Sherry Boschert

SAN FRANCISCO – Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four. “Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

The physicians rated the impact of EHR on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO – Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four. “Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

The physicians rated the impact of EHR on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO – Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system and timed their activities, she said in a poster presentation at the triennial congress of the International Medical Informatics Association.

They studied 20 physicians before EHR implementation, 16 of those after adoption of the system, and 4 newly recruited physicians after EHR implementation, for a total of 20 physicians before and after the system change. The urban and suburban outpatient clinics included neighborhood health centers, hospital-based practices, and community practices.

Talking to or examining a patient (direct patient care) took about 14 minutes in the pre-EHR era of paper-based records and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care, which involved reading, writing, or other tasks in support of direct patient care, took 9 minutes before EHR and 10 minutes after EHR. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences with the EHR system on a five-point scale (with five being the best), physicians rated its impact on quality, access, and communication a four. “Physicians recognized the quality improvement achieved by electronic health records,” Ms. Pizziferri said.

The physicians rated the impact of EHR on workload at 3 and overall satisfaction at 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes patient clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

E-mail surveys of the physicians suggested that the time they spent on documentation outside of clinic hours increased from 9 to 10 minutes per established patient after EHR. Future research should study the impact of EHR on nonclinic time, she said.

SAN FRANCISCO – Talking to elderly patients with chronic pain about the differences between addiction, dependence, and tolerance of drugs may help them overcome some fears about using opioids, Kathryn Healey Keller, Pharm.D., said at a joint conference of the American Society on Aging and the National Council on the Aging.

Treatment with opioids is becoming more acceptable for persistent noncancer pain, despite the common fear of addiction, especially among older patients, said Dr. Keller of the University of California, San Francisco, and a medical liaison for Purdue Pharma LP, a pharmaceutical company that specializes in pain medications.

She recommended explaining to patients that physical dependence is inevitable with continuous exposure to opioids because of the characteristics of these drugs, but this is not the same as addiction and “it's not a moral, personal issue,” she said.

Give examples of other drugs that cause dependence with chronic use, such as prednisone or clonidine, she suggested.

Tell patients that dependence means they will have a rebound or withdrawal reaction if they stop taking any of these drugs, and alert them to the potential consequences if they stop opioid use suddenly.

Tolerance to a drug means that patients need more of the drug to maintain the same level of response. Coffee is a good example–people need to drink more of it over time to maintain the same caffeine buzz. Tolerance to opioids is slow to develop when treating stable disease, Dr. Keller noted.

Addiction is a neurobiologic disease involving a genetic predisposition and environmental factors that promote addiction. She said that patients who fear they're becoming addicted to opioids can consider “the four Cs” that help define addiction: Compulsive use, lack of Control, Craving for the drug, and Continued use despite harm to oneself or others.

Properly managed patients on opioids rarely become addicted. Chronic pain can be treated successfully even in patients addicted to opioids if they have the stable support of family and pharmacists, Dr. Keller said.

She recommended that physicians consult guidelines produced by the American Geriatrics Society Panel on Persistent Pain in Older Persons (J. Am. Geriatr. Soc. 2002;50[suppl.]:S205–24), which contain information on nonopioid analgesics, opioid options, and more.

SAN FRANCISCO – Talking to elderly patients with chronic pain about the differences between addiction, dependence, and tolerance of drugs may help them overcome some fears about using opioids, Kathryn Healey Keller, Pharm.D., said at a joint conference of the American Society on Aging and the National Council on the Aging.

Treatment with opioids is becoming more acceptable for persistent noncancer pain, despite the common fear of addiction, especially among older patients, said Dr. Keller of the University of California, San Francisco, and a medical liaison for Purdue Pharma LP, a pharmaceutical company that specializes in pain medications.

She recommended explaining to patients that physical dependence is inevitable with continuous exposure to opioids because of the characteristics of these drugs, but this is not the same as addiction and “it's not a moral, personal issue,” she said.

Give examples of other drugs that cause dependence with chronic use, such as prednisone or clonidine, she suggested.

Tell patients that dependence means they will have a rebound or withdrawal reaction if they stop taking any of these drugs, and alert them to the potential consequences if they stop opioid use suddenly.

Tolerance to a drug means that patients need more of the drug to maintain the same level of response. Coffee is a good example–people need to drink more of it over time to maintain the same caffeine buzz. Tolerance to opioids is slow to develop when treating stable disease, Dr. Keller noted.

Addiction is a neurobiologic disease involving a genetic predisposition and environmental factors that promote addiction. She said that patients who fear they're becoming addicted to opioids can consider “the four Cs” that help define addiction: Compulsive use, lack of Control, Craving for the drug, and Continued use despite harm to oneself or others.

Properly managed patients on opioids rarely become addicted. Chronic pain can be treated successfully even in patients addicted to opioids if they have the stable support of family and pharmacists, Dr. Keller said.

She recommended that physicians consult guidelines produced by the American Geriatrics Society Panel on Persistent Pain in Older Persons (J. Am. Geriatr. Soc. 2002;50[suppl.]:S205–24), which contain information on nonopioid analgesics, opioid options, and more.

SAN FRANCISCO – Talking to elderly patients with chronic pain about the differences between addiction, dependence, and tolerance of drugs may help them overcome some fears about using opioids, Kathryn Healey Keller, Pharm.D., said at a joint conference of the American Society on Aging and the National Council on the Aging.

Treatment with opioids is becoming more acceptable for persistent noncancer pain, despite the common fear of addiction, especially among older patients, said Dr. Keller of the University of California, San Francisco, and a medical liaison for Purdue Pharma LP, a pharmaceutical company that specializes in pain medications.

She recommended explaining to patients that physical dependence is inevitable with continuous exposure to opioids because of the characteristics of these drugs, but this is not the same as addiction and “it's not a moral, personal issue,” she said.

Give examples of other drugs that cause dependence with chronic use, such as prednisone or clonidine, she suggested.

Tell patients that dependence means they will have a rebound or withdrawal reaction if they stop taking any of these drugs, and alert them to the potential consequences if they stop opioid use suddenly.

Tolerance to a drug means that patients need more of the drug to maintain the same level of response. Coffee is a good example–people need to drink more of it over time to maintain the same caffeine buzz. Tolerance to opioids is slow to develop when treating stable disease, Dr. Keller noted.

Addiction is a neurobiologic disease involving a genetic predisposition and environmental factors that promote addiction. She said that patients who fear they're becoming addicted to opioids can consider “the four Cs” that help define addiction: Compulsive use, lack of Control, Craving for the drug, and Continued use despite harm to oneself or others.

Properly managed patients on opioids rarely become addicted. Chronic pain can be treated successfully even in patients addicted to opioids if they have the stable support of family and pharmacists, Dr. Keller said.

She recommended that physicians consult guidelines produced by the American Geriatrics Society Panel on Persistent Pain in Older Persons (J. Am. Geriatr. Soc. 2002;50[suppl.]:S205–24), which contain information on nonopioid analgesics, opioid options, and more.

SAN FRANCISCO – Good mental health in a father can buffer the impact of a mentally ill mother on a child, Robert S. Kahn, M.D., said at the annual meeting of the Pediatric Academic Societies.

In a study of 822 children aged 3–12 years who were living with both parents, the presence of mentally healthy fathers mitigated the effects of mothers' mental illness on emotional and behavioral problems in their children. Mental illness in fathers did not affect children much if the mother was mentally healthy, said Dr. Kahn of Cincinnati Children's Hospital Medical Center at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, and the Ambulatory Pediatric Association.

