Doug Brunk

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper.

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” offers “a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver. The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper.

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” offers “a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver. The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

A new guide produced by the California Academy of Family Physicians aims to bridge the gap between physicians and patients with limited English proficiency.

“Nationwide—but particularly in states like California, New York, Texas, Florida, Nevada, and Georgia—we are experiencing record increases in the number of limited English-speaking patients,” Alice Chen, M.D., medical director of the general medicine clinic at San Francisco General Hospital, told this newspaper.

The document, “Addressing Language Access in Your Practice: A Toolkit for Physicians and Their Staff Members,” offers “a whole range of options depending on the size of your clinic, the type of patient population you have, and your resources,” said Dr. Chen, who helped develop the guide.

The tool kit is organized into three steps meant to help physicians coordinate and implement a solution to potential language barriers in their practices.

▸ Step 1: Identify your limited-English-proficiency patient population.

▸ Step 2: Locate relevant resources in your area, and assess each for your type of practice.

▸ Step 3: Implement the right mix of services for your practice and patient population. The guide gives examples of ways to do this, as well as a case study illustrating the steps one primary care practice took to improve care of patients who speak limited English.

The tool kit also includes sample language-access policies and procedures, a sample job description for a bilingual staff interpreter, and a sample interpreter service waiver. The California Endowment provided financial support for the guide.

The tool kit can be downloaded free at www.familydocs.org/ALA_toolkit.pdf

SAN DIEGO — Health-related quality of life in adolescents and young adults with Kawasaki disease is excellent regardless of coronary sequelae, according to results from a large cross-sectional study of Japanese patients presented at an international Kawasaki disease symposium.

Hiromi Muta, M.D., and his associates mailed a Medical Outcome Study Short Form 36 to 624 Japanese patients aged at least 16 years who had received a diagnosis of Kawasaki disease between 1973 and 1998 and were evaluated by coronary angiography or two-dimensional echocardiography at one of the study sites.

Of the 624 forms sent, 246 were completed and returned, said Dr. Muta of Kurume (Japan) University. Respondents ranged in age from 16 to 34 years. The investigators divided respondents into three groups: those with normal coronary measurements on angiography or echocardiography, those who had had aneurysms, and those who had experienced episodes of ischemia.

The investigators observed no differences in health-related quality of life among patients in all Kawasaki disease groups compared with the normal Japanese population after adjusting for age and gender, Dr. Muta said at the symposium, sponsored by the American Heart Association.

However, 29% of Kawasaki disease patients reported cigarette smoking and 12% were overweight, with a body mass index of 25 kg/m

SAN DIEGO — Health-related quality of life in adolescents and young adults with Kawasaki disease is excellent regardless of coronary sequelae, according to results from a large cross-sectional study of Japanese patients presented at an international Kawasaki disease symposium.

Hiromi Muta, M.D., and his associates mailed a Medical Outcome Study Short Form 36 to 624 Japanese patients aged at least 16 years who had received a diagnosis of Kawasaki disease between 1973 and 1998 and were evaluated by coronary angiography or two-dimensional echocardiography at one of the study sites.

Of the 624 forms sent, 246 were completed and returned, said Dr. Muta of Kurume (Japan) University. Respondents ranged in age from 16 to 34 years. The investigators divided respondents into three groups: those with normal coronary measurements on angiography or echocardiography, those who had had aneurysms, and those who had experienced episodes of ischemia.

The investigators observed no differences in health-related quality of life among patients in all Kawasaki disease groups compared with the normal Japanese population after adjusting for age and gender, Dr. Muta said at the symposium, sponsored by the American Heart Association.

However, 29% of Kawasaki disease patients reported cigarette smoking and 12% were overweight, with a body mass index of 25 kg/m

SAN DIEGO — Health-related quality of life in adolescents and young adults with Kawasaki disease is excellent regardless of coronary sequelae, according to results from a large cross-sectional study of Japanese patients presented at an international Kawasaki disease symposium.

Hiromi Muta, M.D., and his associates mailed a Medical Outcome Study Short Form 36 to 624 Japanese patients aged at least 16 years who had received a diagnosis of Kawasaki disease between 1973 and 1998 and were evaluated by coronary angiography or two-dimensional echocardiography at one of the study sites.

