Archives 2023

Case Review: 21-year-old primiparous (first pregnancy) at 35+4 weeks gestational age presents to labor and delivery triage status post a motor vehicle accident (MVA) 4 hours prior to arrival.  Patient reports occasional mild uterine contractions on arrival. Denies vaginal bleeding, or leaking of fluid.  Reports decreased fetal movement since the MVA.  Obstetrical history is significant for anemia, and O negative blood type.

1:30pm: RN progress note – occasional mild uterine contractions. Abdomen soft, non-tender. FHR 125 with moderate variability. Occasional accelerations. Absent decelerations. Occasional mild uterine contractions. Category I fetal heart rate (FHR) tracing reported to attending Ob/Gyn via telephone (in reference to above tracing).

5:30pm: RN progress note – Telephone report provided to Dr. Z. Category I tracing. Reassuring maternal, and fetal status. Rhogam administered. Orders received to discharge patient home with follow up in office as previously scheduled.

11:30pm: Patient returned to labor and delivery triage with onset of painful uterine contractions, and vaginal bleeding. Uncertain if perceiving fetal movement.  Abdomen rigid, and tender to touch. Fetal heart tones absent. Intrauterine fetal demise confirmed via bedside obstetrical ultrasound. Patient desires primary cesarean section.  Placenta abruption confirmed at delivery.

Sinusoidal FHR Pattern: A sinusoidal FHR pattern is uncommon.  The smooth, sine wave-like undulating pattern in the FHR baseline serves to distinguish this pattern from variability.  In the presence of a sinusoidal FHR pattern, there is a cycle frequency of 3 to 5 per minute that persists for 20 minutes.  A sinusoidal FHR pattern can be misinterpreted as moderate variability.  This misinterpretation puts the team (including the patient, and her family) at risk for misdiagnosis, and mismanagement.

An effective way to distinguish FHR  variability from the sinusoidal pattern is by recognizing that variability is defined as fluctuations in the baseline that are irregular in amplitude, and frequency.  By contrast, the sinusoidal pattern is characterized by fluctuations in the baseline that are regular in amplitude, and frequency.  Spontaneous accelerations are absent, nor are they elicited in response to uterine contractions, fetal movement, or stimulation (i.e., digital scalp stimulation, vibroacoustic stimulation).

Causes:  Causes of a sinusoidal FHR pattern can include fetal anemia as a result of Rh isoimmunization (i.e., the mother’s blood protein is incompatible with the fetus’s in the case of a maternal Rh negative [O negative] blood type), fetal maternal hemorrhage (i.e., placenta abruption), twin-to-twin transfusion syndrome, ruptured vasa previa, and fetal intracranial hemorrhage.  Other fetal conditions that have been reported to be associated with a sinusoidal FHR pattern include fetal hypoxia or asphyxia, fetal infection, fetal cardiac anomalies, and gastroschisis. 

Pseudosinusoidal, or medication induced sinusoidal can occur after the administration of some opioids, fetal sleep cycles, or rhythmical movements of the fetal mouth.  These events are of short duration, preceded, and followed by an FHR with normal characteristics.  These short periods of sinusoidal appearing patterns do not require treatment.

Significance / Management: A sinusoidal FHR pattern is associated with an increased risk for fetal acidemia at the time of observation.  This pattern is to be considered a Category III (abnormal), which requires immediate evaluation, intrauterine resuscitation, and expedited birth if unresolved. 

References

Lydon, and Wisner, (2021). Fetal Heart Monitoring Principles and Practices

Miller et al., (2022). Mosby’s Pocket Guide to Fetal Monitoring

Simpson et al., (2021). Perinatal Nursing

P.S. COMMENT AND SHARE: What is your experience reviewing a case involving a sinusoidal FHR pattern? Was the abnormal pattern identified timely? Was the pattern misinterpreted as moderate variability? What was the neonatal outcome?

In this blog, I’ll be reviewing a maternal wrongful death case involving obstetrical hemorrhage.  I’ll identify how to diagnose obstetrical hemorrhage, and review the incidence of obstetrical hemorrhage within the United States.  Following a review of case facts, I’ll highlight key standard of care takeaways that support obstetrical hemorrhage prevention, early identification, and intervention.  The provided takeaways are evidence based practices which serve to reduce the incidence of maternal morbidity, and mortality associated with obstetrical hemorrhage.     

Definition: Obstetrical hemorrhage is defined as a cumulative blood loss of greater than or equal to 1,000 ml. of blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after childbirth, regardless of the mode of delivery (AGOG, 2021). 

Incidence: Obstetrical hemorrhage remains one of the leading causes of pregnancy-related deaths worldwide. In the U.S., during 2017 – 2019, obstetrical hemorrhage accounted for 12.1% of the total pregnancy-related deaths (CDC, 2023).

Case Facts:  A 36-year-old mother experienced profound uterine bleeding immediately after cesarean section for a twin delivery.  The patient was transferred to the post anesthesia care unit (PACU) where she continued to have severe bleeding, vital sign instability, and experienced hemorrhagic shock.  The patient received fluid resuscitation with blood products, and intravenous fluids.  Blood products were not promptly available.  The patient was transferred to the intensive care unit (ICU) where her vital signs continued to worsen.  The Obstetrician urged for an immediate hysterectomy.  After the patient was transferred to the ICU, the anesthesiologist left the hospital for another case at a different hospital, and there was no anesthesiologist available.  A hysterectomy was eventually performed. Due to the postpartum bleeding, and insufficient fluid resuscitation with blood products, the patient developed disseminated intravascular coagulation (DIC).  The patient was pronounced dead shortly after the DIC diagnosis was made. The anesthesiologist settled out.  The case continued to trial against the hospital and Obstetrician.

Plaintiff’s Allegations: The plaintiffs’ counsel contended the patient needed operative intervention much sooner to stop the uterine bleeding.  Plaintiffs’ counsel also contended the hospital blood bank did not promptly deliver the needed blood products. Lastly, the hospital failed to perform lab tests to assess the extent of the patients bleeding.

Defendant’s Allegations: The hospital contended the death was due to the negligence of the other physicians, including the anesthesiologist, for failing to promptly respond to, and manage the evolving shock. 

Physical Injuries Claimed by Plaintiff: Death; loss of love, companionship, comfort, care, assistance, protection, affection, society, moral support; loss of training and guidance; loss of financial support; the reasonable value of household services.

