- Email: [email protected]
Expert Panel to Track Nurses' Effect on Maternal Morbidity and Mortality
IN FOCUS COMMENTARY
Expert Panel to Track Nurses’ Effect on Maternal Morbidity and Mortality Debra Bingham and Andria Cornell
Correspondence Debra Bingham, DrPH, RN, FAAN, 418 Pershing Dr., Silver Spring, MD 20910. [email protected] Keywords case abstraction expert panel recommendations improving perinatal outcomes maternal morbidity maternal mortality maternal mortality review methods measuring and tracking nursing care
Debra Bingham, DrPH, RN, FAAN, is a perinatal consultant and Executive Director for the Institute of Perinatal Quality Improvement, Silver Spring, MD. Andria Cornell, MSPH, is the Senior Program Manager for Women’s Health, Association of Maternal & Child Health Programs, Washington, DC.
The authors report no conflict of interest or relevant financial relationships.
http://jognn.org
ABSTRACT Rates of maternal morbidity and mortality in the United States have increased since 1990. Registered nurses are members of the health care work force who provide essential care to women during pregnancy, during birth, and after birth. Tools are needed to more effectively measure and track the effect of nursing care on maternal health outcomes. The Association of Women’s Health, Obstetric and Neonatal Nurses and the Association of Maternal & Child Health Programs co-convened an expert panel to develop a set of tools for use by public health and clinical leaders to support this effort.
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008 Accepted May 2016
R
egistered nurses represent the largest health care work force in the United States (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010) and provide essential care to the approximately four million women who give birth each year in the United States (Hamilton, Martin, Osterman, Curtin, & Mathews, 2015). Key responsibilities of nurses include ongoing assessments, implementation of tailored interventions based on these assessments, and team mobilization 24 hours per day to ensure optimum outcomes for women and newborns. However, the effect of nursing care provided to the women who give birth each year in the United States is not well understood. In fact, data about nursing care have been described by some experts as the “black box” of health care data; these experts stated that “differentiating nurses based on the delivery outcomes of women under their care may provide an important new lever to improve the quality of care during childbirth” (Edmonds, Hacker, Golen, & Shah, 2016, p. 4).
In the United States, the pregnancy-related mortality ratio rose from 10 deaths per 100,000 live births in 1990 to 17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per 100,000 live
births in 2012 (Centers for Disease Control and Prevention, 2016), which is more than double the 1978 rate of 7.2 deaths per 100,000 live births. In addition, researchers of U.S. maternal mortality trends found that the “raw, unadjusted data from all states regardless of whether they revised their death certificates resulted in a reported U.S. maternal mortality rate” of 21.5 per 100,000 live births in 2014 (MacDorman, Declercq, Cabral, & Morton, 2016, p. 450). Even more tragically, a significant racial disparity exists in the pregnancyrelated mortality ratio: Black women have a more than 3 times greater pregnancy-related mortality risk than White women (Centers for Disease Control and Prevention, 2016). Furthermore, many of these deaths are preventable. For example, the North Carolina Pregnancy-Related Mortality Review Committee found that 40% of pregnancy-related deaths in their state between 1995 and 1999 were potentially preventable (Berg et al., 2005), and the Illinois Maternal Mortality Review found that 32.4% of all pregnancy-related deaths between 2002 and 2012 within their state were potentially preventable (Geller, Koch, Martin, Rosenberg, & Bigger, 2014). Preventability of pregnancy-related deaths differs by race: in North Carolina, 33% of deaths among White women were potentially preventable compared
ª 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
861
IN FOCUS COMMENTARY
Registered nurses represent the largest health care work force in the United States and provide essential care to the approximately 4 million women who give birth each year in the United States.
