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Bill Klaproth (host): Welcome to the ASHRM podcast made possible by the American society for healthcare risk management. To support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit Ashrm.org. That's A S H R M.org/membership to learn more and to become an Ashrm member and we'd like to thank Health Stream for sponsoring this episode. I'm Bill Klaproth. On this podcast, we're going to be talking about boosting access to high quality, equitable child and maternal care. We've got an esteemed panel of guests to discuss this topic for soft.

We've got Dr. Henry Lerner obstetrician gynecologist at Newton-Wellesley hospital. Also Dr. Patricia Scott advanced practitioner coordinator at pediatrics medical group of Tennessee. And we have Linda Zimmer senior program manager of clinical programs at Health Stream. Dr Lerner, Dr. Scott and Linda. Thank you so much for your time. This is such a great topic and an important topic as well, Linda, let me start with you. So we've seen a lot of new changing policies from the CMS and the Biden Harris administration. Around child and maternal care and the need to address slash improve. The health equity of mothers and babies. What are you hearing from customers and partners?

Linda Zimmer: Yes, that's a great question and we enjoy hearing from our customers and partners. The United States does have the highest maternal mortality rate of any wealthy nation in the world. Every year. Women in the United States die of pregnancy related causes at more than double the rate among nations with the same income levels. It's troubling. We hear that along with this ranking, we can narrow the connection down on a more human personal level. This sad experience could impact our communities to the north and south, your neighbors, or even closer through friends and family.

Also, from our customers perspective, poor maternal outcomes take a toll on them, both nurses and the doctors that deliver patient care. Political views aside, it's encouraging that we're having this conversation today and it's encouraging to see focus and urgency being placed on improving maternal outcomes. We should be listening and supporting those with direct patient experience. I'm excited we'll be hearing from two of those individuals today during this podcast. Dr. Lerner and Dr. Scott, most agree when we have these conversation that improving maternal mortality rate is a deeply complex issue.

If you try to plot it out or put it on a board and look at the connections, there's many angles, both horizontally and vertically. For example, the topic of timely access to treatment is multifaceted in itself. If you took that one aside, it has lots of connectors and issues. The majority of women this is an exciting period of time for them and do not have perinatal or postpartum complications. There does remain work to be done for those medical challenges that we see from anxiety and depression to hypertension disorders, which can contribute to long-term lingering chronic issues for our mothers.

Really too, as we listen to customers and look at the new research studies that are being published in data being collected, changing priorities can be challenging in pursuit of their improvement. I can recall from my experience as a nursing director, shifting priorities can be difficult to manage. Several quarters, you would see green on your safety KPIs, then it would turn yellow or red. when you add new initiatives, that should be required, it's really a layering process to maintain progress and roll out new improvement plans based on the studies and the data that's coming out.

This is where teamwork is so important between risk directors and managers and clinical leadership. Additional disruptors that we're hearing from customers. financial strain comes to the top as well as provider and nurse shortages. Really to wrap up this first question, the link for us at HealthStream to improve maternal outcomes is possible through our customer collaborations as well as our partners and offering effective education for clinical staff. Health Stream's Learning application is the most widely adopted learning application among US hospitals and health systems, where approximately 400,000 course activities are completed every day on average. This unique position provides Health Stream an opportunity for meaningful conversations with many health systems and partners across our country.

Bill Klaproth (host): Now that's a lot of courses. That's for sure. Linda, thank you so much. We appreciate that. Dr. Lerner, as the subject matter expert for maternal care. Could you share your thoughts, please?

Dr. Henry Lerner: I agree with every comment that Linda made, that there is a need to improve the quality of care we give mothers and their babies in this country, that there can be financial and logistical barriers to administer that care. And that programs, that educate physicians, nurses, and all hospital care providers are vitally important. and such programs are, provided in large measure by companies such as HealthStream. The one caveat I would make though, is that although officially US maternal mortality statistics are at the bottom of those for the developed world. We have to look at what those numbers say.

If you look at all causes of maternal death, it is not what one would think that a mom comes to the hospital, she's sick and cause her care didn't go well or cause she didn't get to the hospital. that's why she died and that's why our statistics are bad. A very large percentage of maternal deaths have to do with trauma, violence, gunshot, stab wounds, automobile accidents, and suicides. Those are horrible conditions. Society needs very much to work on those. But I just didn't wanna leave the impression that the US healthcare system for patients that access the system that is are in the hospitals is worse than elsewhere. In fact, for any given gestational age of birth, 28 weeks, 30 weeks, 32 weeks, US healthcare statistics are better than any country in the world.

Bill Klaproth (host): Well, that's an important distinction, so thank you for sharing that Dr. Lerner. We appreciate it. And Dr. Scott, could you share your thoughts, please?