Of the 624 forms sent, 246 were completed and returned, said Dr. Muta of Kurume (Japan) University. Respondents ranged in age from 16 to 34 years. The investigators divided respondents into three groups: those with normal coronary measurements on angiography or echocardiography, those who had had aneurysms, and those who had experienced episodes of ischemia.

The investigators observed no differences in health-related quality of life among patients in all Kawasaki disease groups compared with the normal Japanese population after adjusting for age and gender, Dr. Muta said at the symposium, sponsored by the American Heart Association.

However, 29% of Kawasaki disease patients reported cigarette smoking and 12% were overweight, with a body mass index of 25 kg/m

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of.

“We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, Dr. Mason said the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg four times a day and aspirin 100 mg/kg four times a day. Echocardiogram was normal.

The patient responded well to therapy, and the repeat echo was normal.

Dr. Mason noted that the rug in the rehab unit had been replaced 42 days before the onset of Kawasaki disease.

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of.

“We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, Dr. Mason said the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg four times a day and aspirin 100 mg/kg four times a day. Echocardiogram was normal.

The patient responded well to therapy, and the repeat echo was normal.

Dr. Mason noted that the rug in the rehab unit had been replaced 42 days before the onset of Kawasaki disease.

SAN DIEGO — An 11-month-old Asian American boy acquired Kawasaki disease during an extended hospital stay, Wilbert H. Mason, M.D., reported in a poster session at an international Kawasaki disease symposium.

In a later interview, he said this marks the first case of nosocomially acquired Kawasaki disease that he is aware of.

“We think of Kawasaki disease as being developed in the community due to in an infectious agent of some sort,” said Dr. Mason, professor of clinical pediatrics at the University of Southern California and head of the division of infectious diseases at Children's Hospital Los Angeles. “It's a lesson to us that there are a number of viral infections that can be nosocomially acquired, and you can add Kawasaki disease to the list of those.”

The boy arrived at Children's Hospital after being transferred from another hospital with increasing lethargy and weak cry. He was diagnosed with infant botulism and required ventilation for 5.5 months in the ICU.

The boy was transferred to a rehabilitation unit 181 days after hospital admission. On day 32 following the transfer, Dr. Mason said the boy developed high fever, rash, conjunctivitis, red lips and buccal mucosa, palmar erythema, and tachycardia with an extra heart sound. The patient appeared toxic. On day 4 of fever, he was diagnosed with Kawasaki disease and received intravenous gamma globulin 400 mg/kg four times a day and aspirin 100 mg/kg four times a day. Echocardiogram was normal.

The patient responded well to therapy, and the repeat echo was normal.

Dr. Mason noted that the rug in the rehab unit had been replaced 42 days before the onset of Kawasaki disease.

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

In obstetrics, “we're about 10 years behind in the health care field in our use of information technology,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Choosing a perinatal computer system can be a daunting task, because you have to assess the various systems, Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by a clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to,” she said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display big enough for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display screen size is adequate.”

▸ Simple drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to cut the risk of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said.

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative,” she said.

▸ Safeguard features against incomplete records. These provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome, such as a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group (www.pisug.org

Common Errors In Documentation

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document.

▸ Incomplete charting.

▸ Late entries.

▸ Poor grammar and/or spelling.

▸ Improper error correction.

▸ Lack of standardized abbreviations.

▸ Illegibility.

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

In obstetrics, “we're about 10 years behind in the health care field in our use of information technology,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Choosing a perinatal computer system can be a daunting task, because you have to assess the various systems, Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by a clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to,” she said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display big enough for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display screen size is adequate.”

▸ Simple drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to cut the risk of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said.

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative,” she said.

▸ Safeguard features against incomplete records. These provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome, such as a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group (www.pisug.org

Common Errors In Documentation

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document.

▸ Incomplete charting.

▸ Late entries.

▸ Poor grammar and/or spelling.

▸ Improper error correction.

▸ Lack of standardized abbreviations.

▸ Illegibility.

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

In obstetrics, “we're about 10 years behind in the health care field in our use of information technology,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Choosing a perinatal computer system can be a daunting task, because you have to assess the various systems, Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by a clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to,” she said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display big enough for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display screen size is adequate.”

▸ Simple drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to cut the risk of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said.

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative,” she said.