Gross Verdict (Award): $10,850,000 (100% against the hospital.  The obstetrician received a 12-0 defense verdict)

Standard of Care Takeaways:

• Hospital systems should require the performance of antepartum (prenatal), intrapartum (during labor), and postpartum (after delivery of the placenta) hemorrhage risk (re)assessments.
  • These standardized risk assessments are performed in an effort to identify patients at medium or high risk for obstetrical hemorrhage, and guides necessary interventions.
• Use of a stage-based management plan should be adopted that requires the performance of quantitative blood loss (QBL) measurements for every delivery.
  • With the use of a standardized stage-based management plan, best practice interventions are prompted, and are specific to the hemorrhage stage (stage 1-3).
• Standardized hemorrhage medication kits, and supply carts should be readily accessible on every unit caring for obstetrical patients.
  • Care units include labor and delivery, emergency departments, intensive care units, and operating rooms.
• Multi-disciplinary, role-specific obstetrical hemorrhage education, and simulation drills (including all members that care for obstetrical patients) should occur at the time of new hire orientation, whenever there are changes to the policy or procedure, or every one to two years.
• Every organization should have established criteria for identifying obstetrical hemorrhage cases requiring quality review. The quality review process serves as a quality improvement effort, and guides future continuing education.
• Patient education should be provided specific to hemorrhage risk factors, as well as signs, and symptoms of hemorrhage that must be reported.

Closing Remarks: Professional organizational standards exist specific to prevention, early recognition, and timely treatment of obstetrical hemorrhage.  Obstetrical risk reduction strategies should involve adoption of obstetrical hemorrhage safety bundles, perinatal quality review processes, as well as multidisciplinary data review by means of  audit and feedback methodologies.  

Resources:

AGOC, 2021. Postpartum Hemorrhage

Centers for Disease Control and Prevention, (2023). Healthy People 2020. https://www.cdc.gov/nchs/healthy_people/hp2020.htm

Centers for Disease Control and Prevention, (2023).Pregnancy Mortality Surveillance System. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

The Joint Commission, 2023). R3 Report Issue 24: PC Standards for Maternal Safety.  https://www.jointcommission.org/standards/r3-report/r3-report-issue-24-pc-standards-for-maternal-safety/#.ZAdWsB_MJPY

P.S. COMMENT AND SHARE: Have you been involved in a maternal wrongful death case involving obstetrical hemorrhage?  What was the case theme?  What were strengths, and weaknesses of the case?

Barber Medical legal Nurse Consulting, LLC is available to support medical record review of obstetrical care involving a hemorrhage, perinatal quality consults, and obstetrical hemorrhage education.  Email: Contact@barbermedicallegalnurse.com.

In this blog, I’ll present a segment of an electronic fetal monitor (EFM) tracing.  Following review of the tracing, and a brief Q&A, I’ll be highlighting the case theme affiliated with the presented EFM tracing.  Additionally, I’ll provide plaintiff allegations, as well as defenses contended.  Review of the standard of care specific to uterine activity evaluation, and management will be provided. In closing, the impact excessive uterine activity has on fetal well-being will be discussed.   

Ob Provider Progress Note:

2/12/22 0340: vaginal exam 2-3/50/-1. artificial rupture of membranes, clear fluid. fetal heart rate reassuring. pitocin @ 7mU/min.

Nurses Note:

2/12/22 0345: Ob provider at bedside. vaginal exam performed. strip reviewed. baseline fetal heart rate 140, minimal variability, absent accelerations, intermittent late decelerations.  

Q: What assessment is missing from the above documentation?  

A: Assessment of uterine activity

Litigation Case Theme: Failure of the perinatal team to identify, and act on a category II FHR tracing in the presence of uterine tachysystole, and excessive uterine activity resulting in permanent neurological injuries in the infant. 

Plaintiff Allegations:

• Failure of the perinatal team to assess and intervene
• Failure of the perinatal team to recognize a non-reassuring FHR pattern, and excessive uterine activity
• Inappropriate oxytocin management
• Failure to initiate intrauterine resuscitation, and interventions in response to excessive uterine activity

Defenses:

• The standard of care was adhered to
• Documentation reflected prompt, and appropriate actions by the perinatal team
• Electronic fetal monitoring cannot be used as a diagnostic tool; therefore, birth injury cannot be attributed solely to FHR interpretation
• The fetal injury likely occurred during the antenatal period; therefore, actions during labor and delivery had no impact on the outcome

Standard of Care: the evaluation of uterine activity must occur, and is equally as relevant as the assessment of the fetal heart rate. 

Complete assessment of uterine activity: components of uterine activity assessment, and documentation include –  

• uterine contraction frequency: ranges from 2 – 5 per 10 minutes.
• duration of uterine contractions: ranges from 45 – 80 seconds.
• strength or intensity of uterine contractions: 40 – 70 mm Hg (millimeters of mercury) in the first stage of labor.  May rise to >80 mm Hg in the second stage of labor.  Contractions palpated as “mild” would peak at <50 mm Hg if measured internally. Contractions palpated as “moderate” or greater would peak at 50 mm Hg or greater if measured internally. 
• resting tone of uterus: the average resting tone during labor is 10 mm Hg.  If assessment is performed by palpation, assessment should palpate as “soft”.
• relaxation time between uterine contractions: this is usually 60 seconds or more in the first stage of labor, and 45 seconds or more in the second stage.
• Montevideo units (MVUs): assessed and documented if an intrauterine pressure catheter (IUPC) is in place.  MVUs range from 100 – 250 MVUs in the first stage of labor.  MVUs may rise to 300 – 400 MVUs in the second stage of labor.  

What is excessive uterine activity? uterine tachysystole is defined as greater than five uterine contractions in 10 minutes, averaged over 30 minutes. 

Tachysystole should be further qualified by the presence of absence of FHR decelerations, and applies to spontaneous and stimulated labors.

All other parameters, as identified above (duration, intensity, resting tone, and relaxation time), should be included in the evaluation.

Management of excessive uterine activity: management of excessive uterine activity should not be based on the presence or absence of FHR changes. 

The goal of management is to identify, and promote normal uterine activity, and correct the underlying cause of any type of excessive uterine activity.

• maternal position change to side-lying
• administration of an intravenous fluid bolus
• removal of cervical ripening agents, or decrease or discontinuation of oxytocin
• use of a tocolytic (e.g., terbutaline) if the above interventions were ineffective, or the excessive uterine activity occurs in the presence of FHR changes indicative of interrupted fetal oxygenation

Excessive uterine activity should trigger interventions, regardless of FHR status.

Fetal effects on FHR from excessive uterine activity: excessive uterine activity can have an adverse effect on fetal oxygenation, and the fetal acid-base status.  Excessive uterine activity can result in decreased fetal cerebral oxygen saturation, as well as fetal acidemia.  Excessive uterine activity can result in birth injuries, specifically, hypoxic ischemic encephalopathy, and subsequent cerebral palsy. 

Conclusion: The assessment of uterine activity during labor is crucial, and is considered a patient safety issue.  Applying known parameters to the assessment of uterine activity influences management decisions, forms the basis of safe use of labor stimulants, and provides a means of defining excessive uterine activity among the multidisciplinary perinatal team.

Resources:

AAP, ACOG (2017). Guidelines for Perinatal Care.

ACOG (2009). Induction of Labor. 

ACOG (2010). Intrapartum Fetal Heart Rate Tracings.

