[No SPF Record] [IMPROVEDX] Fwd: To Keep Women From Dying In Childbirth, Look To California : NPR
rjaffe at CHPSO.ORG
Mon Jul 30 18:21:30 UTC 2018
Here at CHPSO and HQI we’re major partners in the California effort on perinatal safety. Though it is maternal outcomes that is hitting the news, maternal morbidity and mortality was just a bit of it, and our first efforts actually focused on the neonate, not the mother.
I (im-)modestly agree that this is an important effort, but improving diagnosis really hasn’t been a part of it other than forcing the docs to properly identify things such as estimated gestational age—things that do feed into therapeutic decisions and the diagnostic separation of pre-term from term gestations.
As to success, some of the biggest successes were due to the installation of “hard stops” for things that didn’t have to be urgently decided—such as scheduling a mother for elective delivery when the infant was younger than 39 weeks gestational age and there wasn’t a medical indication for early delivery (so, the intervention was focused on the treatment appropriateness not diagnostic accuracy).
Another was the introduction of defined algorithms (and practicing them)—particularly for peri-partum hemorrhage, that guided people through a rather complex set of escalating interventions in a uniform manner. One interesting general side effect of defined algorithms for anything, regardless as to whether diagnoses are specifically identified in the algorithm or not, is that the need for diagnostic thinking is greatly reduced, reducing cognitive load and decreasing the risk of misdiagnosis/mistreatment. The hemorrhage treatment algorithm (https://www.cmqcc.org/resource/3309/download) is based on an underlying model of what is causing the problem, so the need for making a correct diagnosis is reduced. Where a diagnosis is explicitly needed in order to choose next steps, the algorithm often supplies a pre-defined set of appropriate diagnoses for the doc to choose from. For example, “Stage 2” has the following two sets of diagnostic alternatives and treatments:
1. Vaginal birth
a. Bimanual fundal massage (unlike the three following, this is not coupled with a diagnosis but can help make the diagnosis as well as treat the patient).
b. Dx: Retained POC: Tx: D&C.
c. Dx: lower segment/implementation site/atony: Tx: Intrauterine Balloon.
d. Dx: Laceration/hematoma: Tx: Packing, repair as required.
e. Consider interventional radiology if available and adequate experience (again, not explicitly coupled with a dx)
2. Cesarean birth
a. Dx. Continued atony. Tx: B-Lynch suture/intrauterine balloon.
b. Dx. Continued hemorrhage (I guess I’d call this “dx unknown but it’s probably not atony”). Tx: Uterine artery ligation.
Rory Jaffe, MD MBA, Executive Director, CHPSO<http://www.chpso.org/>
1215 K Street, Suite 930
Sacramento, CA 95814
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From: David L Meyers <dm0015 at COMCAST.NET>
Sent: Sunday, July 29, 2018 12:04 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [No SPF Record] [IMPROVEDX] Fwd: To Keep Women From Dying In Childbirth, Look To California : NPR
Interesting story on NPR this morning about California efforts to reduce maternal morbidity and mortality. Diagnostic errors and physician attitude were among the topics discussed. Pat Croskerry was interviewed. Not all diagnosis related but worth a listen.
Another interesting story, this one in today’s NY TImes about the increasing frequency of meat allergies related to tick bites and how the connection was made:
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