest impact on QI implementation effectiveness because they are the individuals who decide how the strategies and tactics will be tailored.

Pregnancy and birth are physiologic processes, unique for each woman, that usually proceed normally. Most women have normal conception, fetal growth, labour, and birth and require minimal-to-no intervention in the process. Women and their families hold different views about childbearing based on their knowledge, experiences, belief systems, culture, and social and family backgrounds.