SPEAKER : Welcome to the WTW podcast, Vital Signs Risk and Insurance for Healthcare, where we discussed the risk management and insurance trends and issues facing the US health care industry. We'll speak with our industry experts and clients in search of ways to improve your risk and insurance vital signs.
JOAN PORCARO : Welcome to the WTW Vital Signs Podcast Program. I'm very excited as today's podcast session continues our series on maternal and fetal health safety. With the nuclear claims on the rise and pressures mounting for the care team, risk reduction and patient safety strategies are really essential.
And in this podcast, we're going to explore the most effective approaches to training care team members on maternal and fetal health and safety. Our speakers today will discuss topics such as hands-on training, artificial intelligence, simulation exercises, continuing education and other best approaches to training.
My name is Joan Porcaro and I'm the Director of Client Relationship Management here at WTW. And I'm both honored and pleased to be joined today by Nancy Travis, Director of Women and Neonatal Services at Cape Coral hospital.
Located in Florida, it's one of the member hospitals of Lee Health. Nancy also serves as chapter leader for the Association of Women's Health, Obstetric, and Neonatal Nurses, or as you might as well remember, AWHONN is another way it's referred to. Good morning and welcome, Nancy.
NANCY TRAVIS : Thank you for having me, Joan. It's a pleasure to be here.
JOAN PORCARO : Thank you, Nancy. And we're also joined today by Carol Curran. She serves as a senior educator in Perinatal Business Development Specialist at Medical Interactive. Good morning, Carol.
CAROL CURRAN : Good morning, Joan. Thank you so much for having me today. I look forward to this.
JOAN PORCARO : Well, I've asked you both to join me here for this discussion on the topic of education. And this topic not only focuses on the patient's positive experience, but also patient safety. And when we think about education, we're also looking at different avenues for reducing liability for the care team as well.
So, I want to start off with an inquiring kind of question. And I'll direct it, I believe, towards Carol. There's been an increase in what we've been hearing called nuclear OB claims, which now has shifted to a new way to refer to these kinds of claims as thermonuclear. Tell us, first, what is a claim that rises to the level of these thermonuclear situations? And then can you tell us a little bit of some of the stories that end up causing these cases to unfold?
CAROL CURRAN : Sure, Joan. I think most of the attendees might understand if you're in the obstetric world that obstetrics as a claim related issue has always risen unfortunately to the top. We typically and still do win the award for the highest paid claims medical malpractice claims. And we also typically stay in the top 5 to 10 in regard to the number and frequency of claims.
The problem with all of this is it puts something that seems so natural, which is childbirth, into a very risky scenario. And there's a couple of reasons for it. I mean, mainly we all know any mother who enters into her pregnancy, labor, and birth is expecting, for obvious reasons, a healthy newborn, neurologically intact with no complications, and wants to take that particular baby home.
The problem is they don't always get that outcome. And so, because of that, it's such a fueled emotional state that lots of mothers, when they don't have that optimal outcome, seek justice through a malpractice claim, which they may or may not win.
So currently right now, as you mentioned, there's two terms kind of out in the legal world called mega claims that is defined as greater than $10 million as an award. And then there's also what is called nuclear claims, which is greater than $100 million in rewards to the plaintiff.
And right now, the largest US verdict is actually an OB claim that happened on the East Coast approximately about four to five years ago. And the amount was 229.6 million. That is one claim.
So, the problem with these claims tends to arise from some of the clinical conditions that can just be normal. The placenta could come off the uterus too early, creating a placental abruption which is an emergent scenario for moms and babies. There can be lots of blood loss. Mom can lose her baby, as well as she could lose her life if the blood loss was excessive.
There's other scenarios where maybe the care team is actually involved in some potential negligent allegations. For instance, there is a drug that we administer very typically around the world. I mean, it's happening right now. 24/7 we administer a drug called oxytocin.
It actually naturally occurs in the human body to start labor. But we also administer it when possibly the mom's labor is slow or she's having some problems, or maybe we want to start her labor for whatever reason. Maybe the pregnancy has gone too long, or she has a medical complication.
The problem is nurses, doctors, midwives, whomever can administer the drug either too quickly, to high doses for whatever reason. There might become too many contractions of which the fetus does not tolerate labor for extended periods of time.
And that drug over a long period of time, not being monitored appropriately and administered appropriately, could put the fetus at risk, and therefore also put the obstetric team at risk because a malpractice claim could ensue that we mal administered that particular drug.
