Implementation of Multidisciplinary Cesarean Practice Guidelines to Reduce Decision-to-Incision Time

Issues Addressed/Background: Urgent and emergent cesarean deliveries remain an important intervention to reduce maternal and neonatal morbidity. Recent studies suggest that initiatives to reduce the decision-to-incision time (DTI) can improve neonatal outcomes without compromising maternal outcomes. Presently at UCSD, documentation of the DTI is inconsistent, which limits our ability to track and evaluate this metric. A preliminary analysis of cesarean deliveries between August-October 2022 showed that only 185 out of 380 (49%) of non-scheduled cesareans were appropriately documented in the medical record.  Therefore, we aim to develop and implement a DTI protocol to streamline communication, team-based roles, and improve documentation for cesarean deliveries at UCSD. Description of Project: Multidisciplinary Cesarean Practice Guidelines were developed to define categories for cesarean deliveries: 1) Emergency, 2) Urgent, 3) Non-emergent/indicated, and 4) Scheduled cases. Goal DTI timeframes and communication steps are specified for each category, including documentation of the DTI and reasons for any case delay. A web-paging team was created to promptly alert all team members (obstetric, anesthesia, surgical technicians, primary and charge nurses) of an urgent cesarean delivery. The protocol includes a preoperative huddle to confirm surgical timing and other clinical considerations. For emergency cases, the current “Code Pink” system was enhanced with additional role assignments for nursing, physician, and technician team members. Operating room posters specific to Hillcrest and Jacobs Medical Centers were created to outline roles and responsibilities in emergency cesarean deliveries. Hands-on simulations for emergency deliveries were conducted prior to implementation. Lessons Learned/Expected Outcomes: The protocol was fully implemented on March 13, 2023. Pre- and post-implementation variables to be assessed include: DTI, proportion of non-scheduled cesarean deliveries with DTI appropriately documented, number of cases with delays charted, and reasons for delay. We also plan to analyze the proportion of cesareans in each category that achieve designated time targets, i.e. urgent cases < 60min, emergency cases < 10min. We anticipate that improved communication and role clarification outlined in the protocol will improve our ability to expedite non-scheduled cesarean deliveries and conduct processes improvement for the unit.  Recommendations/Next Steps: Data will be collected and analyzed for the above variables for the 4-month period before and after protocol implementation. Labor & Delivery leadership will review the analysis to identify ongoing areas for improvement. Future analysis could explore the impact of the protocol on clinical outcomes such as NICU admission, APGAR scores, umbilical cord gasses or maternal morbidity. In addition, measures of team communication and efficiency metrics  (i.e. reasons for case delay) can provide valuable data for systems improvement

Sieć Pediatrycznych Specjalistycznych Poradni Medycyny Środowiskowej (PEHSU): wypełnienie istotnej luki w systemie opieki zdrowotnej

A network of pediatric environmental health specialty units (PEHSUs) in the United States was formed in 1998 out of a recognized need for clinical expertise in children’s environmental health. Documented trends in a rise of pediatric diseases caused or exacerbated by environmental conditions, coupled with the failure of medical schools and residency programs to cover these issues in a significant way, leaves health care providers, parents, communities, and governments at a loss for this specialized knowledge. The PEHSUs fill this gap by providing: 1) medical education, 2) general outreach and communications, and 3) consultative services to communities and health care professionals. This paper presents examples of key situations where PEHSU involvement was instrumental in improved patient outcomes or advancing clinical expertise in children’s environmental health. Challenges and opportunities for future directions for the program are also discussed.Sieć Pediatrycznych Specjalistycznych Poradni Medycyny Środowiskowej (PEHSU) w Stanach Zjednoczonych została utworzona w 1998 roku w wyniku uznania konieczności przeprowadzania ekspertyz w zakresie zdrowia środowiskowego dzieci. Udokumentowane trendy wzrostu chorób dzieci wywołanych lub zaostrzonych przez czynniki środowiskowe i nakładający się równocześnie niedostatek programów nauczania z tego zakresu w szkołach medycznych lub w czasie rezydentury spowodowały brak tej specjalistycznej wiedzy wśród pracowników opieki zdrowotnej, rodziców, społeczności i władz. PEHSU wypełniają ten brak wykonując: 1) edukację medyczną, 2) promocję zdrowia środowiskowego 3) porady konsultacyjne dla społeczności i dla pracowników ochrony zdrowia. W niniejszej pracy przedstawiono najważniejsze przykłady, kiedy udział PEHSU był instrumentem dla polepszenia stanu zdrowia albo postępu ekspertyzy klinicznej w zakresie zdrowia środowiskowego