Dr. Patricia Scott: Well, I really enjoyed what Linda was saying about education because I think that is definitely the key with some of these changes throughout the country. At least in the part of the country where I live in Tennessee, we've had several of our rural hospitals Birthing centers shut down. So that puts more and more emphasis on the birthing centers that are open in those rural areas to be able to deliver the care that these moms and babies need. And a lot of times, those rural facilities don't have the experience and the knowledge base. So I think that's what Linda was referring to with education that Health Stream and other such, foundations can provide. It's so important that all of our staff be educated in how to provide care to these moms and babies.

Bill Klaproth (host): Well, Dr. Scott, thank you so much for sharing that and Dr. Lerner, I wanna go back to you for a minute. When we think about risk or clinical errors in the obese slash labor and delivery unit, can you share with us what are some of the risk factors that you've seen firsthand currently and or historically?

Dr. Henry Lerner: One of the nice things about obstetrics is that the most serious emergencies happen rarely. Things like amniotic fluid embolus, shoulder dystocia, cord prolapse, etcetera. And while that's good for mothers and babies, it does have the downside of meaning that when such emergencies occur, the practitioners who have to deal with them are likely months, if not years, if not perhaps decades away from having seen these in the past, learning how to deal with them and thus being prepared for them. That's why doctors, nurses, and all hospital staff need practice in dealing with these emergencies.

For instance, an amniotic fluid embolus may occur once every decade on a moderately busy labor and delivery unit. And if the last time an obstetrician. Whose patient has an amniotic fluid embolus, saw this condition was in her or his residency programs a decade and a half ago, then that clinician will not be at their peak level of performance in dealing with it. That is why practice in the form of simulation is so vitally important. There are well designed simulation programs. In fact, Health Stream has just issued a series of them. That cover all the major obstetrical emergencies such as amniotic, fluid embolus, cord prolapse, preeclampsia, and eclamptic seizure, postpartum hemorrhage, umbilical cord prolapse, etcetera.

With these programs with very little equipment, practice doctors And nurses working together in as short as 15 to 30 minute intervals can practice handling these emergencies right on their labor and delivery unit to where such emergencies will occur. Not only will this refresh their memories as to how to best treat these emergencies, but they will also see what in their unit might be obstacles for best care. For instance, maybe only by doing a practice drill will it be realized that the crash cart, which is around the corner and down the hall, is too far away from where an emergency, where it is needed might occur. So practicing for obstetrical emergencies via simulation programs is very important.

A second major problem I've seen, and I've had the opportunity to do safety reviews all around the country in scores and scores of labor and delivery units. A second major problem is 24 hour in-house coverage. At a university center, that's not a problem. There are. Layers of residents in-house. There were fellows in-house, there were faculty members in-house, but in your average community hospital night call and weekend call are covered usually from home by the private practice doctors whose practices make up the obstetrical staff of that facility. This is problematic. Because obstetric emergencies usually occur very quickly and that have to be dealt with within minutes.

So if somebody all of a sudden develops a postpartum hemorrhage after the physician has gone home three hours after delivery. If somebody in early labor develops an amniotic fluid embolus, having a doctor, 15 to 20 minutes it's away at home on a Friday night is not the best form of care. That's why many institutions are moving toward a laborist program. A laborist or obstetrical hospitalist is a individual physician or team of physicians that is hired to do shifts 24/7. In the labor and delivery unit, they're always there, like emergency physicians, they are only doing that.

Therefore, they're well rested when they come in, they're experienced and they know their unit. They are there to do backup for private practice doctors who are in their office. They're there to handle emergencies that roll in at any hour of the day or night. They can also teach nurses, residents, students, they can go to the ER to see patients in who are pregnant, who come into that facility. In short, although such a program can be expensive, by improving the throughput that is shortening the time before Pitocin inductions get started, increasing the speed of morning discharge from the hospital.

Hospitals can in the long run, save money and all it takes is avoiding one 10 to 20 million lawsuit to pay for that labor service many times over. Finally, obste is a big field. There is so much to know. That's why residency programs are four years and fellowship programs are several years after that. No person can totally remember everything about best care off the top of their head, that's where checklist comes in. Checklists have been used in the aviation, in the nuclear power and in other high risk industries for many, many years with a simple checklist. In the labor and delivery room, I usually like to see them laminated on a key chain and put on a hook in that room so they can be referred to immediately.

We will know that every step in the correct care for an obstetrical emergency is being taken. Nobody has to worry that they've forgotten something. Nobody has to worry that not everything is being done to help in this emergency. Moreover, it's excellent for training and review. So in short, I think the major risk areas, and there are many, many that we could talk about, but three major risk areas are one, simulation drills to practice infrequently occurring emergencies, two, 24/7 in-house coverage, and three checklists as memory aids, free dealing with emergencies.

