Running head: THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION

Informational Report on The Use of National Institute of Child Health and Human Development (NICHD) Terminology in the Documentation of Electronic Fetal Monitoring at Metro Health Hospital

Prepared for Ingrid Chezlik, RN, MSN, CNO and Dr. Dennis Ruzicka Prepared by Denise S. VanderWeele, RN-C, ADN Childbirth Center at Metro Health Hospital

July 8, 2012

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION

Abstract A recent chart audit at Metro Health Hospital revealed an inconsistent use of the terminology developed by NICHD (the National Institute of Child Health and Human Development) in 2008 for documenting the interpretation of Electronic Fetal Monitoring (EFM). It is the expectation of accreditation agencies such as The Joint Commission on Accreditation of Healthcare Organizations that the NICHD terminology be used in all documentation of all EFM data (JCAHO, 2004). Patient safety is at risk when the information obtained from EFM is not communicated in a format with which all health care team members are familiar (Miller, 2010). The intent of this paper is to discover why the NICHD terminology is not used consistently by health care team members in the documentation of EFM and to propose methods to improve compliance by physicians, residents and nurses at Metro Health Hospital.

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION The Use of NICHD Terminology in the Documentation of Electronic Fetal Monitoring (EFM) at Metro Health Hospital

Electronic Fetal Monitoring (EFM) is currently used in over 85% of the births in the United States (Robinson, 2008) for the surveillance of a fetus during labor and delivery (McRae, 1999). Of the 1768 births at Metro last year, nearly all of them employed EFM. Each patient relied on the interpretation and communication skills of the Childbirth Center staff to provide safe care for mother and child (Lyndon & Watcher, 2011). An informal chart review of the EFM documentation at Metro recently revealed inconsistencies in the use of the standardized terminology developed by NICHD (the National Institute for Child Health and Human Development) in 2008. The use of standardized terminology promotes clear communication and interpretation of data and positively impacts the safety of mother and baby (Simpson & Knox, 2006). The absence or inconsistent use of the same terminology can increase the legal exposure of physicians, nurses and Metro Health Hospital (McRae, 1999). It will also not go unnoticed by accreditation agencies such as the Joint Commission (JCAHO, 2004) or HFAP. This report will explore reasons for the inconsistent use of NICHD terminology by otherwise conscientious doctors, nurses and residents at Metro. It will propose methods to improve communication, understanding and use of standardized terminology. It will also recommend a program of education that will encompass these elements in an accessible, convenient and cost-effective format.

Background In response to The Joint Commissions Sentinel Event # 30 bulletin on the prevention of infant mortality (JCAHO, 2004), NICHD developed standardized terminology to be used in the interpretation and communication of findings in Electronic Fetal Monitoring (EFM). The purpose of this terminology was to minimize the risk of common preventable errors from occurring in obstetrics (Miller, 2012). Although the standardized terminology was embraced by the professional organizations of both obstetricians and obstetric nurses, the education of each professional group in its use has been far from standardized. The attending physicians at Metro receive updated information through their professional journals and attendance at seminars (ACOG, 2009). The nurses attend classes provided by AWHONN, and retest every two years to validate their competence in interpreting EFM (AWHONN, 2012). Some RNs have received additional certification in EFM through the National Credentialing Center. Residents are taught EFM interpretation by a senior resident early in their first year at Metro, and not through either AWHONN or ACOG. These diverse learning venues for NICHD standards can result in mixed compliance between medical disciplines (Sigman, 2007). This gap in consistency could increase the legal risk to doctors, nurses and Metro Hospital (McRae, 1999 and Miller, 2010).

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION The Need for Improvement in the Use of NICHD Terminology in the Clinical Setting