with 46% of deaths among Black women (Berg et al., 2005). It is possible that characteristics of the health care setting contribute to these disparities. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) assembled a team to lead a multiregion quality improvement initiative, and as part of the baseline data, the team examined the relationship between the patient population served and the presence of hospital preparedness elements to effectively respond to postpartum hemorrhage, a leading cause of pregnancy-related death. The team found that for every 10% increase in the total percentage of Black women who gave birth, there was a decrease of one element of hospital preparedness to respond to this obstetric emergency (Bingham, Scheich, Byfield, Wilson, & Bateman, 2016). Further, Howell, Egorova, Balbierz, Zeitlin, and Herbert (2016) found that in hospitals that served high and medium proportions of Black women, Black and White women overall had greater rates of severe maternal morbidity than women who gave birth in hospitals that served low percentages of Black women. In addition, Black women faired more poorly in all categories (Howell et al., 2016). Given the significant role of nurses in the provision of perinatal care, a specific look at nursing care practices can elucidate opportunities to reduce pregnancy-related mortality in the United States. To address this national priority, in 2014 AWHONN and the Association of Maternal & Child Health Programs (AMCHP) co-convened an expert panel of nurses. The three broad objectives that guided the work of the expert panel were (a) to improve methods to track the ability of nurses to affect the rising trends in maternal mortality and morbidity in the United States; (b) to identify data collection opportunities for statebased maternal mortality review committees that will inform the development of effective strategies and tactics to improve the quality of care women receive before, during, and after pregnancy; and (c) to use the expert panel findings to activate and empower nurses, systems of care, and public health and health care provider
862
Nurses’ Effect on Maternal Morbidity and Mortality
partnerships to improve the quality and safety of patient care and reduce maternal mortality and morbidity. Nurse leaders from across the nation and from varied disciplines, such as risk management, practice and regulation, quality improvement, and academia, were selected to participate in the expert panel. Leaders from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention Division of Reproductive Health, the National Council of State Boards of Nursing, and the states of California and Illinois were invited guests and discussants at the in-person meeting. The four objectives for the in-person expert panel meeting were as follows: (a) to describe key nursing practices (independent and collaborative) that affect maternal outcomes, (b) to identify potential perinatal data elements on key nursing practices that can be abstracted from a medical record, (c) to identify opportunities to deploy questions or other data collection strategies as a part of stateand facility-based reviews to better characterize nurses’ influence on maternal mortality and morbidity, and (d) to propose effective strategies and tactics to improve the quality of nursing care women receive before, during, and after pregnancy. The meeting included learning panels on current practices in maternal mortality and morbidity surveillance and data collection initiatives related to performance, care quality, and safety at the facility, state, and national levels. After the learning panels, participants broke into small groups to respond to the meeting objectives. After 2 days of deliberation, the members of the expert panel established four workgroups: Nurse and Facility Interview, Clinical Reasoning and Judgment, Patient–Family Interaction and Education, and Communication. During the following year, the members of these workgroups conducted in-depth literature searches on their respective topics, clarified data elements that could be abstracted from a medical record, developed a supporting code book, and created resources and tools to be used by maternal death case abstractors. These data collection tools were designed to help abstractors glean critical nursing care process data from medical records in an effort to identify nursing care factors that could have contributed to the occurrence of a maternal death. The workgroups used two reference tools: Taxonomy of Error, Root Cause Analysis and Practice-Responsibility (TERCAP;
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008
http://jognn.org
Bingham, D., and Cornell, A.
National Council of State Boards of Nursing, 2011) and the Obstetric Surveillance System Reporting Form (Centre for Maternal and Child Enquires, 2011). This phase of the initiative was completed during two virtual follow-up meetings held in October 2014 and January 2015.
Next Steps The expert panel has met its first two objectives to describe key nursing practices that contribute to maternal outcomes and identify potential perinatal data elements available for abstraction from a medical record. Furthermore, the tool to collect data during interviews of nurses who cared for a woman who suffered injury or death will provide additional data needed to understand the factors and circumstances surrounding the event. The recommendations of the expert panel have also informed the national efforts of AMCHP and the Centers for Disease Control and Prevention to improve the data collection tools and methods of maternal mortality reviews. The AWHONN and AMCHP Tools for Tracking Nurses’ Contribution to Maternal Mortality and Morbidity include the following: (a) TERCAP’s Maternal Morbidity and Mortality Inquiry Tool developed by the Nurse and Facility Interview workgroup, (b) the Nurses’ Contribution to Maternal Mortality and Morbidity Worksheet developed by the Clinical Reasoning and Judgment workgroup, and (c) the Postpartum Discharge Education Audit Tool developed by the Patient–Family Education and Interaction workgroup. Given the importance of timely and accurate communication across the care team in the reduction of maternal mortality and morbidity, the communication workgroup leaders embedded their recommendations for the collection of data on team communication within the tools developed by the other three workgroups. These three tools are outlined in this In Focus Series and are published and available within open access on the Web sites of AWHONN and AMCHP. Nursing leaders, hospital administrators, and public health partners can use these readily available tools when performing a root cause analysis or maternal mortality and morbidity reviews. In the coming year, AWHONN and AMCHP will partner with state maternal mortality review committees that are interested in piloting the tools.
