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Who is at Risk? A Call for Universal Antenatal Mood Disorder Screening

November 29th, 2010 by avatar

Pregnancy is a time when most women are eagerly anticipating and preparing for the birth of their child (or children), so it is surprising to note that approximately 10% of pregnant women may experience a depressive disorder during pregnancy. What is even more heartbreaking is the fact that as many as 2.6% of pregnant women may have thoughts of suicide. In pregnant women with major depression, the rates of suicidal ideation can reach nearly 30%. It is well known that major depression is associated with significant disease co-morbidity and mortality.  Clinicians must know which women are at highest risk for depressive disorders yet screen all their patients for depressive disorders at regular intervals during their prenatal care and provide treatments and/or resources when needed.

Jennifer Melville, MD, MPH, an associate professor in the Department of Obstetrics and Gynecology at the University of Washington School of Medicine, Seattle, WA sought to estimate the prevalence of depressive disorders during pregnancy in her 2004-’09 study, Depressive Disorders During Pregnancy:  Prevalence and Risk Factors in a Large Urban Sample . Melville and her colleagues also wanted to know if there are identifiable risk factors that make certain women more likely to develop depressive disorders than others. The results of this prospective study of 1,888 pregnant women over a five-year period have been published in the current issue of Obstetrics and Gynecology.

A Look at the Research

The methodology used  in this study to determine major and minor depression was based on patient responses to the Patient Health Questionnaire and  in accordance with criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), as follows:

“In our study, women meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for major or minor depression on the Patient Health Questionnaire were classified as experiencing current depression.  The DSM-IV criteria for major depression on the Patient Health Questionnaire require the participant to have, for at least 2 weeks, five or more depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for minor depression (or depression not otherwise specified) require the participant to have, for at least 2 weeks, two to four depressive symptoms present for more than half the days, with at least one of these symptoms being depressed mood or anhedonia.  The criteria for panic disorder require affirmative answers to all five panic symptoms and follow the DSM-IV.”

A summary of the Melville et. al study findings includes:

  • Antenatal depressive disorders were present in 9.9% of study participants and 5.1% of those identified also met the criteria for probable major depression; 4.8% met the criteria for probable minor depression.
  • 3.2% of women had probable panic disorder and of those, 52.5% had co-morbid depression (31% major and 21% minor).  47.5% had isolated panic disorder. 19.6% of women with probable major depression had panic disorder while 14.4% of women with probable minor depression had panic disorder.
  • Suicidal ideation was present in 2.6% of the women studied, but of those with major depression, 29.5% reported suicidal ideation.

Melville and her colleagues found that antenatal depressive disorders are more prevalent in younger, less educated, single women. Other aggravating factors that heightened a woman’s risk of antenatal depression included:

  • women with two or more co-morbidities
  • prior pregnancy complications (including medically required bed rest)
  • psychosocial stressors (lower socioeconomic status and limited resources)
  • domestic violence
  • Asian, African American and Hispanic ethnicity

Discussion

First and foremost, we have to recognize that pregnancy is not a welcomed event for all women.  And, even in women for whom pregnancy is a welcomed event, antenatal mood disorders can still develop.   In fact, many people remain unaware of the prevalence of antenatal depressive disorders—including some clinicians. The first step to combating this problem is through creating heightened awareness.  With evidence-based training (utilizing studies like Melville’s) and implementation of universal screening and intervention protocols during prenatal visits, diagnosing and treating these pregnancy-related mood disorders can become a widespread reality.

If a clinician suspects a prenatal depressive disorder in one of their patients, she must be ready to provide not only prescriptions for medical therapy (if indicated) but also address other medical and social issues contributing to the condition. For women with underlying co-morbidities, clinicians must identify and treat these conditions accordingly.  Challenges to this might include maintaining frequency and consistency in prenatal care: socioeconomic, geographic, and patient age issues can sometimes prompt less-than-optimal attendance of regular prenatal office visits.   Also, for women whom English is not their first language or for whom American culture and medical care are unfamiliar, a similar deleterious effect on prenatal care consistency might be observed. In these cases, clinicians may need to invite the assistance of social workers, other support services, family members and/or friends of the patient to both educate her as well as increase her access to appropriate care.