Bill Klaproth (host): Dr. Lerner. That's excellent. How we are adapting and adjusting and focusing on this issue. Can you talk about the OB safety sims toolkit quickly that's in development?

Dr. Henry Lerner: Absolutely. After several years of doing these safety inspections of labor and delivery units around the country, it seemed to me that a major for middle sized and smaller hospitals was to develop safety teaching programs, and yet these are just the facilities that don't have the extra funds to hire a teaching nurse that don't have physician, woman, or manpower to design these safety courses. So working together with Health Stream, they and I have developed a series of courses that include four components. One, a didactic component that takes about 15 to 20 minutes to get through on each of six different obstetrical emergencies.

The ones I listed previously. Two, a several page script that any facilitator, an obstetrician on the unit, the chief of service, the head nurse, or anybody who's appointed to do so can lead a group of physicians and nurses through. That is there are realistic clinical scenarios involving very little equipment, just using a labor room, a pillow for a patient, and maybe a doll for a baby. Where all these emergencies can be run through, and therefore no clinician will be more than six months or one year away from having practiced an emergency they might see clinically.

These programs are being distributed by Health Stream. They're gonna be available to any clinician's, hospitals, obstetrical services that want them, these and other courses produced by, other designers, we hope will help improve the quality of obstetrical care that's administered to women and babies in America.

Bill Klaproth (host): That sounds good. Thank you for sharing that information, Dr. Lerner. And Dr. Scott, let's transition a little bit to once the baby is born, can you share with us the risk factors that are important to consider once the baby has been delivered and what can be done to avoid them?

Dr. Patricia Scott: Sure. first of all, do you mind if I address something that Dr. Lerner said and kind of pull it to the newborn side?

Bill Klaproth (host): Please do.

Dr. Patricia Scott: Dr. Lerner did a wonderful job talking about the benefit of simulation and training for the OB providers, and I just wanna pull that over and talk a little bit about the infant, because everything he said also applies to the newborn side. Just like Dr. Lerner said, some of these emergencies we see so seldom, so when we do see them, we're not up to speed on best care. And so those simulations he mentioned with shoulder dystocia, pulmonary embolism, we do the same thing in the newborn areas with the birth of a preterm baby. If you're not used to going to the delivery of a 26 week baby, that can be a very difficult experience.

So we do simulations in the newborn world on premature birth. A baby that emergently has a Pneumo Thor. Which is an air evacuation that saves his life. Sometimes just airway management. How do you provide effective, positive pressure ventilation to a baby who's just been delivered, who's not breathing adequately on their own? What about the baby that's born in the emergency department, the baby that's born precipitously? And then Dr. Lerner mentioned some of the obstetric emergencies such as a prolapse cord, placental abruption. There's special care that those babies need after those maternal conditions.

And so simulation in those circumstances for the newborn side are equally important. And I loved his point about, if nothing else, it helps you examine your processes in your facility, where are your supplies located? How do you call the blood bank for emergency release blood? How do you activate your team? How do you activate getting your provider in the room in the middle of the night? There's so many things, so many processes that we can practice that will make us feel more confident when this horrible situation occurs. Some people in simulation, creating muscle memory so you know how to do these things. So I just wanted to add the infant into his discussion about that.

Bill Klaproth (host): Yeah, that sounds good. Well, thank you for sharing that. Yeah. And then if you could give us the risk factors that are important for us to remember, once the baby has been delivered and what we can do to avoid them?

Dr. Patricia Scott: I'd be glad to. I think again, Kind of springboarding off what Dr. Lerner said. Maternal risk factors, that's a huge risk factor for the baby. If the mom has had an abruption, if the mom has diabetes, if the mom has hypertension, all of that plays into the baby and what we will see in the patient. And then of course, I think I have to mention gestational age because a preterm baby's needs are so, Than a term baby's needs. And based on those, we have to look at all kinds of things. And we cover this in NRP Neonatal Resuscitation Program. The NRP program.

And in Stable, which Stable has modules with Health Stream as well. And we start by looking at, in stable, we start with looking at sugar. What is safe care? Dr. Lerner talked a lot about safe care, stable talks about safe care as well. Also in that module, what is the baby's glucose? That can be a problem. Think about a baby whose mom was diabetic. Now the baby's been delivered and so that baby is at risk for low blood glucose or hypoglycemia. If it's a preterm baby, we worry about thermo regulation. I think sometimes we, we don't realize how important temperature control is to a baby, especially a preterm baby.

