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

Xavier Prida dr.xavier.prida at GMAIL.COM
Mon Jul 30 22:42:39 UTC 2018


Not to be lost- absent in the transcript but contained in the audio
segment- is Pat Croskerry highlight of "zebra retreat". It bears on the
concept of comprehensiveness in differential diagnosis.  Just don't focus
on common diagnosis(his example- Guillan Barre' in post partum patient).

Xavier

* praesent superare odio  (r**ise above)*

Xavier E. Prida MD FACC FSCAI
Assistant Professor of Medicine
Program Director Cardiology Fellowship Training
USF Morsani College of Medicine
Department of Cardiovascular Sciences
2 Tampa General Circle
STC 5 th Floor
Tampa, Fl 33606
813 259 0992(O)

On Mon, Jul 30, 2018 at 5:26 PM, Rory Jaffe <rjaffe at chpso.org> wrote:

> Maybe the best summary (though I may be offending my obstetrician
> colleagues) is: “Don’t think, just do.” Or, to be more politically correct
> about it, it’s like giving pilots emergency checklists instead of letting
> them “wing it” on their own. Individual thought processes are de-emphasized
> (though not completely eliminated)—following protocols and being prepared
> are emphasized.
>
>
>
>
>
> Rory Jaffe, MD MBA, Executive Director, CHPSO <http://www.chpso.org/>
>
> 1215 K Street, Suite 930
> <https://maps.google.com/?q=1215+K+Street,+Suite+930+%0D%0ASacramento,+CA+95814&entry=gmail&source=g>
> Sacramento, CA 95814
> rjaffe at chpso.org
> (916) 552-2600
>
>
>
> [image: CHPSO-logo-tag-outlines] <http://chpso.org/>
>
>
>
> Subscribe to CHPSO newsletters and announcements
> <https://urldefense.proofpoint.com/v1/url?u=http://eepurl.com/rNG3T&k=q2ic6PGnSSvGRm9uYENyDA%3D%3D%0A&r=1aaywgLlHZ49GLomgN2gpcNMVuk1qp9k63bo%2BqwiIHQ%3D%0A&m=nPo4DNBluQoKznFSpyRgz65%2Ffkdcc45e0bJdcK4fOdA%3D%0A&s=002145da16c17f816d8bd5309d7966b755c6462eb3621af67612bf8c116d1f8a>
>
> [image: cid:image001.jpg at 01D42017.F94EE1A0]
> <http://www.hqinstitute.org/hqi2018>
>
>
>
> *From:* Rory Jaffe
> *Sent:* Monday, July 30, 2018 1:38 PM
> *To:* 'Ruth Ryan' <ruth at ryan-graham.com>; Society to Improve Diagnosis in
> Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
> *Subject:* RE: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Fwd: To Keep Women
> From Dying In Childbirth, Look To California : NPR
>
>
>
> Peripartum hemorrhage is a good example as to where the intellectual
> diagnostic process was not a major target of the improvement efforts. I’m
> not saying that diagnosis was not an issue—just that it wasn’t the biggest
> issue. And, for my specific example, hemorrhage, I’d say that inaccurate
> data collection (inaccurate blood loss estimates) was more important than
> cognitive failures in establishing the severity of the hemorrhage.
>
>
>
> Look at table 2 in this publication: https://www.cmqcc.org/sites/
> default/files/Main%20etal%20SMM%20HEM%20at%20SMFM%20copy.pdf
>
>
>
> They have three domains for their safety bundle elements: readiness,
> recognition and prevention, response. The recognition and prevention domain
> includes diagnosis. Most of their bundle elements are in the readiness and
> response domains. In the recognition and prevention domain, two elements
> appear to address diagnosis: 1) risk assessment (which is not addressing
> the diagnosis of hemorrhage but does provide a diagnosis that could
> increase readiness and/or take measures to deliver differently to avert
> hemorrhage) and 2) measurement of cumulative blood loss as accurately as
> possible. Of those two, #2 is a big change in accuracy, and probably a big
> driver in improving diagnosis of severe hemorrhage.
>
>
>
> Matter of fact, they didn’t even standardize the diagnostic definition:
> “While we attempted to standardize the definition of obstetric hemorrhage,
> that remained a work in progress”
>
>
>
>
>
>
>
>
>
>
>
> Rory Jaffe, MD MBA, Executive Director, CHPSO <http://www.chpso.org/>
>
> 1215 K Street, Suite 930
> <https://maps.google.com/?q=1215+K+Street,+Suite+930+%0D%0ASacramento,+CA+95814&entry=gmail&source=g>
> Sacramento, CA 95814
> rjaffe at chpso.org
> (916) 552-2600
>
>
>
> [image: CHPSO-logo-tag-outlines] <http://chpso.org/>
>
>
>
> Subscribe to CHPSO newsletters and announcements
> <https://urldefense.proofpoint.com/v1/url?u=http://eepurl.com/rNG3T&k=q2ic6PGnSSvGRm9uYENyDA%3D%3D%0A&r=1aaywgLlHZ49GLomgN2gpcNMVuk1qp9k63bo%2BqwiIHQ%3D%0A&m=nPo4DNBluQoKznFSpyRgz65%2Ffkdcc45e0bJdcK4fOdA%3D%0A&s=002145da16c17f816d8bd5309d7966b755c6462eb3621af67612bf8c116d1f8a>
>
> [image: cid:image001.jpg at 01D42017.F94EE1A0]
> <http://www.hqinstitute.org/hqi2018>
>
>
>
> *From:* Ruth Ryan <ruth at ryan-graham.com>
> *Sent:* Monday, July 30, 2018 1:02 PM
> *To:* Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.
> IMPROVEDIAGNOSIS.ORG>; Rory Jaffe <rjaffe at chpso.org>
> *Subject:* RE: [IMPROVEDX] [No SPF Record] [IMPROVEDX] Fwd: To Keep Women
> From Dying In Childbirth, Look To California : NPR
>
>
>
> 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
>       1. 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).
>       2. Dx: Retained POC: Tx: D&C.
>       3. Dx: lower segment/implementation site/atony: Tx: Intrauterine
>       Balloon.
>       4. Dx: Laceration/hematoma: Tx: Packing, repair as required.
>       5. Consider interventional radiology if available and adequate
>       experience (again, not explicitly coupled with a dx)
>    2. Cesarean birth
>       1. Dx. Continued atony. Tx: B-Lynch suture/intrauterine balloon.
>       2. 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
> <https://maps.google.com/?q=1215+K+Street,+Suite+930+%0D%0ASacramento,+CA+95814&entry=gmail&source=g>
> Sacramento, CA 95814
> rjaffe at chpso.org
> (916) 552-2600
>
>
>
> [image: CHPSO-logo-tag-outlines] <http://chpso.org/>
>
>
>
> Subscribe to CHPSO newsletters and announcements
> <https://urldefense.proofpoint.com/v1/url?u=http://eepurl.com/rNG3T&k=q2ic6PGnSSvGRm9uYENyDA%3D%3D%0A&r=1aaywgLlHZ49GLomgN2gpcNMVuk1qp9k63bo%2BqwiIHQ%3D%0A&m=nPo4DNBluQoKznFSpyRgz65%2Ffkdcc45e0bJdcK4fOdA%3D%0A&s=002145da16c17f816d8bd5309d7966b755c6462eb3621af67612bf8c116d1f8a>
>
> [image: cid:image001.jpg at 01D42017.F94EE1A0]
> <http://www.hqinstitute.org/hqi2018>
>
>
>
> *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.
>
>
>
> 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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> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
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>
> To unsubscribe from IMPROVEDX: click the following link:
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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