Melville’s study confirms what other research had already identified:  domestic violence bears a hefty association with antenatal depressive disorders (odds ratio = 3:45).  While some clinicians may experience discomfort in questioning their patients about the possibility of domestic violence, the data suggests this line of questioning should be imperative.   If  a clinician suspects or confirms a case of abuse he must be prepared to immediately provide appropriate resources to his patient in the form of patient education pamphlets, hotline phone numbers, shelter information and counseling resources.  Alternatively, a trained individual within the practice can also act as a liaison between the patient and appropriate resources, along with maintaining follow- up with the patient at each subsequent prenatal visit.   Because domestic violence happens to women of all ages, races and ethnicities and in all socioeconomic brackets, clinicians must screen all their prenatal patients for this antenatal mood disorder risk factor.

Antenatal depressive disorders are more common than most people realize and they are a real challenge for clinicians to manage.  Melville and her colleagues have provided a useful set of identifiable risk factors that can alert clinicians to patients with potential problems. My greatest concern is that this data may lead some clinicians to screen only those women who have one of the herein analyzed risk factors or who appear to fit the criteria and ignore the potential for antenatal depressive disorders in other women.  The researchers acknowledge that this study has limitations despite being carried out on a large sample and producing data very similar to previous studies. Therefore, they recommend that further studies be conducted to determine if the risk factors identified for antenatal depressive disorders are applicable to a wider subset of patients.  I commend Melville, et. al for their work and for acknowledging the study’s limitations. All pregnant women are at risk for antenatal depressive disorders, with some possessing a greater risk than others. As such, it behooves clinicians to make the extra effort to screen all antenatal women at regular intervals during pregnancy for depressive disorders.

Posted by:  Darline Turner-Lee, BS, MHS, PA-C,

Patient Advocacy, Practice Guidelines, Prenatal Illness, Research , , , , , , , , , , , , , , , , ,

Follow Up: A Deeper Look at Root Cause Analyses

November 28th, 2010 by avatar

Last week we took a look at root cause analysis (RCA) in a real case of hospital maternal death. We discussed the importance of repeatedly asking “Why?” at each step of the process (the 5-Whys approach) that led to the fatal error in which an epidural medication was accidentally infused into a laboring woman’s central bloodstream. We saw how grouping contributing factors into categories and depicting them on a fishbone diagram can be a helpful aid for understanding and identifying root causes.

Although widely used throughout the health care industry, the 5-Whys and Fishbone methods are not the only, nor even necessarily the best, assessment tools for conducting an RCA. There is no “one size fits all” root cause analysis approach. Some RCA experts argue that the 5-Whys method implies that failure results from only one linear sequence of events (e.g., the nurse hung the wrong bag because she was tired because she worked a double shift because hospital policy allowed for chronic staffing shortages) thereby missing other potential causes of system failure. Others point out that the Fishbone approach is also overly simplistic, failing to demonstrate the interactions between some root causes and potentially missing others.

A reader comment posted last week by a career RCA analyst spurred me to critically re-examine the scientific rigor and validity of my own blog post (never let it be said that Science and Sensibility bloggers are resistant to constructive feedback!).  Bob Latino is a nationally recognized expert in RCA and CEO of Reliability Center, Inc., a consulting firm specializing in improving equipment, process, and human reliability.  Mr. Latino is also the author of several books on root cause analysis for patient safety in health care settings. In order to address the shortcomings of the 5-Whys and Fishbone methods, Mr. Latino developed the PROACT Logic Tree as an alternative tool for use within RCA. He took the same St. Mary’s case that we used to construct the fishbone diagram and applied it to his Logic Tree (pdf).

