[No SPF Record] [IMPROVEDX] Fwd: To Keep Women From Dying In Childbirth, Look To California : NPR

Ruth Ryan ruth at RYAN-GRAHAM.COM
Mon Jul 30 20:02:16 UTC 2018


Dear Dr. Jaffe,

According to the articles I’ve  been seeing* it seemed the increasing rate of maternal mortality in the US is very much a problem of delayed diagnosis of such things as hemorrhage and pre-eclampsia and PE. Plus racial disparities contributing to those misdiagnoses.  It reminds me of surgeons believing that the issue of misdiagnosis doesn’t much apply to them; their mishaps tend to come from surgical complications.

But isn’t failure to recognize a complication a failure to make a timely diagnosis?

Ruth Ryan

* NY Times magazine, The Hidden Toll, also sub-titled Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis, The answer to the disparity in death rates has everything to do with the lived experience of being a black woman in America. Apr 15, 2018.  https://www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html
Plus the coverage of the young NICU nurse, wife of a physician, who died after delivery not long ago of eclampsia recognized too late.
Then there was the case of Serena Williams, delayed diagnosis of complications.
AMA Wire 7/27/18: Analysis: Hospitals routinely ignore guidance intended to save new mothers’ lives.  USA Today (7/26/18) reports on its own investigation, finding that each year more than 50,000 mothers are severely injured and about 700 mothers die giving birth. According to USA Today, “the best estimates say that half of these deaths could be prevented and half the injuries reduced or eliminated” by following routine guidance. Journalists “obtained more than a half-million pages of internal hospital quality records and examined the cases of more than 150 women whose deliveries went terribly wrong.” Additionally, journalists contacted 75 birthing hospitals “to track whether they follow recommended procedures,” together revealing a “stunning lack of attention to safety recommendations and widespread failure to protect new mothers.”
In good news, David provided this: 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. https://www.npr.org/2018/07/29/632702896/to-keep-women-from-dying-in-childbirth-look-to-california



From: Rory Jaffe <rjaffe at CHPSO.ORG>
Sent: Monday, July 30, 2018 2:22 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Fwd: To Keep Women From Dying In Childbirth, Look To California : NPR

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
     *   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).
     *   Dx: Retained POC: Tx: D&C.
     *   Dx: lower segment/implementation site/atony: Tx: Intrauterine Balloon.
     *   Dx: Laceration/hematoma: Tx: Packing, repair as required.
     *   Consider interventional radiology if available and adequate experience (again, not explicitly coupled with a dx)
  2.  Cesarean birth
     *   Dx. Continued atony. Tx: B-Lynch suture/intrauterine balloon.
     *   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
rjaffe at chpso.org<mailto:rjaffe at chpso.org>
(916) 552-2600

[CHPSO-logo-tag-outlines]<http://chpso.org/>

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From: David L Meyers <dm0015 at COMCAST.NET<mailto:dm0015 at COMCAST.NET>>
Sent: Sunday, July 29, 2018 12:04 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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.

https://www.npr.org/2018/07/29/632702896/to-keep-women-from-dying-in-childbirth-look-to-california<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.npr.org_2018_07_29_632702896_to-2Dkeep-2Dwomen-2Dfrom-2Ddying-2Din-2Dchildbirth-2Dlook-2Dto-2Dcalifornia&d=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=M2hzc8Zut-EFzno7FyxlzD0Haw-IGoWlt6HjBk0Ek5M&s=vmouDDwDPOkE0J1jX9ySylPdjjV57IuwgEw3x2Mo4TY&e=>

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:

https://www.nytimes.com/2018/07/24/magazine/what-the-mystery-of-the-tick-borne-meat-allergy-could-reveal.html?rref=collection/sectioncollection/magazine&action=click&contentCollection=magazine&region=rank&module=package&version=highlights&contentPlacement=2&pgtype=sectionfront<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.nytimes.com_2018_07_24_magazine_what-2Dthe-2Dmystery-2Dof-2Dthe-2Dtick-2Dborne-2Dmeat-2Dallergy-2Dcould-2Dreveal.html-3Frref-3Dcollection_sectioncollection_magazine-26action-3Dclick-26contentCollection-3Dmagazine-26region-3Drank-26module-3Dpackage-26version-3Dhighlights-26contentPlacement-3D2-26pgtype-3Dsectionfront&d=DwMFaQ&c=hx0HUg_nG-xRkKlwWZeJFCbvzzw0Ym5DwdL_1FKbReI&r=ykcs2wU25yxj5BckI49bSg&m=M2hzc8Zut-EFzno7FyxlzD0Haw-IGoWlt6HjBk0Ek5M&s=GnEc-U56_2PjZzEnlck3Tm3Q0CnIBZr_8HnxaBt6Ia0&e=>



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