It actually has physiologic consequences that can make other body systems at fault as well. What about airway? That's a very important piece of it. Is the baby effectively ventilating himself? If not, then we need to provide that. Blood pressure. What labs do we need to obtain? We always have to remember support of the family. Most of our families do not expect the delivery of a sick baby, nor do they expect that their baby may need to go to a different facility for care. So the emotional component for families. it is just tremendous. Or it can be tremendous.

So just kind of circling back, I think the big risk factors are, is the mom healthy or does the mom have some diseases that can affect the baby, or conditions that can affect the baby? And then are we delivering a 26 week baby or a 39 week baby? There's a huge difference in the care that those babies are gonna need.

Bill Klaproth (host): Yeah, really important to understand those risk factors. So thank you for that, Dr. Scott. Linda back to you. Health Stream is known to be the leader in workforce development solutions. So what's your recommendation for organizations looking to expand access to high quality care and improve the health equity of mothers and babies?

Linda Zimmer: Yes. Thanks Patricia and Henry for your comments. Healthstream is committed to offering effective education for our customers. And I want to pause again on the word effective because we understand that more education is not usually the answer. It's how we deliver it, be it very effective, so that clinicians can deliver high quality care with compassion for all mothers, including those with high risk pregnancies. Some of the examples that we have focused on and had success regarding personalized learning is first assign the content based on the scope of practice. So the example of this includes one of our programs has two online micro sims, one for providers and one for nurses.

So that there's a pathway based on your role, it's meaningful. They don't need to take content that doesn't apply to their scope of practice. Another example is our adaptive learning functionality, which reduces the time that it takes for learners to complete. How this works is that the learner takes a pre-assessment test. Based on how they score, if they just missed advanced questions that have been categorized, then they just have to take a higher level module. For example, the learner, Mrs. Novice questions, advanced beginner, as well as those expert questions. Then he or she will need to take all the modules pertaining to that topic. We've seen a lot of success with that.

And then also just in wrapping up, we've talked about this, how important and imperative it is to do in-person interprofessional skills training. It promotes that high functioning team that is really necessary when those emergencies do occur. Lastly, one success story that we've seen is with our quality OB behavioral health bundle, the course related to maternal anxiety and depression. We've included universal screening tools. The questions on how do you identify who's most at risk, as well as when do you use this screening tool. So here at Health Stream we strive to improve clinical competency by simplifying the process and provide cost effective training. It's a privilege to be part of improving healthcare by developing healthcare staff. Those that deliver the care.

Bill Klaproth (host): Well, simplifying the process always helps in that, cost-effective training is good as well. So thank you for that, Linda. So as we get to the end of our interview, this has been an amazing topic. As we talk about boosting access to high quality equitable child and maternal care. Any final thoughts from you, Dr. Lerner, and then Dr. Scott, I like to get some final thoughts from you as well. Anything else you want to mention right now Dr. Lerner?

Dr. Henry Lerner: I think my co speakers did an excellent job of covering the topic that we are dealing with today. That is, how can we best provide the highest levels of up-to-date care on our maternity and pediatric neonatal services? This has to deal with the fact that both of these areas, obstetrics and pediatrics, are complex areas that through the work of thousands of clinicians and researchers over the years, we have developed care levels to a very high standard. It is now our job as clinician educators to make certain that everybody practicing in these specialties is able to learn about and access these latest best practices in their field to provide the best care for the mothers and babies in our country.

Bill Klaproth (host): Dr. Lerner, thank you so much for sharing that. We appreciate it. And Dr. Scott, I know you wanted to add something as well, so if you could please share your final thoughts, we would appreciate that.

Dr. Patricia Scott: I think all of us are very concerned about every single baby that is born in the United States. But I think something that we need to think about are, we have babies that are born in tertiary facilities, but we also have babies that are born in community hospitals in the United States. There are just under 70,000 babies that need to be transported each year. So when we have those community physicians and community nurses educationally prepared, With stable education, it is imperative to the care of these babies. And when we use the same curriculum to teach all perinatal staff, even at the tertiary facilities, it gives everyone the same foundation and goals for that baby's care. So I think it's just important that we remember those community facilities that don't have as many resources.

Bill Klaproth (host): Dr. Scott, thank you for adding that. We really appreciate that. Once again, I want to thank this great panel, Dr. Lerner, Dr. Scott and Linda Zimmer. Thank you for your time. We appreciate it.

Dr. Patricia Scott: Thank you.

Dr. Henry Lerner: Thank you.

Linda Zimmer: Thank you.

Bill Klaproth (host): And for more information, please visit healthstream.com. Once again, that's healthstream. All one word .com. The ASHRM podcast was made possible by the American society for healthcare risk management to support efforts to advance safe and trusted healthcare through enterprise risk management, you can visit Ashrm.Org. That's ashrm.org/membership to learn more and to become an ASHRM member. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth. Thanks for listening.