Understanding the Logic Tree:

The Logic Tree is read from top to bottom as a reverse time line by following the red boxes. At the top of the tree is the Event (red box), which is the negative outcome that triggered the need for an RCA—in this case, a maternal death. Underneath the Event are Modes (red boxes), which are the manifestations of the failure that lead to the Event—in this case, cardiovascular collapse.  It is important to remember that the Event and the Mode(s) are known facts, and the Event is the last “effect” in the chain of factors.  From the Event and Mode(s), we go backwards in short increments of time to recreate the path to failure.

From the point of the Mode(s), instead of asking Why? as we did with the fishbone diagram, the Logic Tree instead asks How could? The answers comprise the tree’s branches and are called Hypotheses. For example,

How could the patient have experienced a sudden cardiovascular collapse?

  • Hypothesis 1: Because she experienced a fatal allergic reaction to medication.
  • Hypothesis 2: Because she had an underlying heart condition.
  • Hypothesis 3: Because she had an undetected serious illness such as sepsis.
  • Hypothesis 4: Because there was a malfunction in the medical equipment.
  • Hypothesis 5: Because there was an error in diagnosis (e.g., we thought she was in labor when she was really having a heart attack).
  • Hypothesis 6: Because there was an error made in medical treatment.

As you might imagine, not all of the hypotheses are true and some can be ruled out fairly quickly. The point is that, whether or not the hypotheses turn out to be true, by asking How could?, the Logic Tree method systematically seeks out all the possibilities (not only the most likely) and then uses evidence to back up what did and did not occur.

We keep asking How could? and follow the cause-and-effect chain back down the Tree until we get to the Root Causes (circled boxes). There are three progressively in-depth levels of Root Causes: Physical, Human and Latent.  Physical Root Causes (purple boxes) are the immediate, observable consequences of a poor decision (e.g., patient received wrong medication).  Human Root Causes (blue boxes) are decision-making errors (e.g., nurse picked up the wrong medication bag).  Deepest are the Latent Root Causes (brown boxes) which are flawed organizational errors that feed bad information to the decision-makers (e.g., inadequate supervision and training).

According to Mr. Latino, the main advantages of the Logic Tree are that it:

  • Supports tightly-coupled cause-and effect relationships,
  • Requires evidence to back-up proposed Hypotheses, and
  • Requires in-depth understanding to identify system flaws that contribute to human errors as a result of poor decision-making.

SECOND AND FINAL CALL TO ALL BIRTHING PROFESSIONALS: YOUR INPUT NEEDED!

The RCA is only the first step to remedying real and potential problems in our maternity care delivery system. Mr. Latino has graciously offered to extend his expert analytical skills to a project I proposed in my last blog post, which I will repeat here. Neither Mr. Latino nor I are birthing professionals, so here is your chance to weigh in! Read Rima Jolivet’s thought-provoking allegorical tale of two births As you compare the two women’s stories, consider the factors that contributed to Karen’s negative birth experience. Even if the causes were not stated explicitly in the article, draw upon your own experience as a birthing professional and fill in the gaps. Think about:

  1. Patient characteristics: Are there pre-existing or co-morbid medical conditions, physical limitations, language and communication barriers, cultural issues, social support needs that play a role?
  2. Task factors: What protocols and procedures are in place for labor and delivery, for use of analgesia, for dystocia, for C-sections? Are they safe? Are they practical? Are they effective? Are they consistently applied?
  3. Individual staff: How did the knowledge, skills, training, motivation, and health of Karen’s providers affect her care?
  4. Team factors: How well do the various health care professionals involved in Karen’s care work together? What is the nature of the communication? Are there hierarchies? What is the responsiveness of nursing supervisors or attending physicians? How easily can a team member ask for help or clarification?
  5. Work environment: Is the labor and delivery unit adequately staffed? What is the workload? What happens when the census fluctuates unexpectedly? What is the staffing level of experience, functionality of the equipment, quality of administrative support?
  6. Organizational and management factors: How do the values of the hospital translate into clinical practice? Do their standards and policies focus more on patient safety and quality of care, or volume and speed? Are management’s priorities patient- or provider-centered? Does senior leadership foster a culture of teamwork and safety or blame and shame?