The secondary analysis of cross-sectional data from a longitudinal survey of families included parental mental health assessments using the K10, a new, validated 10-item screen for serious mental illness, including mood or anxiety disorders. Children were assessed through the use of two scales: the Behavior Problem Index (BPI) Externalizing scale for problems such as impulsiveness, disobedience, and lying and the BPI Internalizing scale for problems such as depression, anxiety, and fearfulness.

Higher maternal scores on the K10 (indicating greater mental illness) were associated with increased child scores on the BPI scales (indicating greater behavioral and emotional problems). The highest BPI scores were seen in children whose parents both were mentally ill. Child scores on the BPI scales were lower but still elevated if the mother, but not the father, had mental illness.

Compared with families in which both parents were mentally healthy, having both parents score in the highest quartile on the K10 screen added 5 points to the child's BPI Externalizing score and 3 points to the BPI Internalizing score.

If only the mother scored in the highest quartile on the K10, this added 2 points to the child's BPI Externalizing score and 1 point to the Internalizing score. If only the father scored in the highest quartile on the K10, this added less than 1 point to the child's score on either BPI scale.

If both parents were mentally ill, 9% of children scored in the top 10th percentile on the BPI Externalizing scale and 8% were in the top 10th percentile on the Internalizing scale.

If only the mom was mentally ill, 2% and 3% of children scored in the top 10th percentile on the Externalizing and Internalizing scales.

SAN FRANCISCO – Good mental health in a father can buffer the impact of a mentally ill mother on a child, Robert S. Kahn, M.D., said at the annual meeting of the Pediatric Academic Societies.

In a study of 822 children aged 3–12 years who were living with both parents, the presence of mentally healthy fathers mitigated the effects of mothers' mental illness on emotional and behavioral problems in their children. Mental illness in fathers did not affect children much if the mother was mentally healthy, said Dr. Kahn of Cincinnati Children's Hospital Medical Center at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, and the Ambulatory Pediatric Association.

The secondary analysis of cross-sectional data from a longitudinal survey of families included parental mental health assessments using the K10, a new, validated 10-item screen for serious mental illness, including mood or anxiety disorders. Children were assessed through the use of two scales: the Behavior Problem Index (BPI) Externalizing scale for problems such as impulsiveness, disobedience, and lying and the BPI Internalizing scale for problems such as depression, anxiety, and fearfulness.

Higher maternal scores on the K10 (indicating greater mental illness) were associated with increased child scores on the BPI scales (indicating greater behavioral and emotional problems). The highest BPI scores were seen in children whose parents both were mentally ill. Child scores on the BPI scales were lower but still elevated if the mother, but not the father, had mental illness.

Compared with families in which both parents were mentally healthy, having both parents score in the highest quartile on the K10 screen added 5 points to the child's BPI Externalizing score and 3 points to the BPI Internalizing score.

If only the mother scored in the highest quartile on the K10, this added 2 points to the child's BPI Externalizing score and 1 point to the Internalizing score. If only the father scored in the highest quartile on the K10, this added less than 1 point to the child's score on either BPI scale.

If both parents were mentally ill, 9% of children scored in the top 10th percentile on the BPI Externalizing scale and 8% were in the top 10th percentile on the Internalizing scale.

If only the mom was mentally ill, 2% and 3% of children scored in the top 10th percentile on the Externalizing and Internalizing scales.

SAN FRANCISCO – Good mental health in a father can buffer the impact of a mentally ill mother on a child, Robert S. Kahn, M.D., said at the annual meeting of the Pediatric Academic Societies.

In a study of 822 children aged 3–12 years who were living with both parents, the presence of mentally healthy fathers mitigated the effects of mothers' mental illness on emotional and behavioral problems in their children. Mental illness in fathers did not affect children much if the mother was mentally healthy, said Dr. Kahn of Cincinnati Children's Hospital Medical Center at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, and the Ambulatory Pediatric Association.

The secondary analysis of cross-sectional data from a longitudinal survey of families included parental mental health assessments using the K10, a new, validated 10-item screen for serious mental illness, including mood or anxiety disorders. Children were assessed through the use of two scales: the Behavior Problem Index (BPI) Externalizing scale for problems such as impulsiveness, disobedience, and lying and the BPI Internalizing scale for problems such as depression, anxiety, and fearfulness.

Higher maternal scores on the K10 (indicating greater mental illness) were associated with increased child scores on the BPI scales (indicating greater behavioral and emotional problems). The highest BPI scores were seen in children whose parents both were mentally ill. Child scores on the BPI scales were lower but still elevated if the mother, but not the father, had mental illness.

Compared with families in which both parents were mentally healthy, having both parents score in the highest quartile on the K10 screen added 5 points to the child's BPI Externalizing score and 3 points to the BPI Internalizing score.

If only the mother scored in the highest quartile on the K10, this added 2 points to the child's BPI Externalizing score and 1 point to the Internalizing score. If only the father scored in the highest quartile on the K10, this added less than 1 point to the child's score on either BPI scale.

If both parents were mentally ill, 9% of children scored in the top 10th percentile on the BPI Externalizing scale and 8% were in the top 10th percentile on the Internalizing scale.

If only the mom was mentally ill, 2% and 3% of children scored in the top 10th percentile on the Externalizing and Internalizing scales.

CABO SAN LUCAS, MEXICO — Higher rates of complications in babies born through assisted reproductive technology have led to malpractice lawsuits, Aubrey Milunsky, M.B., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“There is a medicolegal industry that is evolving at breakneck speed” related to ART, said Dr. Milunsky, who chaired the conference and is professor of human genetics, pediatrics, ob.gyn., and pathology at Boston University. ART plays a role in approximately 1% of the 4 million births in the United States each year, said Dr. Milunsky, who is also director of the Center for Human Genetics, Boston.

Compared with naturally conceived pregnancies, ART pregnancies carry nearly a threefold increased risk for low birth weight and more than a fivefold increased risk for fetal or infant death. Singletons delivered after ART are 40% more likely to be small for gestational age, 54% more likely to be delivered by cesarean section, and 27% more likely to require intensive care, compared with naturally conceived singletons. Multifetal pregnancies are more common with ART.

Maternal serum screening produces more false-positive results in ART pregnancies than in naturally conceived ones.

The overall rate of birth defects is 40%‐200% higher in ART pregnancies than the background rate of 3%‐4% in the general population. Three rare “imprinting” birth defects (disorders that appear to develop more in one sex than in the other) have been reported in a handful of ART pregnancies: Beckwith-Wiedemann syndrome, Angelman's syndrome, and retinoblastoma.

When parents have gone to such great lengths to conceive a child through ART and are desperate to have a successful pregnancy, anything less than a “perfect” baby may be extra disappointing, and complications may seem extra burdensome, he added.

Sean Tipton, spokesman for the American Society for Reproductive Medicine in Washington, commented in a subsequent telephone interview, “We're not aware of any explosion in litigation in this area. It's certainly not news to anyone that children of infertility patients are not as healthy as children of healthy people.”

Complications in ART pregnancies could be attributed to the underlying cause of the infertility, the advanced age of many women who seek ART, or issues related to multiple gestations, he said.

At the meeting, Dr. Milunsky highlighted some of the key areas for potential litigation related to ART:

▸ Informed consent. It is difficult and probably rare to get truly informed consent for all stages of ART a patient may go through, such as hormonal therapy, intracytoplasmic sperm injection, manipulation of the gamete or zygote in vitro, or insertion of cells into the womb.