AWHONN (2021). Perinatal Nursing.

AWHONN (2022). Intermediate Fetal Monitoring Course.

Miller et al., (2022). Pocket Guide to Fetal Monitoring.

P.S. Comment and Share: What is your experience working with a case theme centered around excessive uterine activity? What were some strengths? What were some challenges?

Fetal heart rate (FHR) pattern interpretation, communication, and documentation is a common area of liability.  Reviewing the standards of care that support verdicts, as well as learning from past plaintiff, and defense counsel allegations, aids in the ability to bridge the gap between perinatal medicine, and the law.   

In this blog, I’ll be reviewing a medical malpractice birth injury case with a theme specific to failure to monitor, as well as failure to identify, and act on a non-reassuring fetal heart rate tracing.  I’ll discuss allegations from both the plaintiff and defense counsels that led to the plaintiff verdict.  Facts of the case will be reviewed, and medical legal risk reduction strategies will be offered, specific to fetal heart rate monitoring interpretation, communication, documentation, and education.  The referenced risk reduction strategies represent current evidence-based standards of care specific to electronic fetal monitoring.   

Case Facts: On April 4, 2013, Ms. Jones, a 24-year-old, who was 40 weeks pregnant, presented to University Medical Center for a routine prenatal exam, and reported she was experiencing some contractions. She underwent a non-stress test, which was completely normal, and reassuring. Jones was sent home, and was instructed to return for routine testing one week later. That night, April 4, 2013, at approximately 2:01 a.m., Jones was admitted to the University Medical Center’s triage unit for observation after she reported decreased fetal movement.  Jones was evaluated in triage with a series of tests, including a non-stress test, and an attempted vibroacoustic stimulation. The non-stress test was not reactive, and the vibroacoustic stimulation failed. The resident doctors admitted Jones for non-reassuring fetal well-being, and delivery for fetal distress at approximately 4:20 a.m. At approximately 5:20 a.m., Jones was transferred into a labor room from triage at the hospital’s labor and delivery unit. Instead of performing a cesarean section for non-reassuring fetal well-being, and fetal distress, at approximately 7:53 a.m., Jones was induced for a trial of labor with the induction agent Cervidil (Dinoprostone). The fetal heart rate remained non-reassuring throughout Jones’ labor according to all medical records, and all testimony at trial. After approximately 11 hours of non-reassuring fetal heart rate tracing, and a failed induction of labor, Jones was evaluated by a board-certified attending physician for the first time at 1:05 p.m. Following the attending physician’s evaluation, a decision was made to proceed with an emergency cesarean section for fetal distress, according to numerous medical records. At approximately 1:49 p.m., Jones gave birth to plaintiff newborn Jones. The birth was performed by cesarean section. Newborn Jones was admitted to the hospital’s neonatal intensive care unit, and remained an inpatient for three weeks.

Plaintiff Counsel Allegations: Plaintiffs’ counsel alleged that the party sued was negligent in its treatment of Jones and that it failed to deliver her unborn baby immediately by cesarean section, and instead induced her with a contraindicated induction of labor medication. Counsel asserted that it was a violation of the standard of care to induce Jones for vaginal delivery, despite obvious, and documented non-reassuring fetal well-being, and fetal distress for a period of about 12 hours. The experts opined the nursing staff failed to properly assess, and analyze the fetal heart monitor, and the signs of fetal distress, failed to properly communicate with the attending physicians, failed to advocate for the safety of newborn Jones, including preventing the administration of a contraindicated medication, and advocating for earlier necessary delivery. The Jones’ maternal fetal medicine expert, and obstetrical expert testified that the attending physicians at the sued hospital deviated from the standard of care by failing to personally evaluate Jones considering the documented findings of non-reassuring fetal well-being, and fetal distress. The experts stated the attending physicians failed to properly oversee the resident doctors who were managing Jones improper induction. Ultimately, the experts opined that all of the attending physicians, and the residents deviated from accepted practice by attempting to induce Jones instead of performing an immediate cesarean section at or around the time she arrived to the hospital with identified fetal distress. The maternal fetal, and obstetrical experts concluded that had newborn Jones been delivered by cesarean section, as was required by the standard of care, he would not have suffered from brain damage

Defense Counsel Allegations: Defense counsel contended nothing it did was negligent, and that Jones’ brain damage was caused by an undiagnosed, in utero infection that occurred sometime before April 4, 2013. The defense contended there was no significant hypoxia since the cord gases showed normal oxygen, and only mild acidemia that would not account for the significant brain damage. There were other objective laboratory results that could only be explained by an event more than 24 hours prior to delivery. The only explanation that would explain everything was an in-utero infection, supported by chorioamnionitis on the placental pathology, and the mother’s complaint of decreased fetal movement for 24 hours. Furthermore, the monitor strips, and other information required continued monitoring but not an immediate or emergency cesarean section. The hospital’s expert neonatologist testified that there was an in-utero event that caused brain damage at least 24 hours prior to delivery. The most likely cause of the brain damage, based on laboratory results including the cord gases, was an infection that occurred at least 24 hours prior to the delivery, and an earlier delivery would not have changed the outcome. The defense’s expert in obstetrical nursing opined that the fetal monitor strips were stable throughout, that the nursing monitoring was within the standard of care, and that there was no reason for the nurses to “go up the chain of command” to suggest an immediate cesarean section. The hospital’s expert in maternal fetal medicine testified that the cord gases ruled out hypoxic injury during the time of the hospitalization. Additional objective laboratory evidence clearly supported an injury at least 24 hours prior to delivery. This was supported by Jones’ complaint of decreased fetal movement on arrival at the hospital, and chorioamnionitis on the placenta pathology report. Furthermore, the fetal monitor strips were stable throughout Jones’ course at the hospital, and there was nothing requiring a decision to proceed to immediate cesarean section in this first-time mom until that decision was reached.

Result: Plaintiff verdict in the amount of $53 million.  Injury type(s): brain-cerebral palsy; mental/psychological-birth defect; mental/psychological-learning disability; mental/psychological-cognition, impairment; pulmonary/respiratory-hypoxia

Standard of Care Takeaways:

• Fetal heart rate (FHR) pattern interpretation, communication, and documentation is a common area of liability, and patient harm.
• Use of the standardized nomenclature recommended by the National Institute of Child Health, and Human Development (NICHD) to describe FHR patterns in all professional communication, and medical record documentation is the standard of care.
• FHR assessment must include baseline FHR, variability, presence or absence of accelerations, and decelerations, and pattern evolution when communicating normal, abnormal, and indeterminate FHR patterns.
• Ensure that agreed upon definitions of fetal well-being are established, and documented on admission prior to induction or augmentation of labor, initiation of epidural analgesia, patient transfer, and discharge.
• Develop common expectations for intrauterine resuscitation based on the presumed etiology of the FHR pattern.
• Establish agreement among team members specific to which types of FHR patterns require bedside evaluation by the primary (supervising or collaborating) care provider, and timeframe involved.
• Organizations should require ongoing multidisciplinary fetal monitoring education.  Organizations should require all nurses, physicians, residents, and advanced practice RN’s (midwives, nurse practitioners, physician assistants) responsible for care of pregnant women to demonstrate competency in interpreting electronic fetal monitoring (EFM) data.