▸ Safeguard features against incomplete records. These provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome, such as a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group (www.pisug.org

Common Errors In Documentation

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document.

▸ Incomplete charting.

▸ Late entries.

▸ Poor grammar and/or spelling.

▸ Improper error correction.

▸ Lack of standardized abbreviations.

▸ Illegibility.

Source: Lisa A. Miller

LOS ANGELES — The California Academy of Family Physicians has launched a widespread initiative designed to help its members optimize the care of patients with diabetes.

Called “New Directions in Diabetes Care,” the 4-year program “will be bringing together lots of advances that have been learned in the field of disease management, such as registries, tracking chronic disease patients, [and] identifying [patient] populations,” Bo Greaves, M.D., said at the academy's annual meeting.

“The Institute for Healthcare Improvement has been working for several years on a breakthrough collaborative to analyze what the systems of care are in mom-and-pop family practice and other physician offices, and how can we make some quantum leap improvements in those systems of care,” added Dr. Greaves, a Rohnert Park, Calif.-based family physician who is the CAFP's president-elect.

“There's a lot of material out there and yet a lot of it has not yet been implemented. We hope this initiative will be a big step for our academy to help fuse that,” Dr. Greaves said.

The project's goal “is directed at inducing organizational changes in physicians' offices to better accommodate care management systems and streamline patient care to lead to improved efficiency and greater provider and patient satisfaction,” according to a fact sheet.

The CAFP is currently recruiting 15–20 practices from across the state to take part.

Starting this fall, physicians in the practices will participate in a series of online learning sessions, implement changes based on what they learn, and then report back to the other members of the collaborative.

Listservs and other online forums will enable physicians to share information and experiences.

“By 4 years [from now] we hope that we have spread a new approach to diabetes care based on population management, access, and high quality care, not just at a visit, but throughout the relationship with the patient,” Dr. Greaves said.

Partners in the project include the department of family and community medicine at the University of California, San Francisco, and Lumetra, the Medicare Quality Improvement Organization for California.

LOS ANGELES — The California Academy of Family Physicians has launched a widespread initiative designed to help its members optimize the care of patients with diabetes.

Called “New Directions in Diabetes Care,” the 4-year program “will be bringing together lots of advances that have been learned in the field of disease management, such as registries, tracking chronic disease patients, [and] identifying [patient] populations,” Bo Greaves, M.D., said at the academy's annual meeting.

“The Institute for Healthcare Improvement has been working for several years on a breakthrough collaborative to analyze what the systems of care are in mom-and-pop family practice and other physician offices, and how can we make some quantum leap improvements in those systems of care,” added Dr. Greaves, a Rohnert Park, Calif.-based family physician who is the CAFP's president-elect.

“There's a lot of material out there and yet a lot of it has not yet been implemented. We hope this initiative will be a big step for our academy to help fuse that,” Dr. Greaves said.

The project's goal “is directed at inducing organizational changes in physicians' offices to better accommodate care management systems and streamline patient care to lead to improved efficiency and greater provider and patient satisfaction,” according to a fact sheet.

The CAFP is currently recruiting 15–20 practices from across the state to take part.

Starting this fall, physicians in the practices will participate in a series of online learning sessions, implement changes based on what they learn, and then report back to the other members of the collaborative.

Listservs and other online forums will enable physicians to share information and experiences.

“By 4 years [from now] we hope that we have spread a new approach to diabetes care based on population management, access, and high quality care, not just at a visit, but throughout the relationship with the patient,” Dr. Greaves said.

Partners in the project include the department of family and community medicine at the University of California, San Francisco, and Lumetra, the Medicare Quality Improvement Organization for California.

LOS ANGELES — The California Academy of Family Physicians has launched a widespread initiative designed to help its members optimize the care of patients with diabetes.

Called “New Directions in Diabetes Care,” the 4-year program “will be bringing together lots of advances that have been learned in the field of disease management, such as registries, tracking chronic disease patients, [and] identifying [patient] populations,” Bo Greaves, M.D., said at the academy's annual meeting.

“The Institute for Healthcare Improvement has been working for several years on a breakthrough collaborative to analyze what the systems of care are in mom-and-pop family practice and other physician offices, and how can we make some quantum leap improvements in those systems of care,” added Dr. Greaves, a Rohnert Park, Calif.-based family physician who is the CAFP's president-elect.