▸ Extreme prematurity. Birth weights under 2,500 g are 70% more common in ART singletons than in naturally conceived ones. “Even though the technology is so phenomenal in terms of saving them … the outcome is intellectually disastrous” for many of the extremely small babies, he said. As in non-ART pregnancies, damaged babies lead to lawsuits that often try to pin the blame on medical personnel.

▸ Erroneous diagnosis. Chromosomal testing of a blastomere biopsy can miss problems absent in one cell but present in others. “It's surprising, if not amazing, how often the embryo is made up of two sets of cells—normal and abnormal,” he said.

When a fertilized egg multiplies into 8‐16 cells in vitro, a gene analysis for cystic fibrosis (CF) typically involves one of those cells. But in some cases allele dropout occurs in the cell chosen for analysis, giving the false impression that the cell—and hence the blastomere—does not contain a CF mutation. At least two lawsuits resulted from missed CF diagnoses due to allele dropout.

▸ Genetic counseling. Failure to refer both parents for genetic counseling results in inadequate information gathering. “People undergoing ART rarely have a full genetic evaluation, I find,” Dr. Milunsky said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ Targeted ultrasound. Given the higher risks for complications in ART pregnancies, targeted ultrasound should be done during the second trimester in all ART pregnancies to search for detectable abnormalities.

▸ Chorionic villus sampling/amniocentesis. Don't let the parents' drive to succeed in pregnancy keep you from offering invasive testing, which can endanger the pregnancy. Your responsibility is to communicate any increased risk to the parents and give them options for management. “Let them make the choice, and you make the documentation,” he said.

CABO SAN LUCAS, MEXICO — Higher rates of complications in babies born through assisted reproductive technology have led to malpractice lawsuits, Aubrey Milunsky, M.B., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“There is a medicolegal industry that is evolving at breakneck speed” related to ART, said Dr. Milunsky, who chaired the conference and is professor of human genetics, pediatrics, ob.gyn., and pathology at Boston University. ART plays a role in approximately 1% of the 4 million births in the United States each year, said Dr. Milunsky, who is also director of the Center for Human Genetics, Boston.

Compared with naturally conceived pregnancies, ART pregnancies carry nearly a threefold increased risk for low birth weight and more than a fivefold increased risk for fetal or infant death. Singletons delivered after ART are 40% more likely to be small for gestational age, 54% more likely to be delivered by cesarean section, and 27% more likely to require intensive care, compared with naturally conceived singletons. Multifetal pregnancies are more common with ART.

Maternal serum screening produces more false-positive results in ART pregnancies than in naturally conceived ones.

The overall rate of birth defects is 40%‐200% higher in ART pregnancies than the background rate of 3%‐4% in the general population. Three rare “imprinting” birth defects (disorders that appear to develop more in one sex than in the other) have been reported in a handful of ART pregnancies: Beckwith-Wiedemann syndrome, Angelman's syndrome, and retinoblastoma.

When parents have gone to such great lengths to conceive a child through ART and are desperate to have a successful pregnancy, anything less than a “perfect” baby may be extra disappointing, and complications may seem extra burdensome, he added.

Sean Tipton, spokesman for the American Society for Reproductive Medicine in Washington, commented in a subsequent telephone interview, “We're not aware of any explosion in litigation in this area. It's certainly not news to anyone that children of infertility patients are not as healthy as children of healthy people.”

Complications in ART pregnancies could be attributed to the underlying cause of the infertility, the advanced age of many women who seek ART, or issues related to multiple gestations, he said.

At the meeting, Dr. Milunsky highlighted some of the key areas for potential litigation related to ART:

▸ Informed consent. It is difficult and probably rare to get truly informed consent for all stages of ART a patient may go through, such as hormonal therapy, intracytoplasmic sperm injection, manipulation of the gamete or zygote in vitro, or insertion of cells into the womb.

▸ Extreme prematurity. Birth weights under 2,500 g are 70% more common in ART singletons than in naturally conceived ones. “Even though the technology is so phenomenal in terms of saving them … the outcome is intellectually disastrous” for many of the extremely small babies, he said. As in non-ART pregnancies, damaged babies lead to lawsuits that often try to pin the blame on medical personnel.

▸ Erroneous diagnosis. Chromosomal testing of a blastomere biopsy can miss problems absent in one cell but present in others. “It's surprising, if not amazing, how often the embryo is made up of two sets of cells—normal and abnormal,” he said.

When a fertilized egg multiplies into 8‐16 cells in vitro, a gene analysis for cystic fibrosis (CF) typically involves one of those cells. But in some cases allele dropout occurs in the cell chosen for analysis, giving the false impression that the cell—and hence the blastomere—does not contain a CF mutation. At least two lawsuits resulted from missed CF diagnoses due to allele dropout.

▸ Genetic counseling. Failure to refer both parents for genetic counseling results in inadequate information gathering. “People undergoing ART rarely have a full genetic evaluation, I find,” Dr. Milunsky said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ Targeted ultrasound. Given the higher risks for complications in ART pregnancies, targeted ultrasound should be done during the second trimester in all ART pregnancies to search for detectable abnormalities.

▸ Chorionic villus sampling/amniocentesis. Don't let the parents' drive to succeed in pregnancy keep you from offering invasive testing, which can endanger the pregnancy. Your responsibility is to communicate any increased risk to the parents and give them options for management. “Let them make the choice, and you make the documentation,” he said.

CABO SAN LUCAS, MEXICO — Higher rates of complications in babies born through assisted reproductive technology have led to malpractice lawsuits, Aubrey Milunsky, M.B., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“There is a medicolegal industry that is evolving at breakneck speed” related to ART, said Dr. Milunsky, who chaired the conference and is professor of human genetics, pediatrics, ob.gyn., and pathology at Boston University. ART plays a role in approximately 1% of the 4 million births in the United States each year, said Dr. Milunsky, who is also director of the Center for Human Genetics, Boston.

Compared with naturally conceived pregnancies, ART pregnancies carry nearly a threefold increased risk for low birth weight and more than a fivefold increased risk for fetal or infant death. Singletons delivered after ART are 40% more likely to be small for gestational age, 54% more likely to be delivered by cesarean section, and 27% more likely to require intensive care, compared with naturally conceived singletons. Multifetal pregnancies are more common with ART.

Maternal serum screening produces more false-positive results in ART pregnancies than in naturally conceived ones.

The overall rate of birth defects is 40%‐200% higher in ART pregnancies than the background rate of 3%‐4% in the general population. Three rare “imprinting” birth defects (disorders that appear to develop more in one sex than in the other) have been reported in a handful of ART pregnancies: Beckwith-Wiedemann syndrome, Angelman's syndrome, and retinoblastoma.

When parents have gone to such great lengths to conceive a child through ART and are desperate to have a successful pregnancy, anything less than a “perfect” baby may be extra disappointing, and complications may seem extra burdensome, he added.

Sean Tipton, spokesman for the American Society for Reproductive Medicine in Washington, commented in a subsequent telephone interview, “We're not aware of any explosion in litigation in this area. It's certainly not news to anyone that children of infertility patients are not as healthy as children of healthy people.”

Complications in ART pregnancies could be attributed to the underlying cause of the infertility, the advanced age of many women who seek ART, or issues related to multiple gestations, he said.

At the meeting, Dr. Milunsky highlighted some of the key areas for potential litigation related to ART:

▸ Informed consent. It is difficult and probably rare to get truly informed consent for all stages of ART a patient may go through, such as hormonal therapy, intracytoplasmic sperm injection, manipulation of the gamete or zygote in vitro, or insertion of cells into the womb.

