Impact of an e-learning training for interpreting intrapartum fetal heart rate monitoring to avoid perinatal asphyxia: A before-after multicenter observational study

INTRODUCTION

Perinatal asphyxia, a condition that results from compromised placental or pulmonary gas exchange during the birth process, is rare but can lead to serious neonatal and long-term consequences. The visual analysis of cardiotocography (CTG) is designed to avoid perinatal asphyxia, but its interpretation can be difficult. Our aim was to test the impact of an e-learning training program for interpreting CTG on the rate of avoidable perinatal asphyxia at term.

METHOD

We conducted a retrospective multicenter before-after study comparing two periods, before and after the implementation of e-learning training program from July 1, 2016 to December 31, 2016, in CTG interpretation for midwives and obstetricians in five maternity hospitals in the Paris area, France. The training involved theoretical aspects such as fetal physiology and heart rhythm abnormalities, followed by practical exercises using real case studies to enhance skills in interpreting CTG. We included all term births that occurred between the "before" period (July 1 to December 31, 2014) and the "after period (January 1 to June 30, 2017). We excluded multiple pregnancies, antenatal detection of congenital abnormalities, breech births and all scheduled caesarean sections. Perinatal asphyxia cases were analyzed by a pair of experts consisting of midwives and obstetricians, and avoidability of perinatal asphyxia was estimated. The main criterion was the prevalence of avoidable perinatal asphyxia.

RESULTS

The e-learning program was performed by 83 % of the obstetrician-gynecologists and 65 % of the midwives working in the delivery rooms of the five centers. The prevalence of perinatal asphyxia was 0.45 % (29/7902 births) before the training and 0.54 % (35/7722) after. The rate of perinatal asphyxia rated as avoidable was 0.30 % of live births before the training and 0.28 % after (p = 0.870). The main causes of perinatal asphyxia deemed avoidable were delay in reactions to severe CTG anomalies and errors in the analysis and interpretation of the CTG. These causes did not differ between the two periods.

CONCLUSION

One session of e-learning training to analyze CTG was not associated with a reduction in avoidable perinatal asphyxia. Other types of e-learning, repeated and implemented over a longer period should be evaluated.

Readmission rates and predictors of avoidable readmissions in older adults in a tertiary care centre

Context

Thirty-day readmissions are used to gauge health care accountability, which occurs as part of the natural course of the illness or due to avoidable fallacies during the index admission. The utility of this metric is unknown in older adults from developing countries.

Aim

To ascertain the unplanned 30-day readmission rate and enumerate predictors of avoidable hospital readmission among early (0-7 days) and late (8-30 days) readmissions.

Settings and Design

A retrospective chart audit of 140 older adults who were readmitted to a premier tertiary care teaching hospital under Geriatrics from the neighboring states of Tamil Nadu, Andhra Pradesh, and Kerala were undertaken.

Methods and Materials

Data from health records were collected from the hospital electronic database from May 2015 to May 2020. The data was reviewed to determine the 30-day readmission rate and to ascertain the predictors of avoidable readmissions among both early and late readmissions.

Results

Out of 2698 older adults admitted to the geriatric wards from the catchment areas, the calculated 30-day hospital readmission rate was 5.18%, and 41.4% of these readmissions were potentially avoidable. The median duration from discharge to the first readmission was ten days (Interquartile range: 5-18 days). Patients had to spend INR 44,000 (approximately 602 USD) towards avoidable readmission. The most common causes for readmission included an exacerbation, reactivation, or progression of a previously existing disease (55.7%), followed by the emergence of a new disease unrelated to index admission (43.2%). Fifty-eight patients (41.4%) were readmitted within seven days following discharge. Early readmissions were seen in patients with malignancies [8 (13.5%) vs. 4 (4.8%); P = 0.017], on insulin (P = 0.04) or on antidepressants (P = 0.01). Advanced age was found to be an independent predictor of avoidable early readmission (OR 2.99 95%CI 1.34-6.62, P = 0.007), and admission to a general ward (as compared to those admitted in a private ward) was an independent predictor of early readmissions (OR 2.99 95%CI 1.34-6.62, P = 0.007).

Conclusion

The 30-day readmission rate in a geriatric unit in a tertiary care hospital was 5.2%. Advanced age was considered to be an independent predictor of avoidable early readmission. Future prospective research on avoidable readmissions should be undertaken to delineate factors affecting 30-day avoidable hospital readmissions in developing nations.

Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis

Background

Several literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions.