“There's a lot of material out there and yet a lot of it has not yet been implemented. We hope this initiative will be a big step for our academy to help fuse that,” Dr. Greaves said.

The project's goal “is directed at inducing organizational changes in physicians' offices to better accommodate care management systems and streamline patient care to lead to improved efficiency and greater provider and patient satisfaction,” according to a fact sheet.

The CAFP is currently recruiting 15–20 practices from across the state to take part.

Starting this fall, physicians in the practices will participate in a series of online learning sessions, implement changes based on what they learn, and then report back to the other members of the collaborative.

Listservs and other online forums will enable physicians to share information and experiences.

“By 4 years [from now] we hope that we have spread a new approach to diabetes care based on population management, access, and high quality care, not just at a visit, but throughout the relationship with the patient,” Dr. Greaves said.

Partners in the project include the department of family and community medicine at the University of California, San Francisco, and Lumetra, the Medicare Quality Improvement Organization for California.

The rate of active progressive HIV encephalopathy in children with HIV infection receiving highly active antiretroviral therapy was less than 2% and the cumulative prevalence of arrested disease was 10%, results from a prospective study demonstrated.

“In the era of HAART, HIV has been transformed from an invariably fatal disease to a chronic disease in which survival is expected,” Claudia Chiriboga, M.D., of the division of pediatric neurology at Columbia University Medical Center, New York, and her associates said. “PHE in the post-HAART era is thus an infrequent and reversible complication of HIV infection that responds to effective antiretroviral control and that may relapse if viral control is lost.”

Few studies have sought to determine the incidence of progressive HIV encephalopathy (PHE) since HAART was introduced in the late 1990s. Dr. Chiriboga and her associates prospectively evaluated 126 children with HIV who have been assessed yearly by a neurologist at Harlem Hospital Center since 1988 (J. Pediatr. 2005;146:402–7).

The children received baseline evaluations from a pediatrician and neurologist in 2000. The investigators reviewed medical records for HIV disease manifestations, antiretroviral treatment, and immunologic and virologic measures. They also assessed the children for PHE, developmental delay, and attention-deficit hyperactivity disorder.

All children had been perinatally infected with HIV. Half were male, and only 11 were older than 3 years. Their mean age at baseline evaluation was 23 months, and they were followed for an average of 82 months.

The investigators observed that in 2000, the rate of active PHE was 1.6% (2 children), and the prevalence of arrested PHE was 10% (13 children). They also found that the majority of survivors experienced residual motor and cognitive sequelae and needed special education.

Other observations were that PHE relapse occurred in three children with previously arrested PHE, viral load was the only significant risk factor associated with PHE, and neither HIV nor PHE was associated with the development of ADHD.

The findings suggest that, “as refers to PHE progression, viral load should be monitored [as well as CD4 count] in order to achieve a more comprehensive appraisal of progression of HIV disease,” the investigators said.

The rate of active progressive HIV encephalopathy in children with HIV infection receiving highly active antiretroviral therapy was less than 2% and the cumulative prevalence of arrested disease was 10%, results from a prospective study demonstrated.

“In the era of HAART, HIV has been transformed from an invariably fatal disease to a chronic disease in which survival is expected,” Claudia Chiriboga, M.D., of the division of pediatric neurology at Columbia University Medical Center, New York, and her associates said. “PHE in the post-HAART era is thus an infrequent and reversible complication of HIV infection that responds to effective antiretroviral control and that may relapse if viral control is lost.”

Few studies have sought to determine the incidence of progressive HIV encephalopathy (PHE) since HAART was introduced in the late 1990s. Dr. Chiriboga and her associates prospectively evaluated 126 children with HIV who have been assessed yearly by a neurologist at Harlem Hospital Center since 1988 (J. Pediatr. 2005;146:402–7).

The children received baseline evaluations from a pediatrician and neurologist in 2000. The investigators reviewed medical records for HIV disease manifestations, antiretroviral treatment, and immunologic and virologic measures. They also assessed the children for PHE, developmental delay, and attention-deficit hyperactivity disorder.

All children had been perinatally infected with HIV. Half were male, and only 11 were older than 3 years. Their mean age at baseline evaluation was 23 months, and they were followed for an average of 82 months.