▸ Extreme prematurity. Birth weights under 2,500 g are 70% more common in ART singletons than in naturally conceived ones. “Even though the technology is so phenomenal in terms of saving them … the outcome is intellectually disastrous” for many of the extremely small babies, he said. As in non-ART pregnancies, damaged babies lead to lawsuits that often try to pin the blame on medical personnel.

▸ Erroneous diagnosis. Chromosomal testing of a blastomere biopsy can miss problems absent in one cell but present in others. “It's surprising, if not amazing, how often the embryo is made up of two sets of cells—normal and abnormal,” he said.

When a fertilized egg multiplies into 8‐16 cells in vitro, a gene analysis for cystic fibrosis (CF) typically involves one of those cells. But in some cases allele dropout occurs in the cell chosen for analysis, giving the false impression that the cell—and hence the blastomere—does not contain a CF mutation. At least two lawsuits resulted from missed CF diagnoses due to allele dropout.

▸ Genetic counseling. Failure to refer both parents for genetic counseling results in inadequate information gathering. “People undergoing ART rarely have a full genetic evaluation, I find,” Dr. Milunsky said at the meeting, sponsored by Boston University and the Center for Human Genetics.

▸ Targeted ultrasound. Given the higher risks for complications in ART pregnancies, targeted ultrasound should be done during the second trimester in all ART pregnancies to search for detectable abnormalities.

▸ Chorionic villus sampling/amniocentesis. Don't let the parents' drive to succeed in pregnancy keep you from offering invasive testing, which can endanger the pregnancy. Your responsibility is to communicate any increased risk to the parents and give them options for management. “Let them make the choice, and you make the documentation,” he said.

CABO SAN LUCAS, MEXICO — Abdominal trauma during pregnancy endangers the woman and her fetus, but avoiding some common clinical errors in managing such patients can reduce these risks, according to John A. Marx, M.D.

Abdominal trauma during pregnancy is “a huge concern and underrated,” said Dr. Marx, chairman of emergency medicine at Carolinas Medical Center, Charlotte, N.C.

Abdominal trauma occurs in 1%–12% of all pregnancies and leads to hospitalization in 0.4% of such cases, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Trauma that causes a pelvic fracture leads to maternal death in 9% of cases and fetal death in 38% of cases. Placental abruption—seen in 2%–4% of women who suffer minor abdominal trauma and half of women with life-threatening abdominal trauma—results in fetal death 50%–70% of the time.

Be prepared to recognize shock early and treat it aggressively in pregnant women with abdominal trauma.

Don't rely too much on a nontender abdomen as a sign that everything is okay after abdominal trauma during pregnancy.

Dr. Marx outlined other mistakes to avoid:

▸ Failure to teach proper seat belt use. Motor vehicle accidents cause 70% of all cases of abdominal trauma in pregnancy. Compared with a belted passenger, an unbelted pregnant woman in a car crash has double the risk of vaginal bleeding and quadruple the risk of fetal death.

Advise women to place their lap belt below the uterus and across the hips and place the shoulder belt between the breasts and to the side of the abdomen. Placing the seatbelt improperly across the abdomen increases force on the uterus three- to fourfold, compared with proper seat belt use.

Air bags do protect pregnant passengers, he added. “There's a great deal of misunderstanding about this,” Dr. Marx said.

▸ Failure to order needed radiologic studies. This failure is frequently due to concern about radiating the fetus and represents “a huge error in trauma management,” he said. A dose of 5 rad or less is considered an acceptable cumulative fetal exposure. X-rays that deliver less than half a rad each include films of the anterior-posterior pelvis, lumbosacral spine, thoracic spine, and periapical or lateral views. A CT scan of the abdomen delivers 2.6 rads to the fetus, and a CT of the abdomen and pelvis delivers 3–9 rads, although helical CT decreases radiation exposure by 14%–30%. “You can still do these studies, but you can't do a bunch of them,” he said.

▸ Failure to obtain coagulation studies. The risk of disseminated intravascular coagulation increases during pregnancy.

▸ Overreliance on ultrasound to detect placental abruption. Cardiotocographic monitoring is much more sensitive, though less specific, than ultrasound in diagnosing placental abruption. All women with pregnancies of 24 weeks or greater who sustain blunt trauma to the abdomen should undergo cardiotocographic monitoring, which consists of continuous Doppler monitoring of fetal cardiac activity and electronic recording of uterine activity.

Placental abruption with a 50% tear can quadruple the risk of stillbirth, and a 75% tear increases the risk of stillbirth 39-fold.

▸ Failure to monitor the fetus for 4–24 hours. Four hours is sufficient if the trauma carries low risk, the mother is asymptomatic for placental abruption, and cardiotocographic monitoring results are normal. If the trauma affected a major bodily mechanism, the mother is symptomatic, or monitoring results are abnormal within the first 4 hours, monitor for at least 24 hours.

▸ Failure to avoid supine hypotensive syndrome. “This is another oft-missed and easy-to-treat condition,” he said. Tilting the woman's prone body up and to the left by 15–30 degrees frees the inferior vena cava from pressure from the uterus, which could otherwise cause a significant drop in systolic blood pressure.

▸ Failure to consider domestic violence. The woman's abdomen is the prime site of injury arising from domestic violence during pregnancy. If domestic violence happens once during pregnancy, there's a 60% chance it will happen again. Only 3% of pregnant women who seek care for domestic violence injuries reveal the true cause to physicians.

▸ Failure to perform a perimortem cesarean section promptly. When the woman is dead or moribund but the fetus is viable, performing a C-section within 5 minutes leads to excellent fetal outcomes. Only about 5% of fetuses survive if delivery is delayed at least 15 minutes, and most will have poor neurologic outcomes, Dr. Marx said.

CABO SAN LUCAS, MEXICO — Abdominal trauma during pregnancy endangers the woman and her fetus, but avoiding some common clinical errors in managing such patients can reduce these risks, according to John A. Marx, M.D.

Abdominal trauma during pregnancy is “a huge concern and underrated,” said Dr. Marx, chairman of emergency medicine at Carolinas Medical Center, Charlotte, N.C.

Abdominal trauma occurs in 1%–12% of all pregnancies and leads to hospitalization in 0.4% of such cases, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Trauma that causes a pelvic fracture leads to maternal death in 9% of cases and fetal death in 38% of cases. Placental abruption—seen in 2%–4% of women who suffer minor abdominal trauma and half of women with life-threatening abdominal trauma—results in fetal death 50%–70% of the time.

Be prepared to recognize shock early and treat it aggressively in pregnant women with abdominal trauma.

Don't rely too much on a nontender abdomen as a sign that everything is okay after abdominal trauma during pregnancy.

Dr. Marx outlined other mistakes to avoid:

▸ Failure to teach proper seat belt use. Motor vehicle accidents cause 70% of all cases of abdominal trauma in pregnancy. Compared with a belted passenger, an unbelted pregnant woman in a car crash has double the risk of vaginal bleeding and quadruple the risk of fetal death.

Advise women to place their lap belt below the uterus and across the hips and place the shoulder belt between the breasts and to the side of the abdomen. Placing the seatbelt improperly across the abdomen increases force on the uterus three- to fourfold, compared with proper seat belt use.

Air bags do protect pregnant passengers, he added. “There's a great deal of misunderstanding about this,” Dr. Marx said.