And so that actually is a drug that is probably involved in about 85% to 90% of claims. And then there's fetal monitoring. The ability to read those strips that those two belts we put around the mom's belly, again, can lead to claims.
So, I'll end with the top 10 largest medical malpractice settlement awards. 50% involve OB claims. And there was one at 74.5, that failure to deliver the baby properly and falsification of medical records. 58.6 million for a delayed delivery resulting in birth injury. 31 million induction oxytocin overdose and fetal oxygen deprivation. 23.2 delayed delivery, and 11.4 at misinterpretation of EFM data resulting in birth injury known as cerebral palsy.
So pretty daunting, Joan. And this has been going on for decades. It's really not improving. I started in OB almost 30 years ago. And I actually teach almost the same EFM or any other high-risk OB, risk mitigation strategies, and patient safety strategies as I did years and years ago. I'm still teaching them today.
JOAN PORCARO : Thank you, Carol. I want to pause and go with one other question for you. When we think about the trajectory of OB care, obstetric care in the United States, what aspects of care maybe have changed? And what are the pain points?
CAROL CURRAN : The biggest thing I think for the entire obstetric population practitioners, patients, and everyone, is the change actually in the patient population. Unfortunately, we have seen medical complications increase even at a younger age. That means the moms at whatever age are entering into pregnancy with more complications.
Unfortunately, we have seen a rise in obesity across the nation for many, many years and decades. And so just extra weight that is brought into the pregnancy, again, can bring either undiagnosed cardiac disease, diabetes, maybe any other complications, which now comes into the pregnancy. And those complications then bring more complications as labor and delivery approach.
So, the population has changed. It's also aged. Many women are striving for their careers first, and then getting into childbirth later in life. So, age does also play a part. So, the population has changed. In addition, hospitals have changed.
Over the last few years, we've seen much more closures of hospitals that do have OB care that has led to many, what we call OB deserts, meaning that a mom may have to go much farther to get her care. And that does bring risk. Maybe when she needs something more prompt, she's having to go much farther away to get the adequate resources. And then lastly, providers have changed. And the health delivery model inside the hospitals has changed.
So, as we know post-COVID, we have lost many nurses at the bedside. So that has left staffing shortages a lot of the time. That's even an OB. Physicians have changed over time. Many physicians have left obstetrics and have gone into either just GYN only or they've retired early. And so, the ability or the availability I should say of providers in certain areas of the US particularly are scarce. And that's a problem for the pregnant mothers trying to get access.
So, there's been a lot of changes. There's also the delivery model in regard to there has been much more intervention over the last two decades, meaning we start her labor, get her into labor, kind of push the pregnancy a little faster, those kinds of things.
But interesting enough, the last few years, all of the national governing bodies have seen the risk involved in doing so. And we're trying now trying to do more of a less interventional approach when we can, when the moms are low risk. So, we do try to do that. But things have changed.
JOAN PORCARO : Thank you. I want to just pause again and reflect on methodology of training. So, you've talked about some of the changes in the world of Obstetrics. But a question to both you Carol and Nancy, has the methodology for training of providers and nurses changed along with the growing trends and emerging risks?
CAROL CURRAN : Absolutely, Joan. I think the number one thing and I alluded to this earlier was staffing related issues. Hospital closures, all of these things have led to limitation in time. So online training really has been around for quite some time, but it really hasn't been favored until I would say and I'll let Nancy chime in as well, probably the last 5, 6, 7, 8 years.
And that means the team now instead of being pulled away from the unit 4, 6, 8, hours to go to a one-day course, is really quite difficult right now. And the other thing of doing that is sitting in a room for eight hours to leave with a piece of paper that says I was there is really not productive for anybody. And particularly, the learner, the doctor, or the nurse.
So, what has changed also is a little AI in education and training. And the ability to use a system that can assess the individual nurse or doctor or midwife or whomever has absolute gaps in learning, and then filling those gaps with the exact education and training they need, because if you put 10 people in a room, not everybody needs the same thing.
So, Nancy and I could go, she might need a little bit more in a certain topic that I already know. I may need something else. And so now there are systems out there, automated systems that the user can sit down, take an assessment, they can see where you're at, and then they will give you the certain courses to fill those gaps. But I'll pass the baton to Nancy.
NANCY TRAVIS : Thank you, Carol. I also agree that the online learning has become a necessity for our team, so that they can do the training when it's convenient for them. With a lower number of nurses, you want to have that training available when they can take it.