Add your comments below, and we will include it in the next blog post!

Posted by:  Tricia Pil, MD

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In Response: Why Do We Recommend Kangaroo Care to New Mothers?

November 24th, 2010 by avatar

In Monday’s post from the blog site, Expecting Words, came this suggestion, following the description of a friend of hers who had recently been encouraged to have her baby room in and conduct skin-to-skin newborn care rather than have the baby cared for in the hospital nursery:

…I am shocked at this likely cost-cutting scenario billed as natural mothering.  This was her second birth at this major NYC hospital.  The first time, they had a nursery and she could have some rest.  I can only imagine what a first-time mother feels as she endures her two days in the hospital believing that the nurses must be right and that any time her baby is crying it’s because she hasn’t done enough skin-to-skin contact.  What a set-up for baby blues and postpartum depression.

Wow.  I am sad to think of the women who might read this and believe that their local hospital, in an effort to do something right for moms and babies would be motivated only by budgetary cost-cutting.

Skin-to-skin care, otherwise known as kangaroo care, fosters so much more than relief of work on the hospital nursing staff.  Babies kept skin-to-skin remain more stable in terms of body temperature, heart rate and stress hormone levels.

Studies also repeatedly show that newborns attended to via kangaroo care cry less and breastfeed with greater success.  Not only do infants held skin-to-skin frequently benefit, but mothers do too.   Women utilizing kangaroo care are generally calmer and more relaxed during their interactions with their babies, and report less depressive symptoms than women who do not employ kangaroo care.

My guess is, the hospital mentioned in Expecting Words’ post may have either been working on, or recently achieved Baby Friendly Designation from the  Baby Friendly Hospital Initiative, USA (a program sponsored by both the World Health Organization and UNICEF)  and possibly the Mother-Friendly Childbirth Initiative endorsement from the Coalition for Improving Maternity  Services.  These initiatives are ALL ABOUT improving care and the overall childbearing and early parenting experiences of not only the baby, but the mother as well.  Common sense tells us that a well cared for, well educated woman, in terms of immediate postpartum self care and newborn care, will more likely translate into a calmer, happier, more successful mother.  And a happier baby, to boot.  That’s what kangaroo care is about.  That’s what the initiatives described above are about.  And, I’m guessing, that’s what the woman’s experience described in this post was all about.

I, for one, am thankful for the hospitals which are beginning to look seriously at these issues, and move forward to implement practices and policies that are both mother and baby friendly.

And on that note…Happy Thanksgiving to all!

Practice Guidelines, Science & Sensibility , , , , , , ,

Becoming a Critical Reader: Journal papers that aren’t studies

November 23rd, 2010 by avatar

In this, my last article for the “Becoming a Critical Reader” series, I want to discuss a few types of articles that are frequently found in journals, but are not studies. These can provide important information, and are not by any means worthless, but they are not what we traditionally think of as research.

Opinion pieces – Most issues of a journal will have one or more editorials. In these, the authors get to give their opinion. And like in the rest of life, opinions are not the same as fact. These articles give the reader a chance to see how one individual reads, interprets and applies the research in their practice. Editorial pieces can be unsigned, representing the editorial board of the journal, or can be written by and represent the opinion of an individual.

Practice guidelines – These are statements that organizations put together to help their members practice. Journals are a way that some organizations will spread the word about a new, updated practice guideline, express opinions about current guidelines, etc.

Media reviews – Some journals, like the Journal of Perinatal Education, will publish reviews of various types of media: books, videos, patient education programs, anything that might be relevant to their readers.

Case reports – Sometimes unusual cases come up, and they don’t happen often enough to have a formal study. While you certainly can’t make a definitive statement about a treatment based on a case study, they make for interesting reading. Occasionally a case study might be published, which leads to a reader thinking “I’ve seen that, too!” and before long, care providers can be communicating and sharing ideas for these kinds of oddball situations.

Some journals, like the New England Journal of Medicine present a regular clinical case study in each issue, as sort of a “how would you handle this?” with the resolution as well.

