Ms O’Keefe is Program Director, Perinatal Quality Foundation, Oklahoma City, Oklahoma.

Marin O'Keefe, RN

	Electronic fetal heart rate monitoring (EFM) is an integral part of labor and delivery management with the goals of reducing neonatal mortality and long-term neurologic morbidity. Whether these goals are consistently reached is unclear, but EFM is used in nearly 85% of all deliveries in the United States.

 Despite concerns about its value in improving obstetric care, EFM will continue to be widely used because it is generally accepted as having clinical value and is clearly a labor-saving alternative to intermittent auscultation of the fetal heart.

	Although EFM does not accurately predict poor neurologic outcome, it has clear value in detection of the fetus at increased or decreased risk of ongoing hypoxia and/or acidosis.

 As such, considerable efforts have been made to accurately categorize specific fetal heart rate (FHR) patterns and promulgate agreed-upon definitions and nomenclature of the various aspects of EFM in an effort to improve communication, patient safety, and obstetric outcomes. In 1999 and 2008, the National Institute of Child Health and Human Development (NICHD) held workshops on EFM.

 The American College of Obstetricians and Gynecologists (ACOG) followed in 2010 with guidelines for interpretation and management.

 Here we provide an overview of the Perinatal Quality Foundation (PQF)’s credentialing test, a new method of assessing provider competence with EFM to improve outcomes.

	Using accepted terminology and understanding basic physiologic data are both expected and potentially of critical value for obstetrical care providers using EFM, but such knowledge and language doesn’t necessarily result in an appropriate clinical response to specific FHR patterns in the dynamic setting of active labor. While there may be more than one correct way to manage a particular clinical scenario, incorrect responses can lead to catastrophic outcomes. Labor and Delivery is a leading risk area for medical-legal claims,

 and when negligence is alleged, the focus often is on management decisions, particularly with respect to interpretation of EFM.

	The Joint Commission’s 2004 Sentinel Event alert, while specifically addressing use of EFM (Table 1), advocated for developing clear guidelines for fetal monitoring and interpretation and educating nurses, residents, certified nurse midwives, and physicians in standardized terminology and communication about abnormal FHR tracings.

 Later, several hospitals and some insurance companies, acknowledging the importance of EFM and the frequency and economic risks of negligence claims from obstetrical patients, began to require that all physicians and nurses working on Labor and Delivery units demonstrate an understanding of EFM. Specifically, MCIC Vermont, Inc., a captive insurance company of 5 academic medical centers in the Northeast, required credentialing in EFM for anyone caring for laboring patients in one of their covered institutions.

	Pettker et al reported a steady and significant decline in their Adverse Outcome Index (AOI) and malpractice claims after implementing their safety bundle, which included EFM certification as one of the elements.

 Clark et al showed a roughly 50% reduction in malpractice claims over a 10-year period with their patient safety program with standardized EFM education as an integral component.

 Such an expectation has been gaining more clinical acceptance and has been used by some as a measure of quality in obstetrical care. The challenges, however, include accepting the concept as a reasonable requirement for obstetric caregivers, and having a meaningful tool to measure a nurse’s, physician’s, or midwife’s level of competence in order to establish credentialing.

	The first step in overcoming these challenges is a clear understanding and acceptance of the inherent limitations of the technology. One is the low positive predictive value resulting from the rarity of significant adverse neurologic outcomes.

 Another is the well-documented interobserver variation in EFM interpretation.

 A portion of variation relates to the definitions of FHR variability and the rate scale on FHR monitor tracings. Variability is defined by exact ranges separated by 1 bpm (minimal variability is defined as 1–5 bpm and moderate variability as 6–25 bpm) while the rate scale is plotted in 10-bpm intervals. It is reasonable to estimate differences of ±5 bpm, while smaller differences are problematic with visual interpretation.

	For example, identifying minimal versus moderate variability is essential for differentiating between a Category I and a Category II tracing, but at the margins of the ranges, one provider may legitimately find a 4-bpm variation while another sees a 6-bpm variation. Both of these interpretations fall well within the expected error of the 10-bpm scale.

	PQF has developed a high-quality, reliable and statistically valid credentialing test to assess the knowledge, understanding, and clinical judgment of nurses and physicians who use EFM.

 The assessment was not intended to be an educational product but one specific to credentialing.

	By enlisting a large number of recognized experts in EFM (both physicians and nurses) and developing statistically validated knowledge and judgment questions, the PQF has developed one examination for nurses and another for obstetric providers including physicians and midwives that are available and accessible online (at perinatalquality.org). Five areas of knowledge and judgment are assessed, with particular emphasis on risk and management of Category II FHR tracings. The examination can be taken on any computer with Internet access at the convenience of the examinee.

	Two types of questions are included on the test: traditional knowledge and a newer format that assesses judgment. The former tests basic knowledge of nomenclature and definitions regarding EFM, while the latter assesses judgment, using questions based on script concordance theory (SCT). This type of question design is well suited to EFM management because labor is a dynamic situation requiring appropriate responses to changing clinical findings and information including parity, cervical dilation, labor progress, and underlying maternal or fetal conditions in addition to the FHR tracing.

	Not surprising to those practicing obstetrics, often there is more than one appropriate clinical response with associated incorrect responses as well. The SCT questions take advantage of this clinical reality by asking the examinee to evaluate and re-evaluate management options in the setting of dynamic clinical events and changing FHR tracings.