In a national study, the documentation of EFM patterns during labor using NICHD terminology was found to be in about 80% of the charts audited. The use of NICHD terminology by nurses was found to be in four times as many charts as those recorded by physicians. It was concluded that both physicians and RNs need more education to be compliant with NICHD recommendations in interpreting and documenting EFM patterns (Sigman, 2007). I have found that there is a hybrid of old and new terminology used by the attending (physicians) in their documentation of EFM interpretation, Dr. Jeffrey Postelwaite, faculty member at MSU and Director of Resident Education at Metro stated in a recent interview (J. Postelwaite, personal communication, June 7, 2012).. Nurse Manager Laura McDonald, RN, BSN adds that using a mix of old and new terminology could hinder some of the communication (L. McDonald, personal communication, June 4, 2012) between physicians and nurses. Miscommunication and misinterpretation of EFM have been found to be at the root cause of most obstetric errors (McRae, 1999). Because physicians, residents and nurses share the ultimate goal of the delivery of a healthy mother and baby, it is essential that interdisciplinary communication be understood by using standardized terminology (Simpson & Knox, 2006). The goal of consistent use of NICHD terminology is to have all members of the health care team speaking a common language when describing electronic fetal monitoring (Robinson, 2008). Dr. Postelwaite adds that obstetrics is one of the areas of the hospital that both groups of people (doctors and nurses) depend on the otherthere is a lot of benefit in learning --- if not together, then the exact same information --- so that they can speak the same language (J. Postelwaite, personal communication, June 7, 2012). A study at Northwest Memorial Hospital in Chicago confirms this idea with the conclusion that the value of a common language is that everyone involved has the same understanding of the FHR (Fetal Heart Rate), thereby increasing patient safety by decreasing the risk of miscommunication (Robinson, 2008). Keys to the Consistent Use of NICHD Terminology Multidisciplinary education in the use of NICHD terms in EFM is the cornerstone to building effective communication and teamwork within the obstetric unit (MacEachin, Lopez, Powell, and Corbett, 2009). A multidisciplinary class with further collaboration in the form of proficiency drills, joint rounds, huddles, debriefings and conflict management are methods believed to enhance teamwork and communication (Lyndon & Watcher, 2011). These all contribute to providing safe, effective care for labor and delivery patients. At Metro, the Childbirth Center Nurse Educator provides hour-long classes that analyze recent case studies that highlight communication and spark discussion on how to improve the care given at our institution. These monthly class are available for all nurses, residents and physicians to attend. Continuing education contact hours are awarded after an evaluation is completed. These classes serve as a great reinforcement for the use of NICHD terminology and improved documentation and accomplishes many of the same goals as a debriefing or joint rounding experience as suggested by Lyndon & Watcher (2011).

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION

Random chart audits would also confirm the consistent use of NICHD terminology and serve as an evaluation tool for the effectiveness of the multidisciplinary EFM course offered. Compliance should dramatically increase if all disciplines are given the same information at the same time and are aware of the expectation to use the tools given to them. Barriers to Multidisciplinary Education The biggest barrier to conducting multi- or interdisciplinary education in NICHD terminology for EFM is the time commitment needed to assemble all parties simultaneously. Most courses in EFM are offered in eight or 16 hour class segments. For physicians, this time away from their practice translates into lost revenue through either closing their office, or contracting with another physician to cover their hospital rounds. For nurses, it means taking time away from the nursing unit and finding replacement personnel. A viable alternative to a traditional classroom experience would be one a web-based class that can be accessed 24/7 and completed in small increments of time. This would allow the physician to complete part of the class on a slow day at the office, or from home where there are fewer distractions. A nurse might be able to do a part of the course in the middle of a midnight shift, and then complete it while waiting to transport her child home from an activity. A perceived barrier to on-line learning is that one would miss out on classroom discussion. However, there are some web-based programs that are highly interactive and have lively graphics provide excellent information. Also, if a learner has a difficult time understanding a certain section of material, he or she would be able to review that particular material as many times as is necessary to gain understanding. Compliance by the doctors would be encouraged through providing CMEs (Continuing Medical Education units) upon completion or possibly linking their participation in this course with their privileges to practice at Metro. Including an EFM course with their annual mandatory education well as providing contact hours for continuing education units for nurses would ensure participation. The Residents would view this course it as just another part of their education while at Metro. The cost of training a large group of professionals is always a concern. A grant from the Metro Health Hospital Foundation would need to be requested prior to the next deadline for applications which is August 1, 2012. The Foundation is a philanthropic organization with a long history of supporting this type of initiative because it agrees with its mission, which is in part, to promote health in the community and to decrease infant mortality. Conclusion The use of NICHD terminology in the interpretation and communication of EFM data is required for patient safety and accrediting entities such as JCAHO (Miller & Miller, 2012) and HFAP. Inconsistent use of this standardized nomenclature increases the risk of adverse outcomes due to misinterpretation and miscommunication of vital data (Miller, 2010). Interdisciplinary education in the use of NICHD terminology must be provided equally to so that

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION all care team members are speaking the same language when interpreting EFM (Robinson, 2008). The monitoring of compliance in using the correct terminology should be an ongoing process to reduce the legal liability of everyone, including Metro Hospital (McRae, 1999). Recommendation