With this review we aim to: 1) evaluate the range of causes of unplanned readmissions in a patient journey, and 2) present a cause classification framework that can support future readmission studies.

Methods

A literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel.

Results

Forty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient’s self-management and 19 studies reported causes related to patient’s disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies.

Conclusions

This review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.

In conclusion, we aimed to: 1) evaluate the range of causes for unplanned readmissions, and 2) present a cause classification framework for causes related to readmissions.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0822-9) contains supplementary material, which is available to authorized users.

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis

Background

A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used.

To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review.

Methods

A literature search was conducted in PUBMED and EMBASE using “readmission” and “avoidability” or “preventability” as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods.

Results

Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information.

Conclusion

A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0766-0) contains supplementary material, which is available to authorized users.

[Epidemiology of maternal mortality in France, 2010-2012]

OBJECTIVE

To describe, for the period 2010-2012, the frequency, the causes, the risk factors, the adequacy of care and the avoidability of maternal deaths in France.

METHOD

Data from the National Confidential Enquiry into Maternal Deaths for 2010-2012.

RESULTS

For the period 2010-2012, 256 maternal deaths occurred in France, a maternal mortality ratio of 10.3 per 100,000 live births (95% CI: 9.1-11.7), stable compared to 2007-2009. Compared to women aged 25-29, the risk is multiplied by 2.4 for women aged 35-39, and by 3 for women over 40 years. There are territorial disparities: 1 out of 7 maternal deaths occurs in the French overseas departments, and the maternal mortality ratio in those departments is 4 times that of metropolitan, France; and social disparities: the mortality of migrant women remains 2.5 times higher than that of women born in France, particularly for women born in sub-Saharan Africa whose RMM is 3.5 times that native women. A major finding is the 1/3 decrease in direct maternal mortality over the last 10 years, mainly due to for the first time the statistically significant decrease in mortality from obstetric hemorrhage, the frequency of which was divided by 2 in 10 years. However, almost all of the remaining deaths from hemorrhage are considered preventable and this is still the leading cause of maternal mortality in France (11% of deaths). Overall, 56% of these maternal deaths are considered "avoidable" or "possibly avoidable" and in 59% of cases the care provided was not optimal.

CONCLUSION

Direct maternal mortality and in particular maternal mortality from hemorrhage has decreased significantly over the past 10 years, indicating improved obstetric care. However, territorial and social inequalities persist, and the majority of deaths remain preventable, which shows that the identification of opportunities for improvement must continue. To go even further in understanding the mechanisms involved, and to identify precise avenues of prevention, it is necessary to analyze in detail the stories of each maternal death in order to identify the repetitive elements in the series of deaths. This is what the following articles in this issue propose, with an analysis by cause of death, according to the idea that the same cause produces the same effects.

Hospital re-admission associated with adverse drug reactions in patients over the age of 65 years

CONTEXT

Adverse drug reactions (ADRs) are responsible for 5 % of hospital admissions, but hospital re-admission induced by ADRs remains poorly documented.

OBJECTIVE

The aim of this study was to estimate the rate of hospital re-admission and the factors associated with re-admission in the patients over the age of 65 years. Secondary, we described the characteristics of cases of ADRs leading to re-admission for drugs other than chemotherapy agents.

METHODS

Data were extracted from hospital discharge summaries provided by the Department of Medical Information of Toulouse University Hospital. All patients over the age of 65 years admitted to the hospital in 2010 for an ADR, identified from ICD-10 codes, were selected. All subsequent admissions of members of this cohort within 1 year of discharge following the index admission were reviewed retrospectively. The risk factors associated with hospital re-admission for ADRs were analyzed. Medical records were used for descriptive analysis of re-admission due to drugs other than chemotherapy agents.

RESULTS

We found that 553 of the 1000 patients admitted for ADRs in 2010 were re-admitted to hospital within 1 year. Among them, 87 cases were re-admitted for ADRs (estimated rate of 87/1000 re-admission for an ADR within 1 year). A comparison of the patients re-admitted for ADRs (n = 87) with those of patients re-admitted for other causes (n = 410) suggested that only cancer increased the risk of re-admission for ADRs (OR = 7.69 [4.59-12.88] 95 % CI). ADRs due to the same drug combination were the suspected cause of repeat admission in half the cases (other than chemotherapy). Hospital re-admission was considered avoidable in four cases (22 %).

CONCLUSION

This study shows an estimated rate of re-admission for an ADR around 87/1000 within 1 year, and the same drug combination were the suspected cause of repeat admission in half the cases. At least, 11 % of cases were avoidable.