Conclusion The AWHONN and AMCHP leaders and members of the expert panel envision a time
JOGNN 2016; Vol. 45, Issue 6
IN FOCUS COMMENTARY
Given the significant role of nurses in the provision of perinatal care, a specific look at nursing care practices can elucidate opportunities to reduce pregnancy-related mortality in the United States.
when no woman who gives birth in the United States suffers a preventable injury or death and no racial or ethnic group suffers from disproportionate outcomes. We envision a time when each adverse obstetric event prompts a thorough review supported by comprehensive, rich, and standardized case data, irrespective of the state or jurisdiction in which it occurs. These findings would be aggregated across jurisdictions to support local, regional, and national surveillance and population-based action. By helping maternal mortality and morbidity review committees increase the depth of information gleaned from records and parse case data and elements to draw informed conclusions, reviewers will be closer to understanding how care practices influence perinatal outcomes, including the mechanisms through which racial disparities in outcomes might emerge and to what they can be attributed. This process is analogous to scrutinizing the tragedy of a plane crash: these data and clues are available in the plane’s black box recording to help investigators identify critical opportunities to make future flights safer. It is time for all of us to open the black box of perinatal care by measuring and tracking the effect of nursing care on rising maternal mortality and morbidity. Taking the time to review, reflect, and collect data on lessons learned from a maternal death or injury is how we honor the women who died or were injured and how we honor the nurses and other clinicians who tried to save their lives.
Acknowledgment The activities in this publication were supported by funding from Merck through its Merck for Mothers program and are the sole responsibility of the authors. Merck for Mothers is known as MSD for Mothers outside the United States and Canada. The authors also wish to acknowledge the members of the AWHONN and AMCHP Expert Panel for their work on the panel and as members of workgroups:
863
IN FOCUS COMMENTARY
Margaret Rose Agostino, DNP, MSW, RN-BC, CNE, IBCLC Nurse and Facility Interview Workgroup Adjunct Faculty, Doctor of Nursing Practice Program, Wilmington University
Nurses’ Effect on Maternal Morbidity and Mortality
Associate Dean Academic Programs, University of Utah College of Nursing
REFERENCES Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., … Callaghan, W. M. (2005). Preventability of
Rita Brennan, DNP, RNC-NIC, APN/CNS Communications Workgroup Member Outcomes Manager, Women’s & Children’s Services, Central DuPage Hospital Rene´e Byfield, MS, RN, FNP, C-EFM Nurse and Facility Interview Workgroup Nurse Program Development Specialist Association of Women’s Health, Obstetric and Neonatal Nurses
pregnancy-related deaths: Results of a state-wide review. Obstetrics & Gynecology, 106(6), 1228–1234. http://dx.doi.org/ 10.1097/01.AOG.0000187894.71913.e8 Bingham, D., Scheich, B., Byfield, R., Wilson, B., & Bateman, B. T. (2016). Postpartum hemorrhage preparedness elements vary among hospitals in New Jersey and Georgia. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 45(2), 227–238. http://dx.doi.org/10.1016/j.jogn.2015.12.003 Centers for Disease Control and Prevention. (2016). Pregnancy mortality surveillance system. Atlanta, GA: Author. Retrieved from http:// www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss. html
Robyn D’Oria, MA, RNC, APN Patient-Family Interaction and Education Workgroup Executive Director, Central Jersey Family Health Consortium
Centre for Maternal and Child Enquires. (2011). Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer: 2006-08. The English Report on Confidential Enquires into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology, 118(Suppl. 1), 1–203. http://dx.doi.org/10.1111/ j.1471-0528.2010.02847.x Edmonds, J. K., Hacker, M. R., Golen, T. H., & Shah, N. T. (2016).