Patient Education materials – Some journals, like the Journal of Midwifery and Women’s Health, publish handouts that their subscribers can print out and use in their practice.

Reviews or critiques of other studies – You may see responses to and critiques of studies also published in journals. Sometimes these are short and take the form of a letter to the editor or news brief. Sometimes they are full-fledged articles. It is always a good idea to go back and read the original study yourself and form your own opinion!

Continuing Education modules– Usually connected with a systematic review, practice guideline, or other article, these short quizzes can be returned to the journal or organization for CEUs.

Reports on a conference or meeting – If the journal is published by an organization that holds an annual meeting, they may include information presented at those meetings in the journal. This could be abstracts, papers that were presented, information on how many attended, or a travelogue.

Personal narratives– Occasionally you will find articles describing one person’s experiences in an area related to the journal. You may have a report on one midwife’s efforts to improve neonatal resuscitation training in Africa, or a doctor’s ponderings on the difference between health care now and health care when he began his practice 25 years ago.

While I won’t be going into questions to ask about each of these, I hope that you’ll remember to check your own biases and read them with a critical eye.

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Root Cause Analysis: Turning a needless maternal death into better care for all

November 18th, 2010 by avatar

On the morning of July 5, 2006, a 16-year-old patient came to St. Mary’s Hospital in Madison, Wisconsin, to deliver her baby. During the process of her care, an infusion intended exclusively for the epidural route was connected to the patient’s peripheral IV line and infused by pump. Within minutes, the patient experienced cardiovascular collapse. A cesarean section resulted in the delivery of a healthy infant, but the medical team was unable to resuscitate the mother. The medication error and its consequences were devastating for the patient’s family, the nurse who made the error, and the medical team that labored to save the patient’s life.

This is the real story of a tragic and unnecessary maternal death that occurred not in a mud hut in a third world country, nor in a backwater rural health clinic—but in a fully licensed and accredited 440-bed community teaching hospital that delivers more than 3,500 babies annually and serves as a regional referral center for all of south-central Wisconsin. In a highly unusual and commendable move, senior management at St. Mary’s requested an outside independent investigation of this event and published their findings in an effort to share painful lessons learned with the medical community and the public.

What happens when an unanticipated maternal death occurs? If the event occurred in a hospital accredited by the Joint Commission on Accreditation of Healthcare Organizations (“Joint Commission”), the hospital must complete a root cause analysis (RCA) as a first step. Since 1996, a total of 84 cases of maternal death have been reported to The Joint Commission. The lessons learned from these most extreme patient care outcomes, also called “sentinel events,” have widespread implications for everyone involved in maternal and infant care. As William M. Callaghan, M.D., M.P.H., senior scientist in the Division of Reproductive Health at the Centers for Disease Control and Prevention remarked, “Maternal deaths are the tip of the iceberg, for they are a signal that there are likely bigger problems beneath – some of which are preventable,” says Dr. Callaghan. “It is important to consider the women who get very, very sick and do not die, because for every woman who dies, there are 50 who are very ill, suffering significant complications of pregnancy, labor and delivery.”


What is a root cause analysis?

Root cause analysis, or RCA, is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.” The RCA seeks to answer these questions: What happened? Why did it happen? What will we do to prevent this from happening again? The RCA is not about assigning blame, but rather identifying the direct and indirect contributing factors –latent system errors—that create the “perfect storm” in which the event occurred.

The RCA process might seem deceptively simple. We may be tempted to approach the RCA in the following manner:

What happened? The patient mistakenly received an IV infusion of epidural medication.

Why did it happen? The nurse hung the wrong IV bag.

What we will do to prevent this from happening again? Fire the nurse.

Indeed, this overly simplistic and ineffective “shame and blame” approach is the one that many hospitals take in conducting internal investigations of adverse medical events. A more thorough and credible RCA digs at the underlying factors and causes by asking a series of “Why?” questions, which might look something like this:

What happened?

The patient mistakenly received an IV infusion of epidural medication.

Why did it happen?

The nurse hung the wrong IV bag.

Why did the nurse hang the wrong IV bag?