▸ Failure to order needed radiologic studies. This failure is frequently due to concern about radiating the fetus and represents “a huge error in trauma management,” he said. A dose of 5 rad or less is considered an acceptable cumulative fetal exposure. X-rays that deliver less than half a rad each include films of the anterior-posterior pelvis, lumbosacral spine, thoracic spine, and periapical or lateral views. A CT scan of the abdomen delivers 2.6 rads to the fetus, and a CT of the abdomen and pelvis delivers 3–9 rads, although helical CT decreases radiation exposure by 14%–30%. “You can still do these studies, but you can't do a bunch of them,” he said.

▸ Failure to obtain coagulation studies. The risk of disseminated intravascular coagulation increases during pregnancy.

▸ Overreliance on ultrasound to detect placental abruption. Cardiotocographic monitoring is much more sensitive, though less specific, than ultrasound in diagnosing placental abruption. All women with pregnancies of 24 weeks or greater who sustain blunt trauma to the abdomen should undergo cardiotocographic monitoring, which consists of continuous Doppler monitoring of fetal cardiac activity and electronic recording of uterine activity.

Placental abruption with a 50% tear can quadruple the risk of stillbirth, and a 75% tear increases the risk of stillbirth 39-fold.

▸ Failure to monitor the fetus for 4–24 hours. Four hours is sufficient if the trauma carries low risk, the mother is asymptomatic for placental abruption, and cardiotocographic monitoring results are normal. If the trauma affected a major bodily mechanism, the mother is symptomatic, or monitoring results are abnormal within the first 4 hours, monitor for at least 24 hours.

▸ Failure to avoid supine hypotensive syndrome. “This is another oft-missed and easy-to-treat condition,” he said. Tilting the woman's prone body up and to the left by 15–30 degrees frees the inferior vena cava from pressure from the uterus, which could otherwise cause a significant drop in systolic blood pressure.

▸ Failure to consider domestic violence. The woman's abdomen is the prime site of injury arising from domestic violence during pregnancy. If domestic violence happens once during pregnancy, there's a 60% chance it will happen again. Only 3% of pregnant women who seek care for domestic violence injuries reveal the true cause to physicians.

▸ Failure to perform a perimortem cesarean section promptly. When the woman is dead or moribund but the fetus is viable, performing a C-section within 5 minutes leads to excellent fetal outcomes. Only about 5% of fetuses survive if delivery is delayed at least 15 minutes, and most will have poor neurologic outcomes, Dr. Marx said.

CABO SAN LUCAS, MEXICO — Abdominal trauma during pregnancy endangers the woman and her fetus, but avoiding some common clinical errors in managing such patients can reduce these risks, according to John A. Marx, M.D.

Abdominal trauma during pregnancy is “a huge concern and underrated,” said Dr. Marx, chairman of emergency medicine at Carolinas Medical Center, Charlotte, N.C.

Abdominal trauma occurs in 1%–12% of all pregnancies and leads to hospitalization in 0.4% of such cases, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Trauma that causes a pelvic fracture leads to maternal death in 9% of cases and fetal death in 38% of cases. Placental abruption—seen in 2%–4% of women who suffer minor abdominal trauma and half of women with life-threatening abdominal trauma—results in fetal death 50%–70% of the time.

Be prepared to recognize shock early and treat it aggressively in pregnant women with abdominal trauma.

Don't rely too much on a nontender abdomen as a sign that everything is okay after abdominal trauma during pregnancy.

Dr. Marx outlined other mistakes to avoid:

▸ Failure to teach proper seat belt use. Motor vehicle accidents cause 70% of all cases of abdominal trauma in pregnancy. Compared with a belted passenger, an unbelted pregnant woman in a car crash has double the risk of vaginal bleeding and quadruple the risk of fetal death.

Advise women to place their lap belt below the uterus and across the hips and place the shoulder belt between the breasts and to the side of the abdomen. Placing the seatbelt improperly across the abdomen increases force on the uterus three- to fourfold, compared with proper seat belt use.

Air bags do protect pregnant passengers, he added. “There's a great deal of misunderstanding about this,” Dr. Marx said.

▸ Failure to order needed radiologic studies. This failure is frequently due to concern about radiating the fetus and represents “a huge error in trauma management,” he said. A dose of 5 rad or less is considered an acceptable cumulative fetal exposure. X-rays that deliver less than half a rad each include films of the anterior-posterior pelvis, lumbosacral spine, thoracic spine, and periapical or lateral views. A CT scan of the abdomen delivers 2.6 rads to the fetus, and a CT of the abdomen and pelvis delivers 3–9 rads, although helical CT decreases radiation exposure by 14%–30%. “You can still do these studies, but you can't do a bunch of them,” he said.

▸ Failure to obtain coagulation studies. The risk of disseminated intravascular coagulation increases during pregnancy.

▸ Overreliance on ultrasound to detect placental abruption. Cardiotocographic monitoring is much more sensitive, though less specific, than ultrasound in diagnosing placental abruption. All women with pregnancies of 24 weeks or greater who sustain blunt trauma to the abdomen should undergo cardiotocographic monitoring, which consists of continuous Doppler monitoring of fetal cardiac activity and electronic recording of uterine activity.

Placental abruption with a 50% tear can quadruple the risk of stillbirth, and a 75% tear increases the risk of stillbirth 39-fold.

▸ Failure to monitor the fetus for 4–24 hours. Four hours is sufficient if the trauma carries low risk, the mother is asymptomatic for placental abruption, and cardiotocographic monitoring results are normal. If the trauma affected a major bodily mechanism, the mother is symptomatic, or monitoring results are abnormal within the first 4 hours, monitor for at least 24 hours.

▸ Failure to avoid supine hypotensive syndrome. “This is another oft-missed and easy-to-treat condition,” he said. Tilting the woman's prone body up and to the left by 15–30 degrees frees the inferior vena cava from pressure from the uterus, which could otherwise cause a significant drop in systolic blood pressure.

▸ Failure to consider domestic violence. The woman's abdomen is the prime site of injury arising from domestic violence during pregnancy. If domestic violence happens once during pregnancy, there's a 60% chance it will happen again. Only 3% of pregnant women who seek care for domestic violence injuries reveal the true cause to physicians.

▸ Failure to perform a perimortem cesarean section promptly. When the woman is dead or moribund but the fetus is viable, performing a C-section within 5 minutes leads to excellent fetal outcomes. Only about 5% of fetuses survive if delivery is delayed at least 15 minutes, and most will have poor neurologic outcomes, Dr. Marx said.

CABO SAN LUCAS, MEXICO — Some obstetricians see pediatricians and neonatologists as adversaries when it comes to reducing the risk of a lawsuit after delivering a baby with low Apgar scores.

The alledged problem: Most pediatricians, neonatologists, and pediatric neurologists don't follow a 2003 monograph produced by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) that sets criteria for declaring that a newborn has hypoxic ischemic encephalopathy (HIE), which is an essential component of cerebral palsy, said O. Richard Depp, M.D., at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Until recently, pediatricians and neonatologists who saw a newborn who was not doing well and had depressed Apgar scores simply labeled the problem as HIE. “That is no longer appropriate,” said Dr. Depp, professor of ob.gyn. at Thomas Jefferson University and Drexel University, Philadelphia.

No one should presume a diagnosis of HIE until other causes have been excluded and criteria for HIE have been met, he said. (See sidebar.) Until then, the only appropriate label—and one less likely to spark litigation—is neonatal encephalopathy, which may be due to a number of causes, many of which occur before labor and delivery, according to the monograph.

