Executive Summary
Brandy Libby
Grand Canyon University: Nurse Leadership and Management NRS-451V
January 24, 2014

Executive Summary
The current staff have varied years of experience, and education. Some have not completed an intermediate or advanced fetal monitoring course. Many have not had updated education in reference to the newest nomenclature set forth by the National Institute of Child Health and Development (NICHD) in 2009. Standardizing the interpretation and the communication of varied fetal heart rate (FHR) patterns among all staff is needed to decrease intrapartum mistakes, decrease liability exposure and improve patient outcomes. Improving staff competencies in the interpretation, communication, documentation and management of fetal heart rate tracings is critical to these goals (HANYS (Healthcare Association of New York State), The American Congress of Obstetrics and Gynecology (ACOG) New York State Department of Health [HANYS, ACOG, NYSDOH], 2011). The National Certification Corporation (NCC) recently launched a public campaign named “Just Ask”. The campaign is designed to educate and encourage patients to ask for certified nurses and nurse practitioners. It is the goal of this proposed quality improvement initiative to have all perinatal staff be updated and certified in electronic fetal monitoring by the NCC by the year 2015.
Purpose
Litigation caused by the misinterpretation and management of electronic fetal monitoring (EFM) tracings continue to be a common issue in adverse outcomes in term pregnancies in the United States. Allegations in reference to the communication, interpretation and management of EFM tracings are the most common subjects of law suits related to the neurologically impaired infant (Miller, 2005). A call was made by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for all perinatal staff to form protocols used in interpretation and management of fetal heart rate tracings to include standardized communication in definitions, terminology, and categories (Huerta-Bogdan, 2011). The National Institute of Child Health and Human Development (NICHD) answered this call when they met in a series of workshops to develop standardize definitions for FHR tracings and develop more meaningful evidence-based clinical management of intrapartum fetal compromise thus improving patient outcomes. Decreasing possible litigation, improving patient outcomes and continued forward movement in providing evidence-based practice at the level of excellence expected of organizations with the goal of obtaining future Magnet status are all viable reasons for the proposed initiative to be considered by the board.
Target Population
All members of the obstetrical team are included in the proposed initiative. Staff nurses will be required to take the exam and become certified by the proposed timeline of 2015. All subsequent new hires, with labor and delivery experience, will have one year of hire date to test and pass the certification course. Physicians will be encouraged to take the course and become certified, as well. All participants will be reimbursed for testing and certification costs. The unit nurse manager will be responsible for communicating with staff these guidelines and mentoring them through the process. Individual staff members will take individual responsibility in maintaining their certification every three years by either re-testing or by evidence of approved continuing education units. The complete National Certification Corporation electronic fetal monitoring course and guidelines can be found on the NCC website.
Benefits
Historically, electronic fetal monitoring was designed to ensure safer deliveries, healthier babies and improved neonatal outcome by detecting fetal hypoxemia during the labor process and in turn decrease the risks of cerebral palsy (Huerta-Bogdan, 2011). EFM is the most common tool for intrapartum surveillance used and is used in 85% of all births in the United States (HANYS, ACOG, NYSDOH, 2011). Mothers and babies still can benefit from this technology. Creating a culture of safety and evidenced based competency across the perinatal unit will benefit the obstetric team, individual staff members, the organization as a whole, as well as the patients and the community it serves. The board will appreciate the level of competency from the team when applying for Magnet status. The board may consider another benefit of this project as a positive marketing campaign and using the fact that their labor and delivery nurses are all required to be certified in electronic fetal monitoring. The fact that all the nurses with in the organization’s labor and delivery team are required to be certified could be the deciding factor for a mom who has not made a decision as to where she wants to labor and deliver her baby.
Budget Justification/Cost Analysis
As mention, the education and training level of electronic fetal monitoring is varied by staff nurses, mid-levels and physicians. This, plus the fact, that EFM issues in obstetric negligence claims continue to top the list of litigation, ensures the board that increasing the level of competency of the staff will be financially beneficial, and more importantly priceless in the context of increasing patient outcomes. The initial cost of the program, broken down, will be $210.00 per staff nurse to complete the course. There are currently twenty-five staff registered nurses in need of certification. This breaks down to a total of $5,250.00. There are ten obstetric physicians, with delivering privileges, for another potential possible cost $2,100.00. New hires will be required to complete the course and become certified at one year of employment. The cost for their certification will be covered by the unit’s budget. The cost of healthy moms and babies=priceless.
Evaluation
The web-based tool Agency for Healthcare Research and Quality Hospital Survey (AHRQ) was used in a similar state wide campaign in New York State. This tool could also be used to provide the board and organizational leaders with the basic knowledge need to conduct an effective safety culture assessment (HANYS, ACOG, NYSDOH, 2011). The tool is used to track changes in patient safety over time. It is also used to evaluate safety interventions such as this proposed program. Individualized communication with the staff as to areas of concern, or additional training needed will be ongoing. Anticipated hurdles are those less experienced staff having difficulty passing the exam. For this staff, intermediate and advanced fetal monitoring courses will be offered and reimbursement for these will be offered as well. Periodic fetal tracing reviews will be conducted during unit staff meetings and discussions on appropriate interpretation, communication, documentation, and interventions will be reviewed and discussed as a group. An approved refresher mini course will be added to the annual health streams education required by all labor and delivery staff RNs.
Conclusion
Improving an obstetric unit’s patient safety culture by increasing competency and providing vital training on how to interpret, communicate, and effectively respond appropriately to a fetal heart tracing will be beneficial to all. This quality improvement initiative is obtainable and necessary. This program follows the shared vision of providing high-quality, evidence-based competent care that is deserved by our patients and their unborn babies.

References
HANYS (Healthcare Association of New York State), The American Congress of Obstetrics and Gynecology (ACOG) and New York State Department of Health. (2011). Best Practices in EFM Definitions, Interpretation and management: A statewide campaign to standardize electronic fetal monitoring education. Retrieved from httP://www.hanys.org/quality/clinical_operational_initiatives/obstetrics/docs/2011-05-17_elec_fetal_monitoring_grant_final_report.pdf
Huerta-Bogdan, B. (2011). Improving Interpretation of Electronic Fetal Heart Monitoring. Women’s Health Care: A Practical Journal For Nurse Practitioners, 10(9), 52-56. Retrieved from http://library.gcu.edu:2048/login?url=http://search.ebschost.com/login.aspx?direct=true&db=ccm&AN=2011307833&site=ehost-live&scope=site
Miller, L. A. (2005). System Error in Intrapartum Electronic Fetal Monitoring: A Case Review. Journal of Midwifery Women’s Health, 50(6), 507-516. Retrieved from http://www.medscape.com/viewarticle/516440_print