	Script Concordance Theory is based on the premise that clinicians access networks of organized knowledge (“scripts”) to process information and progress toward solutions to clinical problems. These scripts are made up of links between illness, clinical features, and management options. The principle of this testing concept is that multiple judgments are made in the clinical reasoning process and that this pathway can be probed, compared with those of a group of experts, and measured. The SCT questions are not intended to directly measure specific knowledge or memory, but rather, to assess processing of clinical knowledge, contextual reasoning, and decision making in an evolving clinical situation. The questions are designed to simulate authentic conditions encountered during medical practice.

	Each SCT question has 5 potential answers organized on a Likert scale ranging from “highly likely” through “no effect” to “highly unlikely” that an initial clinical assessment or decision would be changed following the discovery of new clinical information since the last assessment. Importantly, there is never only 1 correct answer to an SCT question. While there might be a best answer, there are actually 2 and at times 3 acceptable responses with the others considered incorrect.

	The SCT format has a theoretic advantage over current EFM certifications because it aims to mirror the uncertainty typically encountered in actual clinical practice.

	The hope is that everyone who takes this test will pass it, but the reality is that some will not. Those who do not pass could perhaps benefit from educational efforts focused specifically on the areas in which they fell short. Medical staffs, nursing leadership, training programs, and specific providers could benefit from identifying areas of educational need and availing themselves of educational opportunities. The overall intent is to improve patient safety and obstetrical care.

	Effective use of the SCT format has been reported in general and gynecologic surgery to assess operative decision making.

 A brief study guide is available on the PQF website (

). The cost of the exam is $150 for an individual, with discounts available for institutions. The PQF certification is current for 3 years although institutions may require it more frequently. The cost of recertification is half that of the initial exam.

	Pettker and Grobman note that although currently there is little direct evidence linking credentialing to improved outcomes, it is an intuitively better approach than didactic teaching and clinical observation alone.

	Since inception the uptake of the exam has dramatically increased among individual and institutional subscribers. More than 1000 people have completed the exam including 525 physicians (50%), 434 nurses (42%), and 78 certified nurse midwives (8%). Currently 24 institutions and health systems are using the exam as part of their EFM competency efforts.

	Of particular note, in 2015 the American Board of Obstetrics and Gynecology (ABOG) began accepting passage of the PQF EFM credentialing examination as an option for meeting one of the annual Maintenance of Certification (MOC) Part IV requirements. The component of the MOC program titled “Improvement in Medical Practice” is focused on improving care within the triple aim framework of patient and population health, patient experience, and cost of care. Options for meeting this requirement have increased dramatically over the last year, including traditional individual case reviews, wide-ranging system and state quality improvement projects, as well as the PQF credentialing exam.

	EFM’s frequent use in everyday obstetrical care, its inherent limitations, and the variations in its interpretation make it necessary that those using the technology have a common understanding and competency. The PQF credentialing examination provides a readily accessible, state-of-the-art, validated testing approach to assess nursing and clinician abilities with the intent of improved maternal, fetal, and neonatal outcomes.

	1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: Final data for 2002. 

	2. Williams KP, Galerneau F. Intrapartum fetal heart rate patterns in the prediction of neonatal acidemia. 

	3. Parer JT, King T, Flanders S, Fox M, Kilpatrick SF. Fetal acidemia and electronic fetal heart patterns: Is there evidence of an association? 

	4. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. 

	5. Electronic fetal heart rate monitoring: research guidelines for interpretation. The National Institute of Child Health and Human Development Research and Planning Workshop. 

	6. American College of Obstetricians and Gynecologists. Practice bulletin no. 116: Management of intrapartum fetal heart rate tracings. 

	7. American College of Obstetricians and Gynecologists. Committee opinion no. 551: coping with the stress of medical professional liability litigation. 

	8. Preventing infant death and injury during delivery. 

	9. Berkowitz RL, D’Alton ME, Goldberg JD, et al. The case for an electronic fetal heart rate monitoring credentialing examination.

	10. Pettker CM, Thung SF, Lipkind HS, et al. A comprehensive obstetric patient safety program reduces liability claims and payments

	11. Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. 

	12. Grimes DA, Peipert JF. Electronic fetal monitoring as a public health screening program: the arithmetic of failure. 

	13. Blackwell SC, Grobman WA, Anoniewicz L, Hutchinson M, Bannerman CG. Interoberver and intraobserver reliability of the NICHD 3-tier fetal heart rate interpretation system

	14. Charlin B, Tardif J, Boshuizen HP. Scripts and medical knowledge: theory and applications for clinical reasoning instruction and research

	15. Charlin B, Roy L, Brailosvsky C, Goulet F, van der Vleuten C. The Script Concordance test: a tool to assess the reflective clinician. 

	16. Park AJ, Barber MD, Bent AE, Dooley YT, Cancz C, Sutkin G, Jelovsek JE,.Assessment of intraoperative judgment during gynecologic surgery using the Script Concordance test

	17. Pettker CM, Grobman WA. Obstetric safety and quality

	18. American Board of Obstetrics and Gynecology. 

https://www.abog.org/new/information.aspx?cat=Maintenance_of_Certification&id=1

Articles

The Perinatal Quality Foundation's exam tests clinician knowledge of fetal heart rate monitoring technology using simulation.

Marin O'Keefe, RN

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