“I think there is a real need for education among our colleagues in other specialties, because I don't think they've really read this,” Dr. Depp said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

Not so, countered Avroy A. Fanaroff, M.B., in a commentary after Dr. Depp's talk. “Our pediatricians are trained to be very cautious about their use of terminology and to apply the ACOG criteria before they put down HIE,” he said. Dr. Fanaroff is professor and chairman of pediatrics and professor of reproductive biology at Case Western Reserve University, Cleveland.

“You practice in one of the pediatric capitals of the world,” responded Dr. Depp. He asked how many obstetricians in the audience of 150–200 people felt comfortably sure that the pediatricians in their hospitals were familiar with the monograph. Less than a handful raised their hands.

An obstetrician from Atlanta stepped up to the microphone and said, “We're fighting for our lives from the plaintiffs' attorneys, who say, 'Well, can you dispute the fact that this pediatric neurologist says this is HIE?' [The neurologist] wasn't there! He doesn't even know what he's saying!”

Dr. Depp suggested that it's time for chairs or division chiefs “to sit down and talk about how they will address this problem in a prospective manner.” At Jefferson University, he sat down with the chairpersons of pediatrics and anesthesia to negotiate an agreement on the proper use of terms such as HIE and neonatal encephalopathy.

Only recently have physicians attempted to distinguish between neonatal encephalopathy and hypoxic ischemic encephalopathy, he noted.

A 1999 international consensus statement, titled, “A template for defining a causal relation between acute intrapartum events and cerebral palsy” provided the first clear guidance and was endorsed by 16 medical organizations, including ACOG (BMJ 1999;319:1054–9).

ACOG and the AAP followed with the monograph, “Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy” (Obstet. Gynecol. 2003;102:628–36).

Dr. Fanaroff agreed that differentiating hypoxic ischemic encephalopathy from neonatal encephalopathy is a complex task. “There are a whole lot of things that need to be sorted out. There are some that are acute events, others that are chronic, others that are acute and chronic, and others that are due to genetics or infection,” Dr. Fanaroff said.

“I think we're all treading on very thin ice, and walking on eggshells” when labeling problems in a newborn's chart.

HIE Criteria Essentials

Four prerequisites must be met in proposing that hypoxic ischemic encephalopathy caused moderate to severe neonatal encephalopathy, resulting in cerebral palsy:

1. Fetal umbilical cord arterial blood obtained at delivery with evidence of metabolic acidosis (pH less than 7 and base deficit of 12 mmol/L or more).

2. Early onset of moderate or severe neonatal encephalopathy in infants born at 34 weeks' gestation or later.

3. Spastic quadriplegic or dyskinetic cerebral palsy.

4. Exclusion of other identifiable causes such as coagulation disorders, infectious conditions, trauma, or genetic disorders.

The monograph also discusses other criteria that together suggest an intrapartum insult occurred.

Source: Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy (Obstet. Gynecol. 2003;102:628–36).

CABO SAN LUCAS, MEXICO — Some obstetricians see pediatricians and neonatologists as adversaries when it comes to reducing the risk of a lawsuit after delivering a baby with low Apgar scores.

The alledged problem: Most pediatricians, neonatologists, and pediatric neurologists don't follow a 2003 monograph produced by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) that sets criteria for declaring that a newborn has hypoxic ischemic encephalopathy (HIE), which is an essential component of cerebral palsy, said O. Richard Depp, M.D., at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Until recently, pediatricians and neonatologists who saw a newborn who was not doing well and had depressed Apgar scores simply labeled the problem as HIE. “That is no longer appropriate,” said Dr. Depp, professor of ob.gyn. at Thomas Jefferson University and Drexel University, Philadelphia.

No one should presume a diagnosis of HIE until other causes have been excluded and criteria for HIE have been met, he said. (See sidebar.) Until then, the only appropriate label—and one less likely to spark litigation—is neonatal encephalopathy, which may be due to a number of causes, many of which occur before labor and delivery, according to the monograph.

“I think there is a real need for education among our colleagues in other specialties, because I don't think they've really read this,” Dr. Depp said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

Not so, countered Avroy A. Fanaroff, M.B., in a commentary after Dr. Depp's talk. “Our pediatricians are trained to be very cautious about their use of terminology and to apply the ACOG criteria before they put down HIE,” he said. Dr. Fanaroff is professor and chairman of pediatrics and professor of reproductive biology at Case Western Reserve University, Cleveland.

“You practice in one of the pediatric capitals of the world,” responded Dr. Depp. He asked how many obstetricians in the audience of 150–200 people felt comfortably sure that the pediatricians in their hospitals were familiar with the monograph. Less than a handful raised their hands.

An obstetrician from Atlanta stepped up to the microphone and said, “We're fighting for our lives from the plaintiffs' attorneys, who say, 'Well, can you dispute the fact that this pediatric neurologist says this is HIE?' [The neurologist] wasn't there! He doesn't even know what he's saying!”

Dr. Depp suggested that it's time for chairs or division chiefs “to sit down and talk about how they will address this problem in a prospective manner.” At Jefferson University, he sat down with the chairpersons of pediatrics and anesthesia to negotiate an agreement on the proper use of terms such as HIE and neonatal encephalopathy.

Only recently have physicians attempted to distinguish between neonatal encephalopathy and hypoxic ischemic encephalopathy, he noted.

A 1999 international consensus statement, titled, “A template for defining a causal relation between acute intrapartum events and cerebral palsy” provided the first clear guidance and was endorsed by 16 medical organizations, including ACOG (BMJ 1999;319:1054–9).

ACOG and the AAP followed with the monograph, “Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy” (Obstet. Gynecol. 2003;102:628–36).

Dr. Fanaroff agreed that differentiating hypoxic ischemic encephalopathy from neonatal encephalopathy is a complex task. “There are a whole lot of things that need to be sorted out. There are some that are acute events, others that are chronic, others that are acute and chronic, and others that are due to genetics or infection,” Dr. Fanaroff said.

“I think we're all treading on very thin ice, and walking on eggshells” when labeling problems in a newborn's chart.

HIE Criteria Essentials

Four prerequisites must be met in proposing that hypoxic ischemic encephalopathy caused moderate to severe neonatal encephalopathy, resulting in cerebral palsy:

1. Fetal umbilical cord arterial blood obtained at delivery with evidence of metabolic acidosis (pH less than 7 and base deficit of 12 mmol/L or more).

2. Early onset of moderate or severe neonatal encephalopathy in infants born at 34 weeks' gestation or later.

3. Spastic quadriplegic or dyskinetic cerebral palsy.

4. Exclusion of other identifiable causes such as coagulation disorders, infectious conditions, trauma, or genetic disorders.

The monograph also discusses other criteria that together suggest an intrapartum insult occurred.

Source: Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy (Obstet. Gynecol. 2003;102:628–36).

CABO SAN LUCAS, MEXICO — Some obstetricians see pediatricians and neonatologists as adversaries when it comes to reducing the risk of a lawsuit after delivering a baby with low Apgar scores.

The alledged problem: Most pediatricians, neonatologists, and pediatric neurologists don't follow a 2003 monograph produced by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) that sets criteria for declaring that a newborn has hypoxic ischemic encephalopathy (HIE), which is an essential component of cerebral palsy, said O. Richard Depp, M.D., at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Until recently, pediatricians and neonatologists who saw a newborn who was not doing well and had depressed Apgar scores simply labeled the problem as HIE. “That is no longer appropriate,” said Dr. Depp, professor of ob.gyn. at Thomas Jefferson University and Drexel University, Philadelphia.