The investigators observed that in 2000, the rate of active PHE was 1.6% (2 children), and the prevalence of arrested PHE was 10% (13 children). They also found that the majority of survivors experienced residual motor and cognitive sequelae and needed special education.

Other observations were that PHE relapse occurred in three children with previously arrested PHE, viral load was the only significant risk factor associated with PHE, and neither HIV nor PHE was associated with the development of ADHD.

The findings suggest that, “as refers to PHE progression, viral load should be monitored [as well as CD4 count] in order to achieve a more comprehensive appraisal of progression of HIV disease,” the investigators said.

The rate of active progressive HIV encephalopathy in children with HIV infection receiving highly active antiretroviral therapy was less than 2% and the cumulative prevalence of arrested disease was 10%, results from a prospective study demonstrated.

“In the era of HAART, HIV has been transformed from an invariably fatal disease to a chronic disease in which survival is expected,” Claudia Chiriboga, M.D., of the division of pediatric neurology at Columbia University Medical Center, New York, and her associates said. “PHE in the post-HAART era is thus an infrequent and reversible complication of HIV infection that responds to effective antiretroviral control and that may relapse if viral control is lost.”

Few studies have sought to determine the incidence of progressive HIV encephalopathy (PHE) since HAART was introduced in the late 1990s. Dr. Chiriboga and her associates prospectively evaluated 126 children with HIV who have been assessed yearly by a neurologist at Harlem Hospital Center since 1988 (J. Pediatr. 2005;146:402–7).

The children received baseline evaluations from a pediatrician and neurologist in 2000. The investigators reviewed medical records for HIV disease manifestations, antiretroviral treatment, and immunologic and virologic measures. They also assessed the children for PHE, developmental delay, and attention-deficit hyperactivity disorder.

All children had been perinatally infected with HIV. Half were male, and only 11 were older than 3 years. Their mean age at baseline evaluation was 23 months, and they were followed for an average of 82 months.

The investigators observed that in 2000, the rate of active PHE was 1.6% (2 children), and the prevalence of arrested PHE was 10% (13 children). They also found that the majority of survivors experienced residual motor and cognitive sequelae and needed special education.

Other observations were that PHE relapse occurred in three children with previously arrested PHE, viral load was the only significant risk factor associated with PHE, and neither HIV nor PHE was associated with the development of ADHD.

The findings suggest that, “as refers to PHE progression, viral load should be monitored [as well as CD4 count] in order to achieve a more comprehensive appraisal of progression of HIV disease,” the investigators said.

SAN DIEGO — African American children with Kawasaki disease are more likely to have higher documented fevers in the hospital, higher erythrocyte sedimentation rates, and higher C-reactive protein levels than their white counterparts, Ian C. Balfour, M.D., reported in a poster session at an international Kawasaki disease symposium.

Although the disparity may be related to genetic differences between African Americans and whites, Dr. Balfour noted that more research is needed to further understand the association.

“At this time, I can't say there is a take-home message,” Dr. Balfour, a pediatric cardiologist with St. Louis University, told FAMILY PRACTICE NEWS in an interview. “I think we need further study to determine why certain patients have higher erythrocyte sedimentation rates and higher levels of C-reactive protein.”

For the study, which he called the first of its kind, Dr. Balfour and his associates reviewed the records of 124 children admitted to Cardinal Glennon Children's Hospital in St. Louis between Jan. 1, 1995, and Dec. 31, 2002, with a diagnosis of Kawasaki disease.

The investigators used analysis of variance and chi-squared testing to analyze multiple clinical parameters in relation to ethnic origin.

Of the 124 children, 76 (61%) were white, 38 (31%) were African American, 7 (6%) were Asian, and 3 (2%) were from other ethnic groups. Age at presentation ranged from 2 to 11 years.

Because the number of Asian patients and those from other ethnicities was so small, Dr. Balfour only discussed clinical differences between African American and white children.

A greater number of African American patients presented with Kawasaki disease before age 6 years, compared with white patients (97.4% vs. 76.3%), but the difference was not statistically significant.

African American children had significantly higher mean fever upon hospital admission, compared with white children (102.2° F vs. 101.3° F).

The African American children also had significantly higher mean erythrocyte sedimentation rates (72.9 mm/hr vs. 55.9 mm/hr).

C-reactive protein levels also differed significantly between the two groups. African American children had mean C-reactive protein levels of 22.3 mg/L vs. 6.9 mg/L among their white counterparts.