And if a nurse is working many hours, they also have to have a home life. So, we give them the option that they can do the trainings, either at the hospital or at home when it's convenient for them, which has been very helpful to get things done.
In addition, the nursing professional development specialist have become creative, and have been offering some new things to the team, such as scavenger hunts to find supplies that are necessary for emergencies, and to prep the team for readiness, for team readiness.
So, we do a lot of role play and that kind of thing that's right on the unit after they've taken their online courses. Escape rooms have become fun. Fun ways to learn. And the creativity of the group of educators that we have now is just incredible.
So, we have looked at the younger population coming in. Carol and I are very seasoned nurses. But the younger population have been grown up using gaming. So, the gaming activities that they have fun with growing up are now being used for educational purposes, and very effectively.
JOAN PORCARO : So, you mentioned the word effective, Nancy, and I want to touch on, how do you measure whether or not the training's been successful? What are some of the different approaches you might use? And I'll throw the question out to both of you.
CAROL CURRAN : Well, from our perspective, our company is one of those AI training producers. And what Nancy and her team has available to them using a system like this is they can either make assignments.
The user can go in and just complete courses or what we call learning paths based on their own needs. And the interesting thing is that we have reporting tools that can then show the improvement. So, you can see the pre-score, and then you can see after gaps are filled, then you can see the improvement.
The other thing that I find pretty interesting and I'll let Nancy chime in on, is also adding information regarding question that may be addressing some form of a specific claim topic. Maybe it's cognition or performance, those types of issues where all claims fall into.
And then also putting a risk score on questions that are embedded in into the training, so that one question might be categorized as high risk, meaning that if the user misses the answer to that question and marks it incorrectly, gets up from the computer and walks over and starts taking care of patients.
The probability that they actually could if they did the same thing the way they answered on the test could impact patient care negatively, and possibly be involved in an adverse outcome. And the system assesses all of that information, so that someone like Nancy at her level can run the reports and see which of her staff is possibly risky or more risky than someone else.
And then certainly can follow up more closely to make sure that their education and training maybe has some additional aspects to it, or she follows them a little bit more closely to make sure they hit the benchmarks that she's put into place. Nancy.
NANCY TRAVIS : That's correct, Carol. And it is so helpful to be able to look back and see if a single nurse is having struggles with a question or is it a group of nurses? Do we need to develop something a little bit more in-depth on one section or another?
And with the knowledge we get, we are able to tailor the clinical needs by putting that person with a preceptor perhaps and working through some more clinical issues right at the bedside, or does she need time and an assignment to a different module within the learning system? So, it is definitely individualized, but can be brought out with the reporting to the group level so we can see exactly what we're missing.
CAROL CURRAN : Yeah, I would add on to that, just one more thing. We didn't mention, but this is a real national accepted way for education and training. And just because Nancy didn't say it, I know they're doing it. But simulation training.
The Joint Commission and other national governing bodies really support and encourage all hospitals' health systems to do multidisciplinary team training. And that is typically done either in-situ on the unit, in real-time in a real labor and delivery room, or there might be a specific area of the hospital where they have set up what's called a simulation training area or room, where the nurses and docs can go down.
They can as a group actually be tested on some OB emergencies to see how they all individually react, and then how they totality as a team react. And that, quite frankly, is really, really helpful to put the bow on the present to see if everything got embedded into everybody's education and training.
NANCY TRAVIS : I would say 100% on that, Carol. Having the simulation training and having physicians, midwives, anesthesiologists, respiratory therapists attend the training with the team just makes your team work that much better. It is incredible.
We have a neonatal simulation place on our unit that is used quite frequently. I think every month, we're having neonatal simulation codes where everybody responds. And we have just opened a simulation training center on our campus, which we are able to take our team down to use. But these trainings are incredible.
And after the training, we've run through the simulation, they debrief as a group. And see what they could have done better. And sometimes they'll choose to rerun that simulation over again just to see what they've learned and how they can make that work better.
CAROL CURRAN : Yeah, I would add just one last thing as well. For any of providers or whomever may listen to this podcast, that really, they work at a much smaller level of facility. They may only do a few deliveries a month. And they're listening to Nancy and I going, Oh, they're just from those big hospitals. They don't know how hard it is for us.
We completely do. And just because Nancy and her system may be blessed with the ability to have that particular simulation center, you don't need all the bells and whistles to do a sim, a simulation. You don't even need the dummies that cost I think now anywhere from $5 to $10,000 that you can use to simulate a pregnant woman and a pregnant emergency.