No one should presume a diagnosis of HIE until other causes have been excluded and criteria for HIE have been met, he said. (See sidebar.) Until then, the only appropriate label—and one less likely to spark litigation—is neonatal encephalopathy, which may be due to a number of causes, many of which occur before labor and delivery, according to the monograph.

“I think there is a real need for education among our colleagues in other specialties, because I don't think they've really read this,” Dr. Depp said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

Not so, countered Avroy A. Fanaroff, M.B., in a commentary after Dr. Depp's talk. “Our pediatricians are trained to be very cautious about their use of terminology and to apply the ACOG criteria before they put down HIE,” he said. Dr. Fanaroff is professor and chairman of pediatrics and professor of reproductive biology at Case Western Reserve University, Cleveland.

“You practice in one of the pediatric capitals of the world,” responded Dr. Depp. He asked how many obstetricians in the audience of 150–200 people felt comfortably sure that the pediatricians in their hospitals were familiar with the monograph. Less than a handful raised their hands.

An obstetrician from Atlanta stepped up to the microphone and said, “We're fighting for our lives from the plaintiffs' attorneys, who say, 'Well, can you dispute the fact that this pediatric neurologist says this is HIE?' [The neurologist] wasn't there! He doesn't even know what he's saying!”

Dr. Depp suggested that it's time for chairs or division chiefs “to sit down and talk about how they will address this problem in a prospective manner.” At Jefferson University, he sat down with the chairpersons of pediatrics and anesthesia to negotiate an agreement on the proper use of terms such as HIE and neonatal encephalopathy.

Only recently have physicians attempted to distinguish between neonatal encephalopathy and hypoxic ischemic encephalopathy, he noted.

A 1999 international consensus statement, titled, “A template for defining a causal relation between acute intrapartum events and cerebral palsy” provided the first clear guidance and was endorsed by 16 medical organizations, including ACOG (BMJ 1999;319:1054–9).

ACOG and the AAP followed with the monograph, “Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy” (Obstet. Gynecol. 2003;102:628–36).

Dr. Fanaroff agreed that differentiating hypoxic ischemic encephalopathy from neonatal encephalopathy is a complex task. “There are a whole lot of things that need to be sorted out. There are some that are acute events, others that are chronic, others that are acute and chronic, and others that are due to genetics or infection,” Dr. Fanaroff said.

“I think we're all treading on very thin ice, and walking on eggshells” when labeling problems in a newborn's chart.

HIE Criteria Essentials

Four prerequisites must be met in proposing that hypoxic ischemic encephalopathy caused moderate to severe neonatal encephalopathy, resulting in cerebral palsy:

1. Fetal umbilical cord arterial blood obtained at delivery with evidence of metabolic acidosis (pH less than 7 and base deficit of 12 mmol/L or more).

2. Early onset of moderate or severe neonatal encephalopathy in infants born at 34 weeks' gestation or later.

3. Spastic quadriplegic or dyskinetic cerebral palsy.

4. Exclusion of other identifiable causes such as coagulation disorders, infectious conditions, trauma, or genetic disorders.

The monograph also discusses other criteria that together suggest an intrapartum insult occurred.

Source: Defining the pathogenesis and pathophysiology of neonatal encephalopathy and cerebral palsy (Obstet. Gynecol. 2003;102:628–36).

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system, she said at the triennial congress of the International Medical Informatics Association.

They studied 20 doctors before EHR implementation, 16 of those after adoption of the system, and 4 physicians recruited after EHR implementation, for a total of 20 physicians before and after the change.

Direct patient care took about 14 minutes in the pre-EHR era and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care—reading, writing, or other tasks in support of direct patient care—took 9 minutes before EHR and 10 minutes after. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences on a five-point scale (with five being the best), physicians rated the EHRs impact on quality, access, and communication a four, Ms. Pizziferri said. Impact on workload was 3 and overall satisfaction, 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system, she said at the triennial congress of the International Medical Informatics Association.

They studied 20 doctors before EHR implementation, 16 of those after adoption of the system, and 4 physicians recruited after EHR implementation, for a total of 20 physicians before and after the change.

Direct patient care took about 14 minutes in the pre-EHR era and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care—reading, writing, or other tasks in support of direct patient care—took 9 minutes before EHR and 10 minutes after. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences on a five-point scale (with five being the best), physicians rated the EHRs impact on quality, access, and communication a four, Ms. Pizziferri said. Impact on workload was 3 and overall satisfaction, 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

SAN FRANCISCO — Adopting an electronic health records system reduced the mean length of visits at five outpatient clinics by 4 minutes per patient, a difference that was not statistically significant but that should allay physicians' fears that the technology might be a burden, Lisa Pizziferri said.

The results come from a time-motion study in which observers shadowed primary care physicians before and after implementation of the electronic health records (EHR) system, she said at the triennial congress of the International Medical Informatics Association.

They studied 20 doctors before EHR implementation, 16 of those after adoption of the system, and 4 physicians recruited after EHR implementation, for a total of 20 physicians before and after the change.

Direct patient care took about 14 minutes in the pre-EHR era and 13 minutes using EHR, said Ms. Pizziferri of Partners HealthCare System Inc., Wellesley, Mass.

Indirect patient care—reading, writing, or other tasks in support of direct patient care—took 9 minutes before EHR and 10 minutes after. Physicians spent about half a minute reviewing schedules before EHR and 1 minute with EHR. Time spent eating, walking, or performing other miscellaneous tasks decreased from 4 minutes to 3 minutes per patient after EHR implementation.

The mean overall time spent with each patient decreased by 4 minutes, and was calculated independently, not by adding up the times of individual tasks, she said. During an average 4-hour observation period per physician, physicians saw 9 patients while using paper records and 10 patients while using EHR.

Asked to rate their experiences on a five-point scale (with five being the best), physicians rated the EHRs impact on quality, access, and communication a four, Ms. Pizziferri said. Impact on workload was 3 and overall satisfaction, 4.

Partners HealthCare designed the Web-based EHR system, called the Longitudinal Medical Record. It includes clinical data, computerized decision support, reminders for health maintenance, and tools for charting, order entry, and management of results or referrals.

SAN FRANCISCO — Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. Investigators found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

The current results echo those of a similar study by Dr. Lee and his associates of errors in 122 prescriptions written for 75 patients in the hospital's day surgery unit, which included mostly adults, with some pediatric patients. They found an error rate of 57% including potentially dangerous errors in 2.5%.

“If this is happening at a tertiary-care hospital with a lot of oversight, with providers who are very comfortable taking care of critically ill patients, this is probably a phenomenon that extends to other institutions and other settings,” Dr. Lee said.

SAN FRANCISCO — Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. Investigators found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

The current results echo those of a similar study by Dr. Lee and his associates of errors in 122 prescriptions written for 75 patients in the hospital's day surgery unit, which included mostly adults, with some pediatric patients. They found an error rate of 57% including potentially dangerous errors in 2.5%.

“If this is happening at a tertiary-care hospital with a lot of oversight, with providers who are very comfortable taking care of critically ill patients, this is probably a phenomenon that extends to other institutions and other settings,” Dr. Lee said.

SAN FRANCISCO — Half of 83 prescriptions for analgesics written for 77 children being sent home from the hospital contained one or more errors, including 2 prescriptions with errors that could have significantly harmed the patients, Benjamin H. Lee, M.D., said at the annual meeting of the American Academy of Pediatrics.

