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September 2014 (vol. 211, no. 3, page 288)
Research
Obstetrics
C OMMENT
We did not find a consistent relationship between the presence of condition-specific protocols and the severity of obstetrics complications. The presence of hemorrhage or shoulder dystocia protocols did not appear to affect the frequency of the outcome itself or the severity of related adverse outcomes. Conversely, the presence of a preeclampsia protocol was associated with less hypertensive morbidity by some measures. Preeclampsia protocols were associated with lower rates of persistent severe maternal hypertension and ICU admission but not with other adverse outcomes related to preeclampsia. It is possible that eclampsia, pulmonary edema, and elevated creatinine levels are sufficiently rare (with correspondingly wide confidence intervals) that this study lacks adequate power to detect differences in these outcomes
ajog.org and meaningful conclusions cannot be reached. The same possibility exists for adverse outcomes associated with shoulder dystocia. We simply assessed whether a protocol was present or not present and showed that the presence of a protocol had little association with the presence or severity of poor outcomes. We were not able to assess the quality of the protocol or to quantify or categorize various approaches to implementation. Thus, we cannot comment upon whether particular protocols or implementation methods were associated with improved outcomes. In an effort to regulate and improve quality, some insurance companies request that hospitals have a protocol in place. Our study suggests that the presence or absence of a protocol does not matter and that regulation attempts along this line are not fruitful. Further research seeking to understand the
elements of a high-quality protocol or the best implementation techniques to use is necessary to ensure that the presence of protocols translates into improved outcomes. Merely requiring that a hospital have a protocol is not enough to affect outcomes.
CLINICAL IMPLICATIONS -
-
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Presence of a protocol had little association with the presence or severity of poor outcomes. Merely requiring that a hospital have a protocol is not enough to affect outcomes. Further research seeking to understand the elements of a high-quality protocol or the best implementation techniques to use is necessary to ensure that the presence of protocols translates into improved outcomes.-
CORRECTION September 2014 (vol. 211, no. 3, page 288) Two misplaced decimal points and an omitted superscript created errors in an equation published in an original research paper derived from the 2014 annual meeting of the Society for Maternal-Fetal Medicine (Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.). In the “Materials and Methods” section, paragraph 10 (final paragraph on page 288.e2), the equation for the weighted estimate of the standard deviation for gestational ageedependent reference ranges for the cerebroplacental ratio should read: 0:00113 GA2 þ 0:07156 GA 0:67418 This replaces the equation as published: 0:00013 GA2 þ 0:7156 GA 0:67418
88 American Journal of Obstetrics & Gynecology JULY 2015
Obstetrics
C OMMENT
We did not find a consistent relationship between the presence of condition-specific protocols and the severity of obstetrics complications. The presence of hemorrhage or shoulder dystocia protocols did not appear to affect the frequency of the outcome itself or the severity of related adverse outcomes. Conversely, the presence of a preeclampsia protocol was associated with less hypertensive morbidity by some measures. Preeclampsia protocols were associated with lower rates of persistent severe maternal hypertension and ICU admission but not with other adverse outcomes related to preeclampsia. It is possible that eclampsia, pulmonary edema, and elevated creatinine levels are sufficiently rare (with correspondingly wide confidence intervals) that this study lacks adequate power to detect differences in these outcomes
ajog.org and meaningful conclusions cannot be reached. The same possibility exists for adverse outcomes associated with shoulder dystocia. We simply assessed whether a protocol was present or not present and showed that the presence of a protocol had little association with the presence or severity of poor outcomes. We were not able to assess the quality of the protocol or to quantify or categorize various approaches to implementation. Thus, we cannot comment upon whether particular protocols or implementation methods were associated with improved outcomes. In an effort to regulate and improve quality, some insurance companies request that hospitals have a protocol in place. Our study suggests that the presence or absence of a protocol does not matter and that regulation attempts along this line are not fruitful. Further research seeking to understand the
elements of a high-quality protocol or the best implementation techniques to use is necessary to ensure that the presence of protocols translates into improved outcomes. Merely requiring that a hospital have a protocol is not enough to affect outcomes.
CLINICAL IMPLICATIONS -
-
-
Presence of a protocol had little association with the presence or severity of poor outcomes. Merely requiring that a hospital have a protocol is not enough to affect outcomes. Further research seeking to understand the elements of a high-quality protocol or the best implementation techniques to use is necessary to ensure that the presence of protocols translates into improved outcomes.-
CORRECTION September 2014 (vol. 211, no. 3, page 288) Two misplaced decimal points and an omitted superscript created errors in an equation published in an original research paper derived from the 2014 annual meeting of the Society for Maternal-Fetal Medicine (Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.). In the “Materials and Methods” section, paragraph 10 (final paragraph on page 288.e2), the equation for the weighted estimate of the standard deviation for gestational ageedependent reference ranges for the cerebroplacental ratio should read: 0:00113 GA2 þ 0:07156 GA 0:67418 This replaces the equation as published: 0:00013 GA2 þ 0:7156 GA 0:67418
88 American Journal of Obstetrics & Gynecology JULY 2015