The impact of intimate partner violence on PrEP adherence among U.S. Cisgender women at risk for HIV

BackgroundCisgender women account for 1 in 5 new HIV infections in the United States, yet remain under-engaged in HIV prevention. Women experiencing violence face risk for HIV due to biological and behavioral mechanisms, and barriers to prevention, such as challenges to Pre-Exposure Prophylaxis for HIV Prevention (PrEP) adherence. In this analysis, we aim to characterize intimate partner violence (IPV) among cisgender heterosexual women enrolled in a PrEP demonstration project and assess the associations with PrEP adherence.MethodsAdherence Enhancement Guided by Individualized Texting and Drug Levels (AEGiS) was a 48-week single-arm open-label study of PrEP adherence in HIV-negative cisgender women in Southern California (N = 130) offered daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). From 6/2016 to 10/2018, women completed a survey reporting HIV risk behavior and experiences of any IPV (past 90-days) and IPV sub-types (past-year, lifetime) and biological testing for HIV/STIs at baseline, and concentrations of tenofovir-diphosphate (TFV-DP) in dried blood spots at weeks 4, 12, 24, 36, and 48. Outcomes were TFV-DP concentrations consistent with ≥ 4 or ≥ 6 doses/week at one or multiple visits. Multivariable logistic regression models were conducted to examine associations.ResultsPast-90-day IPV was reported by 34.4% of participants, and past-year and lifetime subtypes reported by 11.5-41.5%, and 21.5-52.3%, respectively. Women who engaged in sex work and Black women were significantly more likely to report IPV than others. Lifetime physical IPV was negatively associated with adherence at ≥ 4 doses/week at ≥ 3 of 5 visits, while other relationships with any IPV and IPV sub-types were variable.ConclusionIPV is an indication for PrEP and important indicator of HIV risk; our findings suggest that physical IPV may also negatively impact long-term PrEP adherence.Clinical trials registrationNCT02584140 (ClinicalTrials.gov), registered 15/10/2015

The Intersection of HIV, Social Vulnerability, and Reproductive Health: Analysis of Women Living with HIV in Rio de Janeiro, Brazil from 1996 to 2016.

Comprehensive care for sexual and reproductive health (SRH) and social needs for women living with HIV remains limited globally. We aimed to assess trends in baseline sociodemographic, clinical, sexual, and reproductive characteristics among a cohort of HIV-infected women in Rio de Janeiro from 1996 to 2016. Participants were stratified into four time periods based on year of enrollment; we compared cross-sectional data from each period. Of 1361 participants (median age 36), most were black or mixed race (60.1%), unemployed (52.1%), and without secondary education (54%). Adolescent pregnancy was common (51.5%), and 18.3% reported sexual debut at < 15 years old. Nearly half (45.2%) had < 5 lifetime sexual partners, yet prior syphilis and oncogenic human papillomavirus prevalence were 10.9% and 43.1%, respectively. Lifetime prevalence of induced abortion was 30.3%, and 16% used no contraceptive method. Future research should explore interactions between social vulnerability, HIV, and poor SRH outcomes and healthcare models to alleviate these disparities

Reproductive health syndemics impact retention in care among women living with HIV in Rio de Janeiro, Brazil.

Syndemic psychosocial and reproductive factors affecting women's retention in HIV care remain understudied. We analyzed correlates of non-retention in a cohort of women with HIV in Brazil from 2000‒2015. Participants self-reported exposure to physical/sexual violence, illicit drug use, adolescent pregnancy, or induced abortion. Lifetime history of these psychosocial stressors were used to create a syndemic score based on the presence or absence of these conditions. All dichotomous variables were summed (range 0 to 4), with greater scores indicating more syndemic factors experienced. Logistic regression models identified predictors of non-retention, defined as < 2 HIV viral load or CD4 results within the first year of enrollment. Of 915 women, non-retention was observed for 18%. Prevalence of syndemic factors was adolescent pregnancy (53.2%), physical/sexual violence (38.3%), induced abortion (27.3%), and illicit drug use (17.2%); 41.2% experienced ≥ 2 syndemic conditions. Syndemic scores of 2 and 3 were associated with non-retention, as well as low education, years with HIV and seroprevalent syphilis. Psychosocial and reproductive syndemics can limit women's retention in HIV care. Syphilis infection predicted non-retention and could be explored as a syndemic factor in future studies