Maternal mortality is an ongoing crisis in the U.S. According to the most recent data available from 2022, the national maternal mortality rate is 22.3 deaths per 100,000 live births. Sadly, stories of pregnant or recently pregnant people whose maternal health conditions get misdiagnosed or overlooked, leading to severe morbidity or even death, are all too common.

THE PROBLEM

In combination with rights to reproductive care changing, this creates more obstacles for bedside clinicians and can limit treatment and actions by the care team. This adds to the challenges faced in addressing this crisis.

"Specifically at St. Luke's, we had experienced two obstetrics and gynecology adverse events in a short timeframe and knew it was time we sought to address the root causes," said Claire Beck, manager, transition to practice, at St. Luke's Health System. "We identified an education program that was appropriate for the full care team that included providers and nurses.

"We also were very involved in our statewide Association of Women's Health, Obstetric and Neonatal Nurses chapter and identified a perinatal safety initiative that AWHONN and Relias co-sponsored at the time in 2016 called 'Mothers and Babies First,'" she continued. "This initiative proposed an educational solution of simulation-based team training."

While monitoring key clinical outcome metrics, St. Luke's would see improvement in its perinatal outcomes. It was particularly focused on obstetric hemorrhage and improving safety in this area. This is what led the organization to Relias OB, with whom it remains a client today.

"Relias OB aligned closely with our perinatal safety initiatives, focused on continuous improvement to ensure our clinical teams are aligned on evidenced-based practice," Beck explained. "We sought to reduce variations in care, drive higher reliability, mitigate risk and improve outcomes for both mothers and babies. We liked the fact the education solution was assessment-based and provided personalized learning – meeting each clinician where they were."

PROPOSAL

Relias OB provides data-driven digital learning technology that can be personalized to each learner. A key differentiator that drew St. Luke's to Relias education was the prioritization of critical thinking skills – not just analyzing whether a clinician can activate their newly acquired skills, but how they can apply this knowledge and critical thinking in rapidly changing care settings.

"We wanted to ensure our training was both educating clinical team members while simultaneously measuring their judgment skills, something that is extremely important in maternal care," Beck noted. "However, high-quality learning is not a 'one and done' occurrence. We have to constantly evaluate how we are meeting our team's needs, and Relias' detailed reporting was the solution to help us do just that.

"With Relias' offering, we can use the assessments not only as tests, but as tools to improve care quality," she added. "With this, we could identify patterns and trends that can help advance our newest and our most experienced nurses with supplementary training."

MEETING THE CHALLENGE

The Relias OB systems are integrated within St. Luke's Perinatal Transition to Practice (TTP) Program. To prevent the stress new nurses feel and instill confidence in their abilities, staff provide them with several months of onboarding and a full year of practice before even assigning a personalized learning course.

New nurses are onboarded using the Perinatal Orientation and Education Program and the Intro to Fetal Monitoring Course (provided on the Relias platform) from AWHONN. To apply the knowledge from this curriculum, staff attend application workshops that use different modalities to promote group learning and teamwork.

"These include structured skill practice sessions, tabletop simulations, escape rooms, unfolding case studies and immersive simulations," Beck said. "In the clinical setting, staff use Elsevier Clinical Skills, which serve to guide their practice as policy and procedures. For practice areas where cesarean births are performed outside of the main OR, the 'Periop 101: A Core Curriculum' cesarean section curriculum is used to prepare our nurses for the circulating role.

"The AWHONN Intermediate and Advanced Fetal Monitoring Courses are then completed at the one-year and three-year mark of employment, respectively," she continued. "We use Relias OB's multilayered learning technology for our ongoing education and assessment process across various maternal health disorders and complications."

The data from the personalized learning courses is used to customize the objectives for the immersive simulations that are conducted in each practice area. The nurses complete the personalized learning courses for hypertensive disorders of pregnancy, obstetric and postpartum hemorrhage, fetal monitoring, and shoulder dystocia.

"Relias OB works by evaluating each clinician's knowledge and judgment, then personalizing training modules based on individual skill sets," Beck explained. "These modules include interactive simulations and real-world scenarios, replicating situations nurses may come across in the field.

"The system continuously analyzes data for ongoing improvement by benchmarking each nurse's performance against their peers, our internal health system and even individuals in other health systems," she continued. "The trainings are data-driven and provide St. Luke's with detailed insights to track and measure our team's progress and improvements."

Just within St. Luke's antepartum, labor & delivery, and postpartum departments, more than 500 nurses have completed education in hypertensive disorders and postpartum hemorrhage. Additionally, more than 200 of its antepartum and labor & delivery nurses have completed fetal monitoring training using Relias OB.

"We have been using these courses in our OB training efforts for more than five years now and have seen great overall improvement," Beck reported. "These digital learning courses allow us to access gaps and areas where concepts need to be reinforced at the individual and site levels."

RESULTS

After completing the fetal monitoring program, St. Luke's seven medical centers achieved improvement over a two-year initiative, with three achieving notably high improvement rates of 39%, 22% and 20% across all nursing staff.

"Over four years since implementation, our nurses achieved an 18% improvement in assessment for hemorrhage," Beck said. "For hypertensive disorders, our nurses achieved 16% improvement. And lastly, a 15% improvement in overall assessment of fetal monitoring was achieved through Relias OB.

"Our educators use the data from the personalized learning courses to remediate staff who scored below the 50th percentile," she continued. "Staff are assigned the related Clinical Pearls and/or associated courses to prepare for retaking the personalized learning course."

Educators also complete one-on-one and group sessions to review areas or concepts with staff. Staff can also attend the regularly scheduled application workshops at any time to review concepts and skills. To promote continual learning and stay current in practice, staff also are encouraged to complete the Clinical Pearls or associated courses outside of the assessment period.

Many nurses use the available continuing nursing education credits for their certification maintenance.

ADVICE FOR OTHERS

"For other organizations looking to introduce similar data-driven training systems, first ensure there is a strong governance structure or steering committee to guide the use of technology and the data that will be reported," Beck advised. "Leadership and educators should create a structured plan to incorporate this technology into ongoing education plans. Involve stakeholders early in this process, defining roles, responsibilities and an accountability plan.

"When data is collected through these learning systems, I recommend universal transparency," she continued. "Leaders should be open with staff on how learning scores will be used, emphasizing these are not to determine whether a clinician has passed or failed a particular skill or area of learning, but rather to inform continual improvement efforts."

Organization leaders should socialize how and what data will be used in these efforts, providing statistics refreshers, especially around percentiles, for learners and educators, Beck added.

"Review this data with each clinician, highlighting opportunities for improvement in a positive and supportive way to prevent the perception that this data will be used in a punitive manner," she said.

"Simply state the facts, discuss any barriers that exist and focus on the next steps for improvement," she concluded. "Lastly, emphasize success and improvement. Promote clinical growth by celebrating wins, whether big or small, individual or group."

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