Closing: Birth injury cases allegedly involving an acute ischemic event during the labor course can be challenging in the absence of understanding the physiology behind fetal monitoring interpretation.  Additionally, knowledge of expected communication, and documentation specific to clinical findings are crucial to understand in an effort to defend a birth injury case with a theme central to failure to monitor, and/or failure to identify, and act on a non-reassuring fetal heart tracing. 

Resources:

AAP, ACOG (2017). Guidelines for Perinatal Care. 8^th edition.

AWHONN (2021). Perinatal Nursing, 5^th edition.

Miller et al., (2022). Pocket Guide to Fetal Monitoring, A Multidisciplinary Approach. 9^th edition.

P.S. COMMENT AND SHARE:  What do you find to be the most challenging aspect of reviewing birth injury cases with a case theme related to fetal monitoring?

Barber Medical legal Nurse Consulting, LLC is available to support your efforts in making sense of the maternal labor records, while educating your team on fetal heart rate strip interpretation.  

Email: Contact@barbermedicallegalnurse.com.

In this blog, I’ll review the most common types of birth injuries.  Additionally, I’ll provide fundamental information regarding elements to consider when reviewing a birth injury claim for merit.  Lastly, I’ll identify commonly missed requests for production and explain the value these missed requests can add to case development.  

What is a Birth Injury: A birth injury is identified as an impairment of the neonate’s body function or structure due to an adverse event that occurred at birth (NIH, 2022).

Most Common Types of Birth Injury Cases:

Hypoxic Ischemic Encephalopathy (HIE):  Neonatal encephalopathy is a syndrome of disturbed neurologic function in the earliest days of life in an infant born at or beyond 35 weeks gestation, manifested by subnormal level of consciousness or seizures, and often accompanied by difficulty with initiating or maintaining respirations, depression of tone and reflexes (ACOG, AAP, 2019).  When evaluating an alleged HIE case, it’s crucial to identify if there was an acute hypoxic ischemia event immediately before or during labor & delivery.  Some examples of an acute hypoxic ischemia event include, but are not limited to:

• Uterine rupture
• Placental abruption
• Umbilical cord prolapse

Causation: When reviewing an alleged HIE case for causation, maternal and genetic risk factors must be considered.  Some examples of maternal risk factors include, but are not limited to, thyroid disease, factor V Leiden, and antiphospholipid syndrome.  It’s equally important to rule out genetic disorders that mimic neonatal encephalopathy.  This review is supported by reviewing the medical history of the parents, as well as reviewing the newborn (as well as previous births) admission assessment, progress notes, and discharge summary to identify the presence or absence of dysmorphic features and other clinically relevant findings such as poor feedings, prolonged hyperbilirubinemia, and metabolic abnormalities all of which may suggest a genetic cause for neonatal encephalopathy.   

Neonatal Brachial Plexus Palsy (NBPP):  NBPP is a weakness or paralyzed upper extremity, with passive range of motion greater than active (ACOG, 2014).   

Causation: When reviewing an alleged NBPP case, it’s important to know the risk factors for NBPP as well as current standards of care.  Risk factors include, but are not limited to:

• Fetal malposition (example: occiput posterior rather than occiput anterior)
• Labor induction
• Labor abnormalities (example: prolonged second stage of labor)
• Operative vaginal delivery (example: vacuum or forceps assisted delivery)
• Fetal macrosomia (example: birth weight > 4,500 gm regardless of gestational age)
• Shoulder dystocia

When reviewing a NBPP case for merit and/or during case development, the following questions will help guide your review and theory:

• Was an elective cesarean delivery considered and offered for the patient without diabetes who carried a fetus with suspected macrosomia with an estimated fetal weight of at least 5,000 grams and for women with diabetes whose fetus was estimated to weigh at least 4,500 grams?
• Was the Oxytocin turned off at the time the shoulder dystocia was identified?
• Were non-rotational maneuvers implemented prior to rotational maneuvers?
• Were maternal pushing forces discontinued when maneuvers were employed?
• Was fundal pressure applied?

Intrauterine Fetal Demise (IUFD): IUFD is a fetal death that occurs at or greater than 20 weeks gestation or at a birth weight greater than or equal to 350 grams (NIH, 2022).

Causation: When reviewing a fetal death case, risk factors must be considered as there are maternal, fetal, and placental risk factors.  Examples of risk factors include, but are not limited to:

• Diabetes
• Obesity
• Advanced maternal age (>35 years old at the time of delivery)
• Substance misuse
• Fetal anemia
• Placental abnormalities

Neonatal Death: Neonatal death is identified as death among live births during the first 28 completed days of life (NIH, 2021).

Causation: When reviewing a neonatal death case, you must be aware of the leading causes of neonatal death.  Some examples include, but are not limited to:

• Preterm birth complications
• Intrapartum related complications (neonatal encephalopathy from birth asphyxia/trauma)
• Neonatal sepsis and other neonatal infections including pneumonia and tetanus

Requests for Production: When reviewing a birth injury case for merit and during the process of case development, it’s crucial to evaluate all relevant medical records including past obstetrical records, past neonatal admission records as well as all outpatient and inpatient electronic fetal monitor (EFM) tracings.  Past obstetrical histories, and previous newborn assessments provide valuable information specific to maternal, and fetal risk factors as well as relevant neonatal assessment findings that could indicate a genetic or metabolic cause to the injury.  Additionally, review of all (inpatient and outpatient) EFM tracings and other forms of fetal surveillance (example: ultrasounds, and biophysical profiles) supports the identification of fetal heart rate and clinical trends, changes, and abnormalities indicative of a compromised fetus.  Review of the intrapartum (labor) EFM tracing, multidisciplinary strip interpretation, intrauterine resuscitative measures employed, and multidisciplinary documentation supports identification of compliance with the standardized 2008 National Institute of Child Health and Human Development (NICHD) nomenclature specific to fetal heart rate strip interpretation.  The 2008 NICHD standardized, and quantitative nomenclature should be used by the labor team to describe intrapartum fetal heart rate tracings in order to reduce miscommunication among providers caring for the laboring patient, while promoting consistent, evidence-based interventions to fetal heart rate patterns.