Unbeknownst to the primary medical or surgical physicians who wrote the discharge analgesic prescriptions, investigators from the Johns Hopkins Medical Institutions' (Baltimore) pediatric pain service secretly monitored the prescriptions during the study and rewrote any they considered dangerous, so no children were harmed, said Dr. Lee of Johns Hopkins.

“We were surprised at this potential adverse drug event rate of 2.4%. That's not insignificant in this small patient series,” he said, adding, “I don't think this is something that's limited to Johns Hopkins Hospital.”

Discharge time is a vulnerable period for inpatients, who lose the safety net of pharmacists, nurses, and multiple physicians who look at medication orders while the patient is hospitalized, he explained. When the patient is sent home with analgesics, a single physician writes the prescription and the discharge orders, which are reviewed usually by a single nurse, with no pharmacists or other providers involved.

The two dangerous prescriptions in the study were for opioids. One included a 10-fold overdose error. The other included instructions for a long-acting medication that could lead a patient to take multiple doses all at once. All patients got prescriptions for opioids at discharge, and 7% also received NSAIDs.

Most of the prescription errors were not clinically significant; the study used a strict definition of error. The two most common causes of errors, however, illustrate problems that could lead to patient harm: a lack of any identification of weight or weight-based dosing in the prescription, and incomplete information about dispensing of the medication.

For patients weighing less than 40 kg, no weight was recorded on 45% of analgesic prescriptions. Investigators found discrepancies between the written prescriptions and the discharge data form in 10% of cases. Physicians wrote an incorrect name or patient identifier in 4% of analgesia prescriptions.

A separate study is underway to see if using a computerized prescription-writing program that includes weight-based dosing for pediatric patients will reduce errors and improve patient safety, Dr. Lee said.

The current results echo those of a similar study by Dr. Lee and his associates of errors in 122 prescriptions written for 75 patients in the hospital's day surgery unit, which included mostly adults, with some pediatric patients. They found an error rate of 57% including potentially dangerous errors in 2.5%.

“If this is happening at a tertiary-care hospital with a lot of oversight, with providers who are very comfortable taking care of critically ill patients, this is probably a phenomenon that extends to other institutions and other settings,” Dr. Lee said.

CABO SAN LUCAS, MEXICO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., said.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital's protocol, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often, there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically, abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol, and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it is not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin was not ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

CABO SAN LUCAS, MEXICO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., said.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital's protocol, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often, there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically, abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol, and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it is not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin was not ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

CABO SAN LUCAS, MEXICO — Before you write an order for Pitocin administration to induce or augment labor, be sure you know your hospital's protocol for Pitocin use, Dennis J. Sinclitico, J.D., said.

In the three most recent obstetrical malpractice cases in which he served as a defense attorney, the physicians gave nurses orders for Pitocin (oxytocin) that contradicted the hospital's protocol, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

That contradiction forces nurses to make decisions about the utilization, titration, and discontinuation of Pitocin “without the comfort and background of their own protocol,” he noted. Often, there is no further physician involvement besides orders to “call me when you're ready” for delivery.

Basically, abandoning nurses with contradictory orders is “a terrible mistake and indefensible in many instances,” said Mr. Sinclitico, a defense lawyer in Long Beach, Calif.

If you want to leave orders for Pitocin use that differ from the hospital's protocol, document why you think your approach to management is important and appropriate. Give the nurses written instructions documenting that your orders differ from the protocol, and tell them how and when to adjust, titrate, or discontinue the Pitocin dosage. Provide written instructions on how and when the nurses should contact you.

Pitocin is a player in virtually every case he defends, even if it is not a relevant factor, Mr. Sinclitico noted. “I can't remember a case recently in which Pitocin was not ordered in some fashion,” he said at the meeting, sponsored by Boston University and the Center for Human Genetics.

The biggest problem he sees in the cases he defends that involve Pitocin administration stem from insufficient response to findings on the fetal heart rate monitoring strip. Fifteen, 20, or 60 minutes go by before nurses or physicians respond to a potential problem identified by the strip, and the health care workers leave insufficient documentation about the course of events, their timing, and reasons for acting or not acting.

“If I have a practice tip for you, it would be to go back to your hospital and emphasize the notion that if you're going to allow nurses to make those judgments, they should be made appropriately and in a timely fashion,” he said.

Because individual responses to Pitocin differ, the dose must be monitored carefully and adjusted as needed. Used properly, Pitocin can prevent the need for cesarean section in some deliveries. Risks from the force of contractions induced by Pitocin include potentially greater reductions in uterine blood flow than occur with natural contractions, which can lead to a greater reduction in oxygen for the fetus and possible fetal distress.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene. Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I'm worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003;289:1389–95). Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer. The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.” It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said. He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene. Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I'm worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003;289:1389–95). Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer. The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.” It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said. He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.

SAN FRANCISCO — The timing of chest compressions in CPR can mean life or death to some patients in cardiac arrest, Lance B. Becker, M.D., said at the annual meeting of the American College of Emergency Physicians.

An observational study of approximately 100 patients being resuscitated in a hospital counted the number and measured the rate of chest compressions through a personal digital assistant operated by a nurse at the rescue scene. Even in this small group of patients, those who received the 80–100 chest compressions per minute during CPR recommended by the American Heart Association were significantly more likely to survive, compared with those who received lower compression rates, said Dr. Becker, director of the emergency resuscitation center and professor of emergency medicine at the University of Chicago.

The study will be published in the Feb. 1, 2005, issue of the journal Circulation, he said.

The results especially are cause for concern when combined with new concepts about three phases of cardiac resuscitation, Dr. Becker added. He and others have proposed that the first, “electrical” phase of ventricular fibrillation is well treated by defibrillation, but patients in a second, “circulatory” phase may be better treated by first receiving compression, then defibrillation. In a third, “metabolic” phase, newer therapies are needed in addition to compression and defibrillation to save more lives, he said. At present, all patients in ventricular fibrillation undergo defibrillation.

“In that second phase, compression is important, but it has to be good compression,” Dr. Becker explained. “I'm worried about this. I think there are really good data that [show] we're not doing a great job on cardiac compression.”

A randomized, controlled trial in 2003 compared standard defibrillation with CPR first, then defibrillation in approximately 200 patients being resuscitated after cardiac arrest outside of hospitals. In a subgroup of patients reached by rescuers more than 5 minutes after cardiac arrest (who could be considered to be in that second phase of ventricular fibrillation), 20% who underwent compression plus defibrillation remained alive 1 year later, compared with 4% in the defibrillation-only group (JAMA 2003;289:1389–95). Animal studies back this concept, Dr. Becker said.

Physicians can begin today to save more lives by insisting that CPR be done appropriately, he suggested.

Dr. Becker and his associates are studying a new device to give resuscitators instant feedback on how well they're doing CPR. An accelerometer and a pressure gauge embedded into a sternal pad placed on the patient's chest are wired to a defibrillator and attached to a minicomputer. The device accurately measures the timing of compressions down to the millisecond and gives a good measurement of the depth of each compression, among other data.

In some patients, the readings show faster ventilation than compression. Hyperventilation in someone who has almost no cardiac output can increase venous return and cause what others have termed “death by ventilation,” Dr. Becker noted.

The investigational device can talk to rescuers with messages such as, “Slow down your ventilation,” or “Speed up your compression.” It is being studied in U.S. hospitals and on patients arresting outside of hospitals in Europe to see if it improves CPR and, thus, survival.

Early results seem “very promising,” Dr. Becker said. He has financial relationships with a series of companies involved in developing the device and is a paid consultant to two of them.