Family Practice Residents Performance of Antenatal Fetal...
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UIC College of Nursing Advancing Nursing Leadership UIC College of Nursing Advancing Nursing Leadership Family Practice Residents Performance of Antenatal Fetal Surveillance Kelly D. Rosenberger, DNP, APRN, CNM, WHNP-BC, Barbara Camune, DrPH, CNM, WHNP-BC, Patricia Ryan-Lewis, PhD, RN, Candance Leaphart-St. Cloud, DO, University of Illinois, Colleges of Nursing & Medicine, Rockford, IL Background Antenatal fetal surveillance with EFM plays a prominent role in modern obstetrics and as such requires a high level of understanding regarding interpretation and the resultant clinical care for appropriate intervention and patient management. Yet, a 2003 survey done by Murphy and colleagues demonstrated lack of formalized education and competency assessment of EFM in residency programs in the United States. Two thirds of fetal deaths occur before the onset of labor with many of these occurring in women at risk for utero-placental insufficiency (Presem, 2011). EFM is used to assess the risk of adverse perinatal outcomes associated with utero-placental insufficiency and is recommended for pregnancies at risk for hypoxia and stillbirth (ACOG, 2009). Safe, high-quality obstetrical care can only be provided if the clinicians are skilled in antenatal fetal surveillance. Purpose Even with the addition of the Advanced Life Support in Obstetrics Course in Residency training, not all clinicians in the outpatient setting are familiar with or currently using the updated interpretation guidelines for EFM as recommended by the National Institute of Child Health and Human Development in 2008 in collaboration with ACOG & the Society for MFM (Macones, Hankins, Spong, Hauth & Moore, 2008). The purpose of this study was to assess and improve clinician knowledge, confidence and practice patterns related to antenatal fetal surveillance with electronic fetal monitoring (EFM) to assure quality care and patient safety. Methods Using a descriptive non-experimental study design, knowledge, confidence and practice patterns of electronic fetal monitoring were studied pre and post educational intervention. This study collected documented data from patient care records, fetal heart rate EFM strips, clinician pre and post-tests related to knowledge of antenatal testing and clinician pre and post surveys related to confidence in properly interpreting fetal monitor strips during EFM. The participants were first, second and third year residents enrolled in a family practice residency program in the Midwestern U.S. Data was entered into a database and using SPSS, cross tabulation with Chi-square, repeated measure t-tests and Cronbach’s Alpha Reliability was performed to determine descriptive statistical analysis. Results A quality improvement intervention aimed at antenatal fetal assessment was successful at improving EFM interpretation in the outpatient setting. There was a statistically significant increase in pre to post intervention knowledge and confidence levels among the residents with a 2-tailed significance P<0.5. Interestingly, the study also found the residents had a higher confidence in their ability to interpret EFM than was actually true. References 1. Murphy, A.A., Halamek, L.P., Lyell, D.J., Druzin, M.L. (2003). Training and competency assessment in electronic fetal monitoring: A national survey. Obstet Gynecol, 101(6):1243-1248. 2. Presem, C. (2011). The Partnership for Maternal, Newborn & Child Health. Retrieved at: http:// www.who.int/pmnch/media/membernews/ 2011/20110414_lancetseries stillbirths/en/ index1.html 3. American College of Obstetricians and Gynecologists. (2009). Practice Bulletin: Intrapartum Fetal Heart Rate Monitoring. (Practice Bulletin No 106) Washington, DC, Author. 4. Macones, G.A., Hankins, G.D.V., Spong, C.Y., Hauth, J., & Moore, T. (2008). The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on definitions, interpretation, and research Guidelines. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37(5): 510-515. Implications The results of this pilot study have several implications for the educational needs of all clinicians providing antenatal fetal monitoring. First, the residents had a higher confidence in their ability to interpret the results of the NST test than was actually found to be true. This indicates that the residents, especially in their first year, may misdiagnose the results of an abnormal NST test and therefore place the fetus at risk. Second, although the residents increased their ability to read and interpret the NST, documentation of the results remained less than optimal. Third, emphasis needs to be placed on the recognition of abnormal NST results in the antenatal clinical setting and the required follow- up for such a diagnosis. It is logical that safe, high- quality obstetrical care can only be provided if the clinicians are skilled in antenatal fetal surveillance. All types of clinicians providing obstetrical care need to have basic knowledge of EFM and should be assessed prior to providing outpatient antepartum care with continued ongoing assessment every few years. Ongoing quality assurance is needed to assess for accuracy of NST interpretation, documentation and clinical recommendations. This study revealed the need for improved antenatal knowledge, confidence levels and documentation among clinicians in the outpatient setting regarding NST interpretation. The DNP educational intervention in this study significantly improved NST interpretation results with the post intervention audit revealing 100% correct NST interpretation. Acknowledgements The current study fulfilled the requirements of the DNP program and was supported by the University of Illinois Rockford College of Nursing and College of Medicine. A special thank you to my dissertation committee for their assistance with this project. 1 st Year Residents 2 nd Year Residents 3 rd Year Residents NST and Chart Audits Cronbach’s Alpha
Transcript of Family Practice Residents Performance of Antenatal Fetal...