Carol Keohane, MS, BSN, RN Communications Workgroup Assistant Vice President, Patient Safety CRICO/Risk Management Foundation of the Harvard Medical Institutions
Nurses count: Tracking performance to improve cesarean delivery rates. Birth, 43(1), 3–5. http://dx.doi.org/10.1111/birt. 12216 Geller, S. E., Koch, A. R., Martin, N. J., Rosenberg, D., Bigger, H. R., & Illinois Department of Public Health Maternal Mortality Review Committee Working Group. (2014). Assessing preventability of maternal mortality in Illinois: 2002-2012. American Journal of
M. Cynthia Logsdon, PhD, WHNP-BC, FAAN Patient-Family Interaction and Education Workgroup Professor, School of Nursing, University of Louisville Associate Chief of Nursing for Research, University of Louisville Hospital, Louisville, KY
Obstetrics & Gynecology, 211(6), 698.e1–698.e11. http://dx. doi.org/10.1016/j.ajog.2014.06.046 Hamilton, B. E., Martin, J. A., Osterman, M. J. K., Curtin, S. C., & Mathews, M. S. (2015). Births: Final data for 2014. National Vital Statistics Reports, 64(12), 1–64. Retrieved from http://www.cdc. gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf Howell, E. A., Egorova, N., Balbierz, A., Zeitlin, J., & Hebert, P. L. (2016). Black-white differences in severe maternal morbidity and site of care. American Journal of Obstetrics & Gynecology, 214(1), 122.
Marla Seacrist, PhD, RN Clinical Reasoning and Judgement Workgroup Associate Professor, California State University Stanislaus
e1–122.e7. http://dx.doi.org/10.1016/j.ajog.2015.08.019 MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Recent increases in the U.S. maternal mortality rate: Disentangling trends from measurement issues. Obstetrics & Gynecology, 128(3), 447–455. http://dx.doi.org/10.1097/AOG.0000000000001556 National Council of State Boards of Nursing. (2011). Practice error and
Danielle Noell, ARNP, NNP-BC, MSN Clinical Reasoning and Judgement Workgroup Fetal, Infant, and Maternal Mortality Review Abstractor
risk factors (TERCAP). Chicago, IL: Author. Retrieved from https://www.ncsbn.org/113.htm U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: survey
Barbara Wilson, PhD, RNC-OB Nurse and Facility Interview Workgroup
864
of
Findings registered
from
the
nurses.
2008
national
Washington,
DC:
sample Author.
Retrieved from http://bhpr.hrsa.gov/healthworkforce/rnsurveys/ rnsurveyfinal.pdf
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008
http://jognn.org
Expert Panel to Track Nurses’ Effect on Maternal Morbidity and Mortality Debra Bingham and Andria Cornell
Correspondence Debra Bingham, DrPH, RN, FAAN, 418 Pershing Dr., Silver Spring, MD 20910. [email protected] Keywords case abstraction expert panel recommendations improving perinatal outcomes maternal morbidity maternal mortality maternal mortality review methods measuring and tracking nursing care
Debra Bingham, DrPH, RN, FAAN, is a perinatal consultant and Executive Director for the Institute of Perinatal Quality Improvement, Silver Spring, MD. Andria Cornell, MSPH, is the Senior Program Manager for Women’s Health, Association of Maternal & Child Health Programs, Washington, DC.
The authors report no conflict of interest or relevant financial relationships.
http://jognn.org
ABSTRACT Rates of maternal morbidity and mortality in the United States have increased since 1990. Registered nurses are members of the health care work force who provide essential care to women during pregnancy, during birth, and after birth. Tools are needed to more effectively measure and track the effect of nursing care on maternal health outcomes. The Association of Women’s Health, Obstetric and Neonatal Nurses and the Association of Maternal & Child Health Programs co-convened an expert panel to develop a set of tools for use by public health and clinical leaders to support this effort.
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008 Accepted May 2016
R
egistered nurses represent the largest health care work force in the United States (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2010) and provide essential care to the approximately four million women who give birth each year in the United States (Hamilton, Martin, Osterman, Curtin, & Mathews, 2015). Key responsibilities of nurses include ongoing assessments, implementation of tailored interventions based on these assessments, and team mobilization 24 hours per day to ensure optimum outcomes for women and newborns. However, the effect of nursing care provided to the women who give birth each year in the United States is not well understood. In fact, data about nursing care have been described by some experts as the “black box” of health care data; these experts stated that “differentiating nurses based on the delivery outcomes of women under their care may provide an important new lever to improve the quality of care during childbirth” (Edmonds, Hacker, Golen, & Shah, 2016, p. 4).