Back into one of my facilities many, many years ago, we had a nurse that was when it was her day off, she came in as our fake pregnant patient, and we started in the emergency room, and we ended up in labor and delivery.
And no one really knew or well, I mean, she wore a shirt to identify as kind of the fake patient. But we could still monitor appropriate care. And at the end of it, like Nancy said, we would all come together. We talk about what went well, what didn't. And that just really guides your quality improvement program.
So, it's not about size and resources. Training can happen anywhere anytime, small, big, lots of resources, little resources. But the point I think of what Nancy, and I are saying is you do need to have education for remediation and to fill your gaps. And then you need to practice. And practicing together really is the best thing to do.
NANCY TRAVIS : 100%. I think sometimes using a person to be the mannequin works even better, because that person really responds to you just like real life. I know we had one of our educators was the person. She was the pregnant lady to do some training with our emergency department team for emergency deliveries, and it was incredible. She was able to act just like a lady that was getting ready to deliver, and the emergency team really had fun with that.
JOAN PORCARO : Thank you both. I really appreciate hearing more about the reality of when we drill, we improve. And we can check on each other and grow from that experience. And when you think about some of the experiences you've had, Nancy, are there any success stories you'd like to share with our audience today?
NANCY TREVIS : Well, I can tell you that obstetric hemorrhage was our practice thing for this past six months. And with that, we had changed some equipment and some drugs in the facility. And with the educators running a little simulation room for us and also an escape room that the staff that have gone through it felt a lot more comfortable, especially the newer nurses that were in practice on OB less than a year.
So, they have all voiced that they were able to get the things that they needed in an emergency situation and in obstetric hemorrhage a lot faster that they understood the concepts after going through the simulation. After having the didactic training online, and then going to the simulation and the escape room session, they were much more comfortable. And they have thanked the educator for that. Really does work in real life.
JOAN PORCARO : We're coming to the close of our session. And one of my favorite questions to always ask our guests is if you could only have one take away point, what would you want to convey? What would you want to say to our listeners?
CAROL CURRAN : I think I'll start, Joan. The sentence I always say to people is you don't know what you don't know sometimes. And I have worked with some very seasoned individuals who have then later gone into some education and training, and their pre-test scores, they just could not believe that was not them how dare they get something below an 80%.
They've been in doing for this long period of time. And they know what they know. And I challenge anyone to say first and foremost, we all don't know everything. Second, information is constantly changing. And it is very hard to keep up. And thirdly, we're always trying to improve.
So even when I was in obstetrics and started way back when to where things and practice habits are now, there has really been some significant improvements in our care. And the only way to stay current is to educate yourself, continue to look at your resources, go to your professional organizations for guidance on improved recommendations and guidelines regarding care. It's completely evidence based.
Many of us grew up with what our grandmothers or someone else may have said helps get the baby out, which maybe it works and maybe it doesn't. But ultimately, evidence-based care is where we need to guide our practices and hospitals. So, I would recommend that believe that you don't know what you don't know, and be open to learning more.
NANCY TREVIS : Excellent, Carol. I think that I have been a nurse this year for 47 years. And I will say that I never have stopped learning. I learn something new every day. And I think that people that say that they know it all are the scariest people of all.
Be involved with your professional organization. Stay up to the minute. Get all the learning you can get. I know there is a lot of free webinars and things that you can get that come across all the time. But be inquiring. Just wonder, how does this work? How can I do things better? And use the evidence to the best of your ability. And like I said, just never stop learning. There's always something else you can do better, and you can learn from someone else.
JOAN PORCARO : Well, as we come to a close, I want to first acknowledge Nancy. Thank you for joining us today.
NANCY TRAVIS : Thank you so much for having me. I look forward to any continued conversations. And I'm always available if anyone has questions.
JOAN PORCARO : And as always, Carol, I appreciate your time and your expertise. Thank you also for joining us today.
CAROL CURRAN : Thank you, Joan. I do really appreciate this opportunity. I love having these discussions. You always kind of hope that you can make a little effort or change in the world or improve mothers' and babies' outcomes. I think this is one great way to do it, is through the education process.
And I'm very proud to be working for a company whose goal is to help improve and fill knowledge and skill gaps in a creative way. Ultimately, to improve maternal fetal outcomes. So, thank you for everything.
JOAN PORCARO : And I also want to take a moment and thank our audience and those who have tuned into our discussion. I hope you'll be joining us for our future discussions in the coming weeks. And again, thank you for listening to our podcast, WTW Vital Signs.
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