Credentialing in EFM
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.1 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.2,3 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.4,5 The American College of Obstetricians and Gynecologists (ACOG) followed in 2010 with guidelines for interpretation and management.6 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.
Why standard terminology?
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,7 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.8 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.9
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.10,11 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.11 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.12 Another is the well-documented interobserver variation in EFM interpretation.13 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.