In the United States, the pregnancy-related mortality ratio rose from 10 deaths per 100,000 live births in 1990 to 17.8 deaths per 100,000 live births in 2011 to 15.9 deaths per 100,000 live
births in 2012 (Centers for Disease Control and Prevention, 2016), which is more than double the 1978 rate of 7.2 deaths per 100,000 live births. In addition, researchers of U.S. maternal mortality trends found that the “raw, unadjusted data from all states regardless of whether they revised their death certificates resulted in a reported U.S. maternal mortality rate” of 21.5 per 100,000 live births in 2014 (MacDorman, Declercq, Cabral, & Morton, 2016, p. 450). Even more tragically, a significant racial disparity exists in the pregnancyrelated mortality ratio: Black women have a more than 3 times greater pregnancy-related mortality risk than White women (Centers for Disease Control and Prevention, 2016). Furthermore, many of these deaths are preventable. For example, the North Carolina Pregnancy-Related Mortality Review Committee found that 40% of pregnancy-related deaths in their state between 1995 and 1999 were potentially preventable (Berg et al., 2005), and the Illinois Maternal Mortality Review found that 32.4% of all pregnancy-related deaths between 2002 and 2012 within their state were potentially preventable (Geller, Koch, Martin, Rosenberg, & Bigger, 2014). Preventability of pregnancy-related deaths differs by race: in North Carolina, 33% of deaths among White women were potentially preventable compared
ª 2016 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.
861
IN FOCUS COMMENTARY
Registered nurses represent the largest health care work force in the United States and provide essential care to the approximately 4 million women who give birth each year in the United States.
with 46% of deaths among Black women (Berg et al., 2005). It is possible that characteristics of the health care setting contribute to these disparities. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) assembled a team to lead a multiregion quality improvement initiative, and as part of the baseline data, the team examined the relationship between the patient population served and the presence of hospital preparedness elements to effectively respond to postpartum hemorrhage, a leading cause of pregnancy-related death. The team found that for every 10% increase in the total percentage of Black women who gave birth, there was a decrease of one element of hospital preparedness to respond to this obstetric emergency (Bingham, Scheich, Byfield, Wilson, & Bateman, 2016). Further, Howell, Egorova, Balbierz, Zeitlin, and Herbert (2016) found that in hospitals that served high and medium proportions of Black women, Black and White women overall had greater rates of severe maternal morbidity than women who gave birth in hospitals that served low percentages of Black women. In addition, Black women faired more poorly in all categories (Howell et al., 2016). Given the significant role of nurses in the provision of perinatal care, a specific look at nursing care practices can elucidate opportunities to reduce pregnancy-related mortality in the United States. To address this national priority, in 2014 AWHONN and the Association of Maternal & Child Health Programs (AMCHP) co-convened an expert panel of nurses. The three broad objectives that guided the work of the expert panel were (a) to improve methods to track the ability of nurses to affect the rising trends in maternal mortality and morbidity in the United States; (b) to identify data collection opportunities for statebased maternal mortality review committees that will inform the development of effective strategies and tactics to improve the quality of care women receive before, during, and after pregnancy; and (c) to use the expert panel findings to activate and empower nurses, systems of care, and public health and health care provider
862
Nurses’ Effect on Maternal Morbidity and Mortality
partnerships to improve the quality and safety of patient care and reduce maternal mortality and morbidity. Nurse leaders from across the nation and from varied disciplines, such as risk management, practice and regulation, quality improvement, and academia, were selected to participate in the expert panel. Leaders from the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention Division of Reproductive Health, the National Council of State Boards of Nursing, and the states of California and Illinois were invited guests and discussants at the in-person meeting. The four objectives for the in-person expert panel meeting were as follows: (a) to describe key nursing practices (independent and collaborative) that affect maternal outcomes, (b) to identify potential perinatal data elements on key nursing practices that can be abstracted from a medical record, (c) to identify opportunities to deploy questions or other data collection strategies as a part of stateand facility-based reviews to better characterize nurses’ influence on maternal mortality and morbidity, and (d) to propose effective strategies and tactics to improve the quality of nursing care women receive before, during, and after pregnancy. The meeting included learning panels on current practices in maternal mortality and morbidity surveillance and data collection initiatives related to performance, care quality, and safety at the facility, state, and national levels. After the learning panels, participants broke into small groups to respond to the meeting objectives. After 2 days of deliberation, the members of the expert panel established four workgroups: Nurse and Facility Interview, Clinical Reasoning and Judgment, Patient–Family Interaction and Education, and Communication. During the following year, the members of these workgroups conducted in-depth literature searches on their respective topics, clarified data elements that could be abstracted from a medical record, developed a supporting code book, and created resources and tools to be used by maternal death case abstractors. These data collection tools were designed to help abstractors glean critical nursing care process data from medical records in an effort to identify nursing care factors that could have contributed to the occurrence of a maternal death. The workgroups used two reference tools: Taxonomy of Error, Root Cause Analysis and Practice-Responsibility (TERCAP;
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008
http://jognn.org
Bingham, D., and Cornell, A.