• Medical Staff By-Laws, Rules and Regulations: When compiling requests for production, don’t over-look the value in reviewing the organization’s medical staff by-laws, as well as the medical staff rules and regulations.  Relevant content can be gleaned from this review that can be applied to case development.  By-Laws: The organization’s medical staff by-laws focus on medical staff (including mid-level providers: midwives, nurse practitioners, physician assistants, nurse anesthetist) privileging, (re)credentialing, professional conduct/corrective action, organizational clinical departments, and committees. Rules and Regulations: The organization’s medical staff rules and regulations focus on requirements of the medical staff.  Some examples include admission/discharge of patients, medical care responsibility, discharge criterion, oversight of adjunct staff (mid-level providers as described above), consultation process, code of conduct, consent forms, orders, practitioner accessibility / response time, continuing medical education, requirements for: health and physical, medical records, progress notes, operative reports, obstetrical records, and discharge summaries.

When reviewing a birth injury case, consider the above elements of causation, as well as suggested requests for production in an effort to strengthen your review.  Lastly, collaborate with medical legal consultants who specialize in birth injury as evidenced by their education, knowledge, training and experience.

References

1. ACOG, AAP, 2019. Neonatal Encephalopathy and Neurologic Outcome, 2nd ed.
2. ACOG, 2014. Neonatal Brachial Plexus Palsy
3. National Institute of Health, 2021. Birth Trauma
4. National Institute of Health, 2021. Neonatal Mortality
5. National Institute of Health, 2022. Intrauterine Fetal Demise

P.S. Comment and Share: What do you identify as the most challenging aspect of developing birth injury cases?

In this blog, I’ll be reviewing the data trends and leading causes of obstetrical (Ob) related malpractice claims.  Additionally, I’ll review identified barriers to adopting evidence-based standards of care while contrasting effective implementation strategies.  I’ll conclude with a summary of the 2020 Joint Commission Perinatal Safety Standards and highlight how the required standards align with the Ob related malpractice trends.   

Trends / Statistics: The average Ob malpractice payment is $947,000 which is more than twice that of other clinical areas (Crico, 2010).  The dollar amount reserved for current and future payment is usually 25% – 35% of the total financial liability cost to the hospital and healthcare system. 

Between 2007-2016, Specific to Ob/Gyns (whose rate is historically higher than the average for all MDs), the risk of having a malpractice case filed against them dropped by 44% (Crico, 2018).

It’s suggested that the drop in claims is a result of quality improvement (QI) initiatives such as training to improve team communication during labor and delivery, and multidisciplinary education on fetal heart rate tracings.

Between 2007-2016, defendant rates declined most steeply in Ob/Gyn.  It’s suggested that the declines correlate with long-term safety interventions (Crico, 2018).

There is a risk of permanent and catastrophic damages that can occur as a result of Ob/Gyn medical errors.  The Ob/Gyn specialty incurs significantly disproportionate financial losses when compared to the total number of medical malpractices cases. 

Most Common Ob Malpractice Claims and Contributing Factors:  The majority of Ob related malpractice cases involve birth asphyxia, shoulder dystocia, intrauterine fetal demise and maternal hemorrhage (AWHONN, 2014).

Contributing Factors:

• Clinical judgement: inadequate patient assessment, inappropriate management of pregnancy, failure to timely diagnose and treat a non-reassuring fetal heart rate tracing, inappropriate management of the 2^nd stage of labor via operative vaginal birth
• Technical skills: inexperience with procedures
• Communication: provider-provider communication breakdowns, inadequate consent, hierarchical issues

According to FOJP (Hospital Insurance Company), a growing concern has emerged specific to permanent injuries related to shoulder dystocia cases.  FOJP found that while clinical judgment factors were trending downward in labor & delivery cases, technical issues were trending upward.  The proposed action plan provided was specific to teamwork and simulation training.

It is common knowledge that defensibility is enhanced when care is consistent with current evidence-based standards of care.  Despite this knowledge, many organizations continue to struggle with implementing policies, QI and process improvement (PI) initiatives that are consistent with current standards.

Common Barriers to Adopting Evidence-Based Standards of Care:

Leadership Barriers

• Lack of knowledge specific to QI/PI and QI/PI data analysis
• Leadership attitudes
• Leadership practices: not consistently applying new operations, lack of sustainability efforts, lack of time and resources

Clinician Barriers

• Lack of clinician knowledge specific to their own practices, lack of audit & feedback processes, novice status, lack of knowledge about QI/PI projects
• Clinician attitudes: not motivated to change, desires autonomy
• Clinician practices: forgot about QI/PI project, changes add more work or slow down work flow

Characteristics of the QI, or PI Project

• Positive or negative effect on clinician income or time
• Complexity of the QI/PI project

Implementation Climate

• Type of hospital
• Amount of resources
• Type of patients

Strategies for Successful Implementation and Sustainability of Evidence-Based Standards of Care:

Educational strategy: grand rounds, conferences, simulation training, competency tests and demonstrations, on-line learning

Data strategy: audit and feedback methodology to support individual and group data sharing of performance against benchmarks, public release of data focused on outcomes reported openly to the community

Discourse strategy: meetings, review of academic research, reminders via checklists, order sets, newsletters, bulletin boards, emails, rewards for reaching a goal, disciplinary discussions providing feedback specific to performance not aligning with required expectations

How the 2020 Joint Commission Perinatal Safety Standards Align with the Ob Related Malpractice Trends: All hospitals accredited by the Joint Commission are required to comply with the 2020 Joint Commission Perinatal Safety Standards.  The safety standards were developed in response to the leading causes of perinatal morbidity and mortality: maternal hemorrhage and severe hypertension/preeclampsia.

A number of the required elements of performance center around:

• The development of written evidence-based procedures for managing Ob emergency events (educational and discourse strategy).

• Providing role-specific education to all staff and providers who treat pregnant and postpartum patients about the organization’s procedures at a minimum every two years (educational strategy).

• Supporting annual multidisciplinary simulation drills to determine system issues as a part of on-going QI efforts (educational strategy).

• Completing regular reviews of severe maternal morbidity and mortality cases to evaluate effectiveness of the care, treatment, and services provided by the response team during the event (data strategy).  

Knowledge is power, power is change.  We, as a multidisciplinary group of clinicians, and legal representatives, need to be the change we wish to see by propelling healthcare policies that are consistent with current evidence-based standards. 

References

AWHONN, 2014. Perinatal Nursing 4^th ed.

AWHONN, 2021. Perinatal Nursing 5^th ed.

Crico, 2010. CBS Benchmarking Report – Medical Malpractice in America

Crico, 2018. CBS Benchmarking Report – Medical Malpractice in America

The Joint Commission, 2019. Provision of Care, Treatment, and Services standards for maternal safety

P.S. Comment and Share: Have you been involved in developing and/or implementing a new perinatal policy, QI, or PI initiative in response to the 2020 Joint Commission Perinatal Safety Standards?  If so, what was the policy/QI/PI initiative and how has it improved outcomes?

What is Sickle Cell Disease (SCD): SCD is a group of inherited red blood cell disorders that affect hemoglobin, the protein that carries oxygen throughout the body.                  