Dr. Balfour noted that coronary artery involvement was similar between the two groups.

The symposium was sponsored by the American Heart Association.

SAN DIEGO — African American children with Kawasaki disease are more likely to have higher documented fevers in the hospital, higher erythrocyte sedimentation rates, and higher C-reactive protein levels than their white counterparts, Ian C. Balfour, M.D., reported in a poster session at an international Kawasaki disease symposium.

Although the disparity may be related to genetic differences between African Americans and whites, Dr. Balfour noted that more research is needed to further understand the association.

“At this time, I can't say there is a take-home message,” Dr. Balfour, a pediatric cardiologist with St. Louis University, told FAMILY PRACTICE NEWS in an interview. “I think we need further study to determine why certain patients have higher erythrocyte sedimentation rates and higher levels of C-reactive protein.”

For the study, which he called the first of its kind, Dr. Balfour and his associates reviewed the records of 124 children admitted to Cardinal Glennon Children's Hospital in St. Louis between Jan. 1, 1995, and Dec. 31, 2002, with a diagnosis of Kawasaki disease.

The investigators used analysis of variance and chi-squared testing to analyze multiple clinical parameters in relation to ethnic origin.

Of the 124 children, 76 (61%) were white, 38 (31%) were African American, 7 (6%) were Asian, and 3 (2%) were from other ethnic groups. Age at presentation ranged from 2 to 11 years.

Because the number of Asian patients and those from other ethnicities was so small, Dr. Balfour only discussed clinical differences between African American and white children.

A greater number of African American patients presented with Kawasaki disease before age 6 years, compared with white patients (97.4% vs. 76.3%), but the difference was not statistically significant.

African American children had significantly higher mean fever upon hospital admission, compared with white children (102.2° F vs. 101.3° F).

The African American children also had significantly higher mean erythrocyte sedimentation rates (72.9 mm/hr vs. 55.9 mm/hr).

C-reactive protein levels also differed significantly between the two groups. African American children had mean C-reactive protein levels of 22.3 mg/L vs. 6.9 mg/L among their white counterparts.

Dr. Balfour noted that coronary artery involvement was similar between the two groups.

The symposium was sponsored by the American Heart Association.

SAN DIEGO — African American children with Kawasaki disease are more likely to have higher documented fevers in the hospital, higher erythrocyte sedimentation rates, and higher C-reactive protein levels than their white counterparts, Ian C. Balfour, M.D., reported in a poster session at an international Kawasaki disease symposium.

Although the disparity may be related to genetic differences between African Americans and whites, Dr. Balfour noted that more research is needed to further understand the association.

“At this time, I can't say there is a take-home message,” Dr. Balfour, a pediatric cardiologist with St. Louis University, told FAMILY PRACTICE NEWS in an interview. “I think we need further study to determine why certain patients have higher erythrocyte sedimentation rates and higher levels of C-reactive protein.”

For the study, which he called the first of its kind, Dr. Balfour and his associates reviewed the records of 124 children admitted to Cardinal Glennon Children's Hospital in St. Louis between Jan. 1, 1995, and Dec. 31, 2002, with a diagnosis of Kawasaki disease.

The investigators used analysis of variance and chi-squared testing to analyze multiple clinical parameters in relation to ethnic origin.

Of the 124 children, 76 (61%) were white, 38 (31%) were African American, 7 (6%) were Asian, and 3 (2%) were from other ethnic groups. Age at presentation ranged from 2 to 11 years.

Because the number of Asian patients and those from other ethnicities was so small, Dr. Balfour only discussed clinical differences between African American and white children.

A greater number of African American patients presented with Kawasaki disease before age 6 years, compared with white patients (97.4% vs. 76.3%), but the difference was not statistically significant.

African American children had significantly higher mean fever upon hospital admission, compared with white children (102.2° F vs. 101.3° F).

The African American children also had significantly higher mean erythrocyte sedimentation rates (72.9 mm/hr vs. 55.9 mm/hr).

C-reactive protein levels also differed significantly between the two groups. African American children had mean C-reactive protein levels of 22.3 mg/L vs. 6.9 mg/L among their white counterparts.

Dr. Balfour noted that coronary artery involvement was similar between the two groups.

The symposium was sponsored by the American Heart Association.