National Council of State Boards of Nursing, 2011) and the Obstetric Surveillance System Reporting Form (Centre for Maternal and Child Enquires, 2011). This phase of the initiative was completed during two virtual follow-up meetings held in October 2014 and January 2015.
Next Steps The expert panel has met its first two objectives to describe key nursing practices that contribute to maternal outcomes and identify potential perinatal data elements available for abstraction from a medical record. Furthermore, the tool to collect data during interviews of nurses who cared for a woman who suffered injury or death will provide additional data needed to understand the factors and circumstances surrounding the event. The recommendations of the expert panel have also informed the national efforts of AMCHP and the Centers for Disease Control and Prevention to improve the data collection tools and methods of maternal mortality reviews. The AWHONN and AMCHP Tools for Tracking Nurses’ Contribution to Maternal Mortality and Morbidity include the following: (a) TERCAP’s Maternal Morbidity and Mortality Inquiry Tool developed by the Nurse and Facility Interview workgroup, (b) the Nurses’ Contribution to Maternal Mortality and Morbidity Worksheet developed by the Clinical Reasoning and Judgment workgroup, and (c) the Postpartum Discharge Education Audit Tool developed by the Patient–Family Education and Interaction workgroup. Given the importance of timely and accurate communication across the care team in the reduction of maternal mortality and morbidity, the communication workgroup leaders embedded their recommendations for the collection of data on team communication within the tools developed by the other three workgroups. These three tools are outlined in this In Focus Series and are published and available within open access on the Web sites of AWHONN and AMCHP. Nursing leaders, hospital administrators, and public health partners can use these readily available tools when performing a root cause analysis or maternal mortality and morbidity reviews. In the coming year, AWHONN and AMCHP will partner with state maternal mortality review committees that are interested in piloting the tools.
Conclusion The AWHONN and AMCHP leaders and members of the expert panel envision a time
JOGNN 2016; Vol. 45, Issue 6
IN FOCUS COMMENTARY
Given the significant role of nurses in the provision of perinatal care, a specific look at nursing care practices can elucidate opportunities to reduce pregnancy-related mortality in the United States.
when no woman who gives birth in the United States suffers a preventable injury or death and no racial or ethnic group suffers from disproportionate outcomes. We envision a time when each adverse obstetric event prompts a thorough review supported by comprehensive, rich, and standardized case data, irrespective of the state or jurisdiction in which it occurs. These findings would be aggregated across jurisdictions to support local, regional, and national surveillance and population-based action. By helping maternal mortality and morbidity review committees increase the depth of information gleaned from records and parse case data and elements to draw informed conclusions, reviewers will be closer to understanding how care practices influence perinatal outcomes, including the mechanisms through which racial disparities in outcomes might emerge and to what they can be attributed. This process is analogous to scrutinizing the tragedy of a plane crash: these data and clues are available in the plane’s black box recording to help investigators identify critical opportunities to make future flights safer. It is time for all of us to open the black box of perinatal care by measuring and tracking the effect of nursing care on rising maternal mortality and morbidity. Taking the time to review, reflect, and collect data on lessons learned from a maternal death or injury is how we honor the women who died or were injured and how we honor the nurses and other clinicians who tried to save their lives.