Normally, red blood cells are disc-shaped and flexible enough to move easily through the blood vessels. If you have sickle cell disease, your red blood cells are crescent, or “sickle” shaped. These cells do not bend or move easily and can block blood flow to the rest of your body.

The blocked blood flow through the body can lead to serious problems, including stroke, eye problems, infections, and episodes of pain called pain crises.

Maternal, Fetal and Neonatal Risks Associated with SCD: There is increased maternal and fetal morbidity and mortality associated with SCD.  There is an increased risk for hypertensive disorders of pregnancy.  For example, the rate of preeclampsia in pregnant women with SCD is approximately 1 in 8 (12%).  Women with SCD also have an increased risk of gestational hypertension (JAMA Pediatrics, 2023). Additionally, there is an increased risk for venous thromboembolisms (blood clots), increased pain, worsening anemia, worsening kidney and liver disease, poor fetal growth, preterm labor, and fetal loss.  Newborns are more likely to have growth problems and suffer from the associated complications of prematurity.

Statistics: SCD affects more than 100,000 people in the United States and 20 million people worldwide (NIH). Based on review of a recent retrospective cohort study published in JAMA Pediatrics (2023), women with SCD had a maternal mortality rate of 14 per 10,000 deliveries compared with 1 per 10,000 deliveries among women without SCD.  SCD complicated 0.37% of pregnancies studied, but contributed to 4.3% – 6.9% of the severe maternal morbidity cases dependent on red blood cell transfusion status.  

In economically advanced countries the rate of fetal and neonatal death is as high as 2.9 per 1,000 deliveries.  There is a five-fold increase in fetal and neonatal deaths in less resourced countries (Hematology, 2019).

Pregnancy Management: There are very few therapeutic interventions that have been studied other than prophylactic and selective blood transfusion therapy to improve perinatal outcomes.  Due to the increased risk of hypertensive disorders in pregnancy and venous thromboembolism associated with SCD, low-dose aspirin prophylaxis (81 mg per day) is recommended between 12 – 28 weeks of gestation for those women with no contraindications to aspirin. Aspirin therapy should be continued until the time of delivery (ACOG, 2022).

Additionally, ACOG (2022) recommends universal hemoglobinopathy testing in women planning pregnancy or at the initial prenatal visit if no prior testing results are available. This testing supports pre-pregnancy, or prenatal diagnosis, genetic counseling and learning of reproductive options early. Hemoglobinopathy testing may be performed using hemoglobin electrophoresis or molecular genetic testing.

ACOG (2022) recommends that women of reproductive-age with SCD who have a personal history of pulmonary embolism or signs / symptoms of hypoxia undergo screening with transthoracic Doppler echocardiography due to the increased risk of pulmonary hypertension. For patients with symptoms, a screening echocardiogram before pregnancy is recommended.   Further evaluation, including right heart catheterization, is ideally performed prior to pregnancy.   High risk findings, such as pulmonary arterial hypertension (PAH) may impact the advisability of pregnancy.  However, if a screening echocardiogram cannot be obtained prior to pregnancy, it can be performed in early pregnancy.  Abnormal echocardiographic findings should be co-managed by a multidisciplinary team, including consultants with expertise in SCD.

(Hematology, 2019)

Review of Causal Connection in Maternal, Fetal and Neonatal Death Cases Complicated by SCD: Causation in a medical liability claim is crucial in order to establish recovery.  The claimant, or defendant, must prove 1) the existence of a duty; 2) a breach of that duty; 3) injury or damages to the claimant; and 4) a causal connection between the breach of duty and the alleged injuries. Causation issues must be carefully considered and are established by reasonable medical probability (a reasonable degree of medical certainty).  This requires showing that the injury was more likely than not caused by a particular stimulus, act, or omission of care based on the standards of care.

It’s crucial to get the correct experts involved in case review and development to ensure that all aspects of causal connection have been evaluated.  Working with experts who are aware of the pathophysiology of CSD, associated maternal, fetal and neonatal co-morbidities, as well as management recommendations will support the evaluation of causation.

Resources:

ACOG, 2022. Hemoglobinopathies in Pregnancy

Hematology, American Society of Hematology Education Program, 2019. Complications in Pregnant Women with Sickle Cell Disease.

JAMA Pediatrics, 2023.  Association of SCD with Racial Disparities and Severe Maternal Morbidities in Black Individuals

The National Institute of Health

P.S. Comment and Share: What is your experience with SCD?  Did your role require you to evaluate causal connection between SCD and maternal, fetal or neonatal injury, or death? 

In this blog I’ll review the objective of the Emergency Medical Treatment and Active Labor Act (EMTALA), obstetrical standards of care, consequences of EMTALA violations, common obstetrical allegations and offer a case scenario for reflection. 

Emergency Medical Treatment and Active Labor Act (EMTALA):  The Federal EMTALA Act was created as anti-discriminatory legislation to protect people who could not afford emergency care services.  The over-arching purpose of EMTALA is to ensure access to health care. 

Obstetrical Standards, Guidelines and Recommendations: EMTALA requires participating hospitals (hospitals participating in the Medicare program) to have policies and procedures that ensure that:

• Healthcare providers offering obstetrical triage:
  • Perform a medical screening examination (MSE) to determine whether an emergency medical condition exists (including a maternal and fetal evaluation)
  • Provide necessary stabilization treatment when an emergency medical condition exists
  • Stabilize the pregnant patient, or if the healthcare provider certifies that the benefits of transfer outweigh the risks, arrange for proper transfer to another hospital.
• Pregnant women may come to the hospital’s labor and delivery unit not only for obstetrical care but also for evaluation and treatment of non-obstetrical illness.  A pregnant woman who presents for care should be evaluated in a timely fashion.  Minimally, evaluation by an obstetrical nurse should include assessment of maternal vital signs, fetal heart rate, and uterine contractions.  Further evaluation includes assessment for vaginal bleeding, acute abdominal pain, temperature of 100.4 degrees Fahrenheit or higher, preterm labor, preterm premature rupture of membranes, hypertension and indeterminate or abnormal fetal heart rate patterns.  If these findings are present or suspected, the responsible obstetrical care provider should be promptly informed.
• The initial triage process requires one nurse to one woman presenting for care.  This ratio may change to one nurse to two, or three women as maternal fetal status is determined to be stable, until patient disposition.
• Any patient who is suspected to be in labor or who has ruptured membranes, or vaginal bleeding should be evaluated promptly.  Minimally, the following should be assessed: maternal vital signs, frequency and duration of contractions, documentation of fetal well-being, urinary protein concentration, cervical dilation and effacement (unless contraindicated such as with placenta previa or preterm premature rupture of membranes), cervical length, fetal presentation and station of presenting part, status of membranes, estimated fetal weight, and assessment of maternal pelvis.  In addition to these assessments, date and time of the patient’s arrival and notification of the obstetrical provider should be included in the medical record.
• If the woman has received prenatal care and a recent examination has confirmed the normal progress of pregnancy, triage evaluation may be limited to an interval history and physical examination directed at the presenting condition. 