Because she confused the epidural bag with the IV penicillin bag which were next to each other on the counter.

Why were the bags next to each on the counter?

Because the work flow process included having epidural medications and supplies set up and ready in the room ahead of time.

Why did the work flow process include having analgesia medication in the room ahead of time?

Because anesthesia had in the past expressed dissatisfaction with nursing staff over patients’ state of readiness for epidurals.

And,

Why did the nurse hang the wrong IV bag?

Because she confused the epidural bag with the IV penicillin bag.

Why did the nurse get confused?

Because she was tired.

Why was the nurse tired?

Because she had worked two consecutive eight-hour shifts the day before, then slept in the hospital before coming on duty again the following morning.

Why did she work consecutive shifts?

Because she was covering for another colleague and her departure would have left the unit inadequately staffed.

As we repeatedly ask “Why?” we start to see groups of factors emerge, and these groups can help us to organize our thinking and later, to identify remedies. These groups might include: patient characteristics, task factors, individual staff factors, team factors, work environment, and organizational and management factors. We can map these factors and groups onto a fishbone diagram, a commonly used RCA visual aid:
(Click on graphic for improved viewing)

Now you try it!
Although root cause analyses are most commonly performed in cases of serious permanent physical or psychological harm, we can apply these same principles to “near-miss” events and instances of suboptimal, although not lethal, care. Read Rima Jolivet’s thought-provoking allegorical tale of two births. As you compare the two women’s stories, consider the factors that contributed to Karen’s negative birth experience. Even if the causes were not stated explicitly in the article, draw upon your own experience as a birthing professional and fill in the gaps. Think about:

  1. Patient characteristics: Are there pre-existing or co-morbid medical conditions, physical limitations, language and communication barriers, cultural issues, social support needs that play a role?
  2. Task factors: What protocols and procedures are in place for labor and delivery, for use of analgesia, for dystocia, for C-sections? Are they safe? Are they practical? Are they effective? Are they consistently applied?
  3. Individual staff: How did the knowledge, skills, training, motivation, and health of Karen’s providers affect her care?
  4. Team factors: How well do the various health care professionals involved in Karen’s care work together? What is the nature of the communication? Are there hierarchies? What is the responsiveness of nursing supervisors or attending physicians? How easily can a team member ask for help or clarification?
  5. Work environment: Is the labor and delivery unit adequately staffed? What is the workload? What happens when the census fluctuates unexpectedly? What is the staffing level of experience, functionality of the equipment, quality of administrative support?
  6. Organizational and management factors: How do the values of the hospital translate into clinical practice? Do their standards and policies focus more on patient safety and quality of care, or volume and speed? Are management’s priorities patient- or provider-centered? Does senior leadership foster a culture of teamwork and safety or blame and shame?

Add your comments below, and I will include them in a root cause analysis of Karen’s case in my next blog post.

References:

Jolivet, R. “Two Birth Stories: An Allegory to Compare Experiences in Current and Envisioned Maternity Care Systems.” Childbirth Connection, 2010. http://www.childbirthconnection.org/pdfs/allegory_illustrating_vision.pdf

“PS104: Root Cause and Systems Analysis.” Institute for Healthcare Improvement Open School for Health Professions. http://www.ihi.org/IHI/Programs/IHIOpenSchool/.

“Sentinel Event Alert: Preventing Maternal Death.” The Joint Commission. Issue 44, January 26, 2010. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm

“Sentinel Event Policy and Procedures.” The Joint Commission. July 2007. http://www.jointcommission.org/NR/rdonlyres/F84F9DC6-A5DA-490F-A91F-A9FCE26347C4/0/SE_chapter_july07.pdf

Smetzer J, Baker C, Byrne FD, Cohen MR. “Shaping Systems for Better Behavioral Choices: Lessons Learned from a Fatal Medication Error.” Jt Comm J Qual Patient Saf. 2010 Apr; 36(4):152-63. http://psnet.ahrq.gov/public/Smetzer-JCJQPS-2010-s4.pdf

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