Acknowledgment The activities in this publication were supported by funding from Merck through its Merck for Mothers program and are the sole responsibility of the authors. Merck for Mothers is known as MSD for Mothers outside the United States and Canada. The authors also wish to acknowledge the members of the AWHONN and AMCHP Expert Panel for their work on the panel and as members of workgroups:
863
IN FOCUS COMMENTARY
Margaret Rose Agostino, DNP, MSW, RN-BC, CNE, IBCLC Nurse and Facility Interview Workgroup Adjunct Faculty, Doctor of Nursing Practice Program, Wilmington University
Nurses’ Effect on Maternal Morbidity and Mortality
Associate Dean Academic Programs, University of Utah College of Nursing
REFERENCES Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., … Callaghan, W. M. (2005). Preventability of
Rita Brennan, DNP, RNC-NIC, APN/CNS Communications Workgroup Member Outcomes Manager, Women’s & Children’s Services, Central DuPage Hospital Rene´e Byfield, MS, RN, FNP, C-EFM Nurse and Facility Interview Workgroup Nurse Program Development Specialist Association of Women’s Health, Obstetric and Neonatal Nurses
pregnancy-related deaths: Results of a state-wide review. Obstetrics & Gynecology, 106(6), 1228–1234. http://dx.doi.org/ 10.1097/01.AOG.0000187894.71913.e8 Bingham, D., Scheich, B., Byfield, R., Wilson, B., & Bateman, B. T. (2016). Postpartum hemorrhage preparedness elements vary among hospitals in New Jersey and Georgia. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 45(2), 227–238. http://dx.doi.org/10.1016/j.jogn.2015.12.003 Centers for Disease Control and Prevention. (2016). Pregnancy mortality surveillance system. Atlanta, GA: Author. Retrieved from http:// www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss. html
Robyn D’Oria, MA, RNC, APN Patient-Family Interaction and Education Workgroup Executive Director, Central Jersey Family Health Consortium
Centre for Maternal and Child Enquires. (2011). Saving mothers’ lives: Reviewing maternal deaths to make motherhood safer: 2006-08. The English Report on Confidential Enquires into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology, 118(Suppl. 1), 1–203. http://dx.doi.org/10.1111/ j.1471-0528.2010.02847.x Edmonds, J. K., Hacker, M. R., Golen, T. H., & Shah, N. T. (2016).
Carol Keohane, MS, BSN, RN Communications Workgroup Assistant Vice President, Patient Safety CRICO/Risk Management Foundation of the Harvard Medical Institutions
Nurses count: Tracking performance to improve cesarean delivery rates. Birth, 43(1), 3–5. http://dx.doi.org/10.1111/birt. 12216 Geller, S. E., Koch, A. R., Martin, N. J., Rosenberg, D., Bigger, H. R., & Illinois Department of Public Health Maternal Mortality Review Committee Working Group. (2014). Assessing preventability of maternal mortality in Illinois: 2002-2012. American Journal of
M. Cynthia Logsdon, PhD, WHNP-BC, FAAN Patient-Family Interaction and Education Workgroup Professor, School of Nursing, University of Louisville Associate Chief of Nursing for Research, University of Louisville Hospital, Louisville, KY
Obstetrics & Gynecology, 211(6), 698.e1–698.e11. http://dx. doi.org/10.1016/j.ajog.2014.06.046 Hamilton, B. E., Martin, J. A., Osterman, M. J. K., Curtin, S. C., & Mathews, M. S. (2015). Births: Final data for 2014. National Vital Statistics Reports, 64(12), 1–64. Retrieved from http://www.cdc. gov/nchs/data/nvsr/nvsr64/nvsr64_12.pdf Howell, E. A., Egorova, N., Balbierz, A., Zeitlin, J., & Hebert, P. L. (2016). Black-white differences in severe maternal morbidity and site of care. American Journal of Obstetrics & Gynecology, 214(1), 122.
Marla Seacrist, PhD, RN Clinical Reasoning and Judgement Workgroup Associate Professor, California State University Stanislaus
e1–122.e7. http://dx.doi.org/10.1016/j.ajog.2015.08.019 MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Recent increases in the U.S. maternal mortality rate: Disentangling trends from measurement issues. Obstetrics & Gynecology, 128(3), 447–455. http://dx.doi.org/10.1097/AOG.0000000000001556 National Council of State Boards of Nursing. (2011). Practice error and
Danielle Noell, ARNP, NNP-BC, MSN Clinical Reasoning and Judgement Workgroup Fetal, Infant, and Maternal Mortality Review Abstractor
risk factors (TERCAP). Chicago, IL: Author. Retrieved from https://www.ncsbn.org/113.htm U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The registered nurse population: survey
Barbara Wilson, PhD, RNC-OB Nurse and Facility Interview Workgroup
864
of
Findings registered
from
the
nurses.
2008
national
Washington,
DC:
sample Author.
Retrieved from http://bhpr.hrsa.gov/healthworkforce/rnsurveys/ rnsurveyfinal.pdf
JOGNN, 45, 861–864; 2016. http://dx.doi.org/10.1016/j.jogn.2016.05.008
http://jognn.org