Consequences of EMTALA Violations:

• Hospital fines up to $250,000 per violation
• Physician fines up to $50,000 per violation
• Hospital termination from its Medicare provider agreement
• Physician exclusion from Medicare and Medicaid programs
• A patient who suffers personal injury from a violation may sue the hospital for damages in civil court
• A receiving facility, having suffered financial loss as a result of another hospital’s violation of EMTALA, can bring suit to recover damages

Common Obstetrical Triage Allegations:

• Failure to perform a medical screening examination
• Failure to include a timely assessment of fetal status as part of the maternal medical screening examination
• Delay in performing a medical screening examination (E.g., having a pregnant woman wait in the waiting room prior to maternal-fetal status being evaluated)
• Failure to have a policy in place delineating conditions that require bedside evaluations by a physician or midwife prior to discharge after MSE by labor and delivery RN
• Failure of provider to complete bedside evaluation for pregnant woman who presents with high-risk medical or obstetrical condition
• Discharge of a pregnant woman who is unstable for discharge (E.g., pregnant woman with elevated blood pressures and complaints of unresolved headache.)
• Discharge of a pregnant woman without establishing fetal well-being (E.g., completion of a non-stress test at or greater than 28weeks gestation)
• Failure to meet all aspects of the EMTALA regulations in assessing, treating, and discharging a pregnant woman who presents for care

Case Scenario:

The patient is a 33-week pregnant woman, presented to Hospital “A” complaining of leaking fluids, pelvic pain and vomiting. An ED nurse told the patient that the hospital did not have an obstetrician on site and that the patient could either start treatment at Hospital “A” and be transferred later, or that her support person could drive her immediately to Hospital “B” where her obstetrician practiced.

After being told this, the patient left Hospital “A” by private vehicle to Hospital “B,” a thirty-minute drive. Hospital “A” never provided the patient or her unborn child a MSE and failed to transfer this patient who had an emergency medical condition. At Hospital “B,” the patient underwent an emergency cesarean delivery and delivered a male infant without a heartbeat. The receiving hospital’s efforts to revive the infant were unsuccessful.

The hospital entered into a $50,000 settlement agreement with the Office of Inspector General regarding allegations that it failed to provide an adequate MSE and transfer for a patient.

References

Moffat J.C. (2021), The EMTALA Answer Book, 1^st edition.

Simpson K.R., Creehan P.A., (2008). Perinatal Nursing, 4^th edition.

Simpson K.R. et al.,  (2021). Perinatal Nursing, 5^th edition.

P.S. Comment and Share: What is your experience with developing EMTALA policies, or auditing compliance?  Do you have an EMTALA violation case to share?

In this blog, I’ll review the findings from the most recent Nurse Professional Liability Exposure Claim Report, as well as findings from the Joint Commission, specific to communication
as a root cause factor that contributes to adverse patient events.  I’ll highlight barriers to effective communication, as well as risk mitigation strategies. 

Communication Barriers: According to the Nurse Professional Liability Exposure Claim Report (2023), communication barriers can prevent or delay nurses from reporting changes in the patient’s condition, invoking the chain of command, clarifying orders, or raising
concerns about systems and processes.

Total Incurred: It has been reported that allegations specific to communication had an average total incurred of $324,260, which is more than one and a half times greater than the overall average total incurred for all nursing professional liability claims of $210,513 (Nurse Professional Liability Exposure Claim Report, 2023).

Risk Mitigation Strategies

Communication Techniques: The Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ) provides supportive education and training specific to effective communication.  Specific techniques that promote effective communication across the multidisciplinary team includes, but is not limited to, the following:

TeamSTEPPS® program: Teaches healthcare teams effective strategies to improve communication across all specialties and promotes situational awareness. One of the several verbal strategies that are recommended includes:

1. TeamSTEPPS® program: Teaches healthcare teams effective strategies to improve communication across all specialties and promotes situational awareness. One of the several verbal strategies that are recommended includes:
   • SBAR: This acronym stands for Situation, Background, Assessment, and Recommendation/Request. SBAR is a communication technique intended to relay significant information regarding a patient’s condition or may be used during hand off report (AHRQ, 2013).   
2. Check-back: Involves closed-loop communication to ensure that
   information communicated by the sender is understood by the
   receiver as intended by repeating back information.
3. Hand-offs: Require timely, complete and accurate transfer of information from one
   caregiver to another (Joint Commission, 2018).

Nurses as Patient Advocates: Nurses have a duty and obligation to serve as patient advocates.  This duty ensures that their patients receive safe and appropriate care.  Nurses must be comfortable implementing the chain of command whenever they believe a practitioner is not responsive to calls for assistance, fails to appreciate the seriousness of a situation or neglects to initiate an appropriate intervention (Nurse Professional Liability Exposure Claim Report, 2023).

Enhancing knowledge of the root cause of adverse events, influences the power to reduce the risk of recurrence.  Identifying the barriers to effective communication and mindfully applying communication techniques reduces adverse patient outcomes.  Supporting a culture of safety within healthcare organizations supports open communication, promotes patient advocacy, shared accountability, and most importantly, patient safety.     

References

Agency for Healthcare Research and Quality. TeamSTEPPS®, (2013). Retrieved from https://www.ahrq.gov/teamstepps/instructor/fundamentals/index.html

Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation, (2017). Retrieved from https://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx

Nurse Professional Liabiilty Exposure Claim Report, (2023). 4th Edition. Retrieved from www.nso.com/nurseclaimreport

The Joint Commission. 8 tips for high-quality hand-offs, (2018). Retrieved from

https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_8_steps_hand_off_infographic_2018pdf.pdf

 P.S. Comment and share: How did communication barriers impact a past, or current case? How were patient outcomes influenced?

In this blog, I’ll be reviewing the purpose of a literature search and the importance of employing a systematic approach.  I’ll highlight search strategies and offer some search tips.  I’ll also identify some common databases used in the field of healthcare law, review different types of publications, as well as ways to access authoritative literature.  Lastly, I’ll highlight the various levels of evidence and how synthesis of your search findings can be applied to work products.

Evidence and standards of care:  Both are evolving faster than ever before and staying current is essential to ensure the best patient care that results in safe outcomes.   The volume and complexity of medical literature is growing rapidly.  Employing a systematic literature search strategy ensures an efficient and comprehensive approach to acquiring the information that you or your client requires.

What’s the Purpose of a Literature Search: The primary purpose is to obtain factual and current information that supports the standards of care.  The acquired knowledge from a literature search can be used to educate yourself, your clients, expert witnesses (can result in impeachment of the expert witness) and the jury.  Additionally, a number of medical consultants utilize literature searches to identify possible expert witnesses. 

Barriers to Systematic Literature Searches: These range from lack of time, lack of knowledge/lack of searching skills, lack of motivation and information overload.  

What’s a Search Strategy? This is a plan that helps locate the information being searched for.