The implementation of an interdisciplinary course would enhance collaboration and communication between doctors, residents and nurses and ultimately provide a safer environment for the patients. When followed up with emergency drills and monthly reviews of EFM data from case studies, the education would be continually reinforced. A follow-up chart audit in six months would verify the compliance of doctors and nurses in using the NICHD terminology. Electronic Fetal Heart Monitoring: Definitions, Interpretation and Management is a web-based course produced by G.E. Healthcare. This course was created by Dr. David A. Miller and Dr. Frank C. Miller, physicians and nationally recognized experts in EFM. The course is divided into four modules that cover NICHD terminology, interpretation of the data, management of the patient, and clinical case studies. It can be accessed with a password 24/7. The course material is also available for review to each participant for a full year after taking the competency test. A product information sheet is attached to this report. Cost The cost of the G.E. Healthcare EFM course is $169 per doctor or nurse and $100 for each resident. Debra Rewerts, RN, Nursing Educator for the Childbirth Center spoke with a product representative while attending the national AWHONN conference last month. G.E. Healthcare is offering Metro a reduced price of $112 for physicians and nurses if we participate in a study about interdisciplinary education in EFM. In the Childbirth Center, there are 58 doctors and nurses and 12 residents who would take this course. With participation in the study, the total cost would be $7696, instead of the full price of $11,002 for 80 people. Benefit If accessed by all doctors, nurses and residents who use EFM technology, improved communication and teamwork would be the result of using this program. All members of the health care team would receive the same information in the same format during the same timeframe. They would all speak the same EFM language. The benefit to Metro Health Hospital would be a decrease in the likelihood of a multimillion dollar lawsuit due to insufficient, incorrect or out-of-date documentation in the use of EFM. In a recent interview with Dr. Jeffrey Postelwaite, he cited the success of a similar project at the hospital he previously practiced, which was about the same size of Metro. The hospital required annual validation of EFM competency for all physicians and nurses. Postelwaite says that by allowing everyone (to be) delivered the same information, the hospital was able to

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION demonstrate that they met a (minimum) standard and lowered their supplemental malpractice premiums (by) a lot more than ten thousand dollars (J. Postelwaite, personal interview, June 7, 2012).

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION References

American Congress of Obstetricians and Gynecologists (2009). ACOG redefines fetal heart rate monitoring guidelines. Practice bulletin #106. Retrieved from www.acog.org/About_ACOG/News_Room/News_Releases/2009/ACOG_Refines_Fetal_ Heart_Rate_Monitoring_Guidelines Association for Womens Health, Obstetrics and Neonatal Nurses (2012). Fetal Heart Monitoring Program. Retrieved from www.awhonn.trainingharbor.com/html/FHR.php General Electric Health Care (2012). Benefits of Electronic Fetal Monitoring Program. Retrieved on 5/31/2012 from http://www.gehealthcare.com/usen/perinatal/clinical_ed/elecfetheart_mon.html Hankins, G. D. & Miller, D. A. (2011). A review of the 2008 NICHD Research Planning Workshop: Recommendations for fetal heart rate terminology and interpretation. Clinical Obstetrics & Gynecology, 54 (1): 3-7 Joint Commission of the Accreditation of Healthcare Organizations (2004) Issue 30: Preventing infant death and injury during delivery. Sentinel Event Alert. Retrieved from http://www.jointcommission.org/assets/1/18/sea_30_reference.pdf
Lyndon, A., Zlatnik, M.G. and Wachter, R. M. (2011). Effective physician-nurse communication: A patient safety essential for labor and delivery. American Journal of Obstetrics and Gynecology. Aug: 205(2). pp. 91-96. Database: PUBMED

MacEachin, S. R., Lopez, C.M., Powell, K. J., & Corbett, N. L. (2009). The fetal heart rate collaborative project: situational awareness in electronic fetal monitoring. Journal of Perinatal & Neonatal Nursing, Oct-Dec; 23(4); pp. 314-23 database: CINAHL McRae, M. J., (1999). Fetal surveillance and monitoring: legal issues revisited. Journal of Obstetric, Gynecologic & Neonatal Nursing (JOGNN). 28(3) p. 310. Miller, D. A., M.D. (2010) Intrapartum fetal monitoring: Maximizing benefits and minimizing risks. Contemporary OB/GYN. Retrieved from www.contemporatyobgyn.net Miller, D. A ., MD & Miller, F. C., MD (2012). Electronic fetal heart rate monitoring: definitions, interpretations and management. Retrieved from www.acog.org/About_ACOG/ACOG_Districts/District_II/~/media/Districts/District%20 II/PDFs/GE_EFM_Product_Sheet.pdf Robinson, B. MD, MPH (2008). A review of NICHD standardized nomenclature for cardiotocography: The importance of speaking a common language when describing electronic fetal monitoring. Obstetrics & Gynecology, 1(2), pp. 56-60.

THE USE OF NICHD TERMINOLOGY IN EFM DOCUMENTATION

Sigman, F. M. (2007). A comparison of perinatal care providers use of the National Institute of Child Health and Human Development standardized terminology in documentation of intrapartal fetal heart rate patterns. (Doctoral dissertation, University of Missouri- Saint Louis). Retrieved from database: CINAHL Simpson, K. R., James, D. C., and Knox, G.E. (2006) Nurse-physician communication during labor and birth: implications for patient safety. Journal of Obstetric, Gynecologic and Neonatal Nurses Jul-Aug; 35(4) pp. 547-56 Database: MEDLINE