UIC College of Nursing Advancing Nursing Leadership UIC College of Nursing Advancing Nursing Leadership
Family Practice Residents Performance of Antenatal Fetal Surveillance Kelly D. Rosenberger, DNP, APRN, CNM, WHNP-BC, Barbara Camune, DrPH, CNM, WHNP-BC, Patricia Ryan-Lewis, PhD, RN,
Candance Leaphart-St. Cloud, DO, University of Illinois, Colleges of Nursing & Medicine, Rockford, IL
Background Antenatal fetal surveillance with EFM plays a prominent role in modern obstetrics and as such requires a high level of understanding regarding interpretation and the resultant clinical care for appropriate intervention and patient management. Yet, a 2003 survey done by Murphy and colleagues demonstrated lack of formalized education and competency assessment of EFM in residency programs in the United States. Two thirds of fetal deaths occur before the onset of labor with many of these occurring in women at risk for utero-placental insufficiency (Presem, 2011). EFM is used to assess the risk of adverse perinatal outcomes associated with utero-placental insufficiency and is recommended for pregnancies at risk for hypoxia and stillbirth (ACOG, 2009). Safe, high-quality obstetrical care can only be provided if the clinicians are skilled in antenatal fetal surveillance.
Purpose Even with the addition of the Advanced Life Support in Obstetrics Course in Residency training, not all clinicians in the outpatient setting are familiar with or currently using the updated interpretation guidelines for EFM as recommended by the National Institute of Child Health and Human Development in 2008 in collaboration with ACOG & the Society for MFM (Macones, Hankins, Spong, Hauth & Moore, 2008). The purpose of this study was to assess and improve clinician knowledge, confidence and practice patterns related to antenatal fetal surveillance with electronic fetal monitoring (EFM) to assure quality care and patient safety.
Methods Using a descriptive non-experimental study design, knowledge, confidence and practice patterns of electronic fetal monitoring were studied pre and post educational intervention. This study collected documented data from patient care records, fetal heart rate EFM strips, clinician pre and post-tests related to knowledge of antenatal testing and clinician pre and post surveys related to confidence in properly interpreting fetal monitor strips during EFM. The participants were first, second and third year residents enrolled in a family practice residency program in the Midwestern U.S. Data was entered into a database and using SPSS, cross tabulation with Chi-square, repeated measure t-tests and Cronbach’s Alpha Reliability was performed to determine descriptive statistical analysis.
Results A quality improvement intervention aimed at antenatal fetal assessment was successful at improving EFM interpretation in the outpatient setting. There was a statistically significant increase in pre to post intervention knowledge and confidence levels among the residents with a 2-tailed significance P<0.5. Interestingly, the study also found the residents had a higher confidence in their ability to interpret EFM than was actually true.
References 1. Murphy, A.A., Halamek, L.P., Lyell, D.J., Druzin, M.L.
(2003). Training and competency assessment in electronic fetal monitoring: A national survey. Obstet Gynecol, 101(6):1243-1248.
2. Presem, C. (2011). The Partnership for Maternal, Newborn & Child Health. Retrieved at: http://www.who.int/pmnch/media/membernews/2011/20110414_lancetseries stillbirths/en/index1.html
3. American College of Obstetricians and Gynecologists. (2009). Practice Bulletin: Intrapartum Fetal Heart Rate Monitoring. (Practice Bulletin No 106) Washington, DC, Author.
4. Macones, G.A., Hankins, G.D.V., Spong, C.Y., Hauth, J., & Moore, T. (2008). The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring: Update on definitions, interpretation, and research Guidelines. Journal of Obstetric, Gynecologic and Neonatal Nursing, 37(5): 510-515.
Implications The results of this pilot study have several implications for the educational needs of all clinicians providing antenatal fetal monitoring. First, the residents had a higher confidence in their ability to interpret the results of the NST test than was actually found to be true. This indicates that the residents, especially in their first year, may misdiagnose the results of an abnormal NST test and therefore place the fetus at risk. Second, although the residents increased their ability to read and interpret the NST, documentation of the results remained less than optimal. Third, emphasis needs to be placed on the recognition of abnormal NST results in the antenatal clinical setting and the required follow-up for such a diagnosis. It is logical that safe, high-quality obstetrical care can only be provided if the clinicians are skilled in antenatal fetal surveillance. All types of clinicians providing obstetrical care need to have basic knowledge of EFM and should be assessed prior to providing outpatient antepartum care with continued ongoing assessment every few years. Ongoing quality assurance is needed to assess for accuracy of NST interpretation, documentation and clinical recommendations. This study revealed the need for improved antenatal knowledge, confidence levels and documentation among clinicians in the outpatient setting regarding NST interpretation. The DNP educational intervention in this study significantly improved NST interpretation results with the post intervention audit revealing 100% correct NST interpretation.
Acknowledgements The current study fulfilled the requirements of the DNP program and was supported by the University of Illinois Rockford College of Nursing and College of Medicine. A special thank you to my dissertation committee for their assistance with this project.
1st Year Residents
2nd Year Residents
3rd Year Residents NST and Chart Audits
Cronbach’s Alpha