A literature search strategy is an intellectual and practice focused endeavor.  The process should start with a clinical question, followed by a formal written search strategy.

The Clinical Question: Use key words from a clinical question to guide the literature search.  Use of the PICOT format guides search success.  This is a process in which clinical questions are phrased in a manner that yields the most relevant information from a search.  P = patient population, I = intervention or issue of interest, C = Comparison intervention or status, O = outcome, T = timeframe for (I) to achieve (O). 

• Example Clinical (PICOT) Question: In newborns who meet inclusion criteria for therapeutic hypothermia (P), does passive cooling, (I) compared to not being passively cooled, (C) result in a lower incidence of neonatal encephalopathy O) if implemented within the first 6 hours of life (T)? 

• Note: Keywords to be used in the literature search are highlighted.

Written Search Strategy: Use of a literature search tool will help you track your original search, and refined searches.  This method allows you to track your keywords, synonymous words, Boolean phrases used (will be discussed below), the search engine(s) used, and the number of sources your search yielded

• (See Literature Search Tool attached)

Know What Type of Service or Resource is Needed Before you Begin your Search:  The type of service or resource is going to guide the source you retrieve information from. 

• Textbooks: A good resource forfactual information.  Textbooks contain summaries of known established facts from previously published literature as well as new material from the author.
  • Learn about the resources your local medical library offers.  Many medical textbooks can be found within a medical library. 
  • Inquire about the availability of an interlibrary loan service if the library doesn’t own a specific textbook (or journal) you’re looking for.  The library can get the textbook from another library.
  • “Doody’s Core Titles” is a listing of authoritative textbooks. 

• Databases:  To locate new or changing information use databases to search for medical or journal articles.  
• Know the Databases: Each database covers its own range of journals and each has its own search protocol.
• Multiple relevant databases should be searched systematically
• Commonly Used Online Databases (not an inclusive list):
• 1. MEDLINE/PubMed: http://www.ncbi.nlm.nih.gov/pubmed

This database is free, however, can be over-whelming as it has over 35 million references.   The database provides full text articles in over 5,500 journals.  This database serves as a flagship database for journal articles in health sciences.

2. Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus): http://www.ebsco.com/products/research-databases/cinahl-plus

This is a comprehensive database specific to nursing and allied health research offering more than 770 journals and full text articles.

How Do You Gain Access to Databases?: Through the use of the internet, subscription through work or home, medical library, private or public library, freelance librarian or a database vendor (E.g., Ovid technologies, HealthSource, ProQuest, SNT). 

How Can Membership in Professional Organizations Assist with Literature Searches?  Through active membership, you have access to published journals, practice bulletins and committee opinions.  Additionally, with active membership, you’re better positioned to remain current with the evolving evidence and standards of care.  Examples of professional organizations: American Medical Association (AMA), American Nurses Association (ANA), American Association of Nurse Practitioners (AANP), American College of Obstetricians and Gynecologists (ACOG), Association of Operating Room Nurses (AORN), etc.

Value in Building your Personal Reference Library:  Through membership in professional organizations, you can quickly begin to build your own reference library.  Many organizations circulate their published journals  on a monthly or quarterly basis.  These can be maintained for future reference in a hard or electronic copy.  Over time, purchase authoritative textbooks that pertain to your specialty.  If you’re uncertain which textbook to purchase, inquire with a consultant in the field, a clinician or educator.    

When Synthesizing Information from your Search, Know the Levels of Evidence:  Level of evidence refers to the degree that information can be trusted, based on study design.  Many of you are familiar with the levels of evidence being represented as a pyramid with systematic reviews on top, followed by randomized controlled trials, then observational studies such as cohort studies or case controlled studies, with case studies and expert opinion at the bottom.

 It’s important to correlate this pyramid to the notion that all evidence (information) is not created equal.  When evaluating sources of evidence to use, you want to focus on high level (level 1-2) evidence.  These high level sources of evidence help clinicians to translate research into practice, and inform clinician and patient decision making.  

Importance in Knowing the Types of Publications:

• Peer reviewed publications are generally authoritative.  Commonly used peer-reviewed journals (not an inclusive list):
  • Annals of Internal Medicine:  https://www.acpjournals.org/journal/aim
  • The Journal of the American Medical Association (JAMA): https://jamanetwork.com/
  • The Lancet: https://www.thelancet.com/
  • The New England Journal of Medicine: https://www.nejm.org/

• Industry, published by or about a particular industry is not consistently authoritative. 

• Newsletters have general health information, but are not considered authoritative. 

What is an Authoritative Source of Literature? Work known to be reliable because its authority or authenticity is widely recognized by experts in the field.  These sources are generally accepted as controlling in the subject area.

How to locate authoritative textbook sources:

• Refer to “Doody’s Core Title’s”
• Look for textbooks placed in the library’s core, reference, or reserve collections
• Refer to publications used in medical and/or nursing schools, or teaching aids in hospitals
• Begin growing your personal reference library

How to locate authoritative journal articles:

• Review relevant content in the Cochrane Reviews. Cochrane Reviews is a collection of databases of systematic reviews and meta-analyses which summarize and interpret the results of medical research, technology assessments, and clinical trials for the purposes of making informed clinical decisions.  http://www.cochrane.org/
• Check textbooks for relevant references to journal articles you may be able to use.  Search for journal articles written by the authors of relevant textbooks.
• Consult with experts, specialists, authorities for names of authoritative publications or authors.

Other Search Tips:

• Determine how far back you want to go with your literature search. 
  • For standard of care issues, search the year the incident occurred. 
  • For causation issues, search the most current information. 
• Validate information by cross-referencing with other sources.
• Use a filtered search strategy to narrow your search to peer reviewed sources.
• Consider synonymous terms to use in subsequent searches to yield a more robust, or more manageable search.
• Consider alternative relevant databases if your search, and refined searches, don’t yield results.
• The chosen database may require or allow for Boolean search operators. 
  • Use of the word “and” or a “+” sign between two or more words will narrow your search. 
  • Use of the word “or” or a “/” will broaden your search.
  • Use of the word “not” or “-“ will indicate that the word shouldn’t appear in your search
  • Use of the word “near” will indicate words that should be found close to each other in your search.
• Consider pleural and alternative spellings.  E.g., splint, splints, labor, labour.
• Some databases allow you to search by author.  This will help narrow your search.

 A systematic literature search is an intellectual and practice focused endeavor that can be mastered over time. 

If you have a medical related case that could be strengthened by a systematic literature search, but don’t know where to begin, contact Barber Medical Legal Nurse Consulting, LLC. 

Resources:

Evidence Based Practice in Nursing and Healthcare, 4^th ed. 2019. A Guide to Best practice.

How to Read a Paper, 6^th ed. 2019. The Basics of Evidence-Based Medicine and Healthcare.

P.S. Comment and Share:  How do you plan to integrate this information into practice?