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OBSTETRICS P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations and electronic fetal monitoring: gaining consensus and collaboration Larry Veltman, MD; Kristine Larison, RN, RNC, BSN, MBA “Late deceleration: Visually apparent usually symmetrical gradual decrease and return of the fetal heart rate (FHR) associated with a uterine contraction. A gradual FHR decrease is defined as from the onset to the FHR nadir of 30 seconds or more. The decrease in FHR is calculated from the onset to the nadir of the de- celeration. The deceleration is delayed in timing, with the nadir of the deceleration oc- curring after the peak of the contrac- tion. In most cases, the onset, nadir, and re- covery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively.” 1 At the depositions: “She was having late decelerations and I really wanted him to come in.” “She really did not seem that con- cerned about the tracing. She never asked me to come to see the patient.” T his hypothetical scenario is the re- sult of a communications failure that could occur despite the standard- ized terminology and suggested manage- ment regimens agreed on at a consensus conference sponsored by the National Institute of Child Health and Human Development (NICHD) in April of 2008. 2 The terminology was accepted and endorsed by both the American Col- lege of Obstetrics and Gynecologists and Association of Women’s Health, Obstet- ric, and Neonatal Nurses. 3,4 Several commercial interests have initi- ated efforts to make these definitions and interpretations available to the perinatal community. 5 There are, however, con- tinuing concerns that this new approach will not necessarily result in improved teamwork, a collaborative approach to care, and improved responsiveness when intervention is needed. Some organizations have recognized that even with mandatory certification of their medical and nursing staffs in the understanding of the new terminology, improved outcomes need to be associ- ated with team training for all members of the perinatal team. 6 So it can be said that although the standard definitions provided by the NICHD Consensus Conference provide a foundation for in- terpretation, it is the integration of all of the characteristics of the fetal tracing combined with the clinical picture of the patient that must be considered and discussed. Despite the efforts of a few organiza- tions’ attempts to improve teamwork and communication surrounding the in- terpretation of fetal heart tracings, this communications component of care has been largely unaddressed. The essential missing link centers on the process of ef- fective communication between health care professionals that will eventually lead to a consensus-based management plan that results in the best outcome for the mother and her fetus. Recognition of patterns, the decision to call the patient’s provider, the nature of the call and the tenor of the conversation, reaching con- sensus of interpretation, and finally reaching a management plan are all part From the Department of Perinatal Medicine, Providence St Vincent Medical Center, Portland, OR. Received Dec. 5, 2009; revised Jan. 30, 2010; accepted March 18, 2010. Reprints: Larry Veltman, MD, FACOG, 205 SE Spokane, Suite 320, Portland, OR 97202. [email protected]. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.03.033 A revised nomenclature regarding electronic fetal heart rate monitoring was accepted at a National Institute of Child Health and Human Development consensus conference in 2008. At the heart of patient safety are communication strategies that enhance teamwork and collaboration between health care professionals. Communications is a complex 2-way process that involves more than transfer of factual information. P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations in Obstetrics is an acronym that helps facilitate this communication process in perinatal care. P.U.R.E. stands for purpose- ful, unambiguous, respectful, and effective. The P.U.R.E. Conversations approach involves refinement of the mental processes associated with delivering the message, delivery of the message with data, accuracy, and direct requests for action, attention to relationships and behaviors between the communicating parties, and real-time assessment of the effec- tiveness of the communication. When the new electronic monitoring nomenclature is combined with an effective communication tool, one could expect to see a reduction in communication failures that could lead to adverse perinatal outcomes. Key words: communications, electronic fetal monitoring, liability in obstetrics, patient safety Cite this article as: Veltman L, Larison K. P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations and electronic fetal monitoring: gaining consensus and collaboration. Am J Obstet Gynecol 2010;203:440.e1-4. Clinical Opinion www. AJOG.org 440.e1 American Journal of Obstetrics & Gynecology NOVEMBER 2010

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Page 1: P.U.R.E. (purposeful, unambiguous, respectful, and effective) Conversations and electronic fetal monitoring: gaining consensus and collaboration

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BSTETRICS

.U.R.E. (purposeful, unambiguous, respectful, and effective)onversations and electronic fetal monitoring:aining consensus and collaboration

arry Veltman, MD; Kristine Larison, RN, RNC, BSN, MBA

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Late deceleration:

Visually apparent usually symmetricalgradual decrease and return of the fetalheart rate (FHR) associated with auterine contraction.A gradual FHR decrease is defined asfrom the onset to the FHR nadir of 30seconds or more.The decrease in FHR is calculatedfrom the onset to the nadir of the de-celeration.The deceleration is delayed in timing,with the nadir of the deceleration oc-curring after the peak of the contrac-tion.In most cases, the onset, nadir, and re-covery of the deceleration occur afterthe beginning, peak, and ending of thecontraction, respectively.”1

t the depositions:

She was having late decelerationsnd I really wanted him to come in.”She really did not seem that con-erned about the tracing. She neversked me to come to see the patient.”

his hypothetical scenario is the re-sult of a communications failure

hat could occur despite the standard-zed terminology and suggested manage-

rom the Department of Perinatal Medicine,rovidence St Vincent Medical Center,ortland, OR.

eceived Dec. 5, 2009; revised Jan. 30, 2010;ccepted March 18, 2010.

eprints: Larry Veltman, MD, FACOG, 205 SEpokane, Suite 320, Portland, OR 97202.

[email protected].

002-9378/$36.002010 Mosby, Inc. All rights reserved.

ooi: 10.1016/j.ajog.2010.03.033

40.e1 American Journal of Obstetrics & Gynecolo

ent regimens agreed on at a consensusonference sponsored by the Nationalnstitute of Child Health and Humanevelopment (NICHD) in April of

008.2 The terminology was acceptednd endorsed by both the American Col-ege of Obstetrics and Gynecologists andssociation of Women’s Health, Obstet-

ic, and Neonatal Nurses.3,4

Several commercial interests have initi-ted efforts to make these definitions andnterpretations available to the perinatalommunity.5 There are, however, con-inuing concerns that this new approachill not necessarily result in improved

eamwork, a collaborative approach toare, and improved responsiveness whenntervention is needed.

Some organizations have recognizedhat even with mandatory certification ofheir medical and nursing staffs in thenderstanding of the new terminology,

mproved outcomes need to be associ-ted with team training for all members

A revised nomenclature regarding electroniNational Institute of Child Health and HumanAt the heart of patient safety are communicollaboration between health care professprocess that involves more than transferunambiguous, respectful, and effective) Cohelps facilitate this communication processful, unambiguous, respectful, and effective.refinement of the mental processes associamessage with data, accuracy, and direct reqbehaviors between the communicating pativeness of the communication. When thecombined with an effective communicationcommunication failures that could lead to a

Key words: communications, electronic fetal

Cite this article as: Veltman L, Larison K. P.U.R.E.Conversations and electronic fetal monitoring:Gynecol 2010;203:440.e1-4.

f the perinatal team.6 So it can be said r

gy NOVEMBER 2010

hat although the standard definitionsrovided by the NICHD Consensusonference provide a foundation for in-

erpretation, it is the integration of all ofhe characteristics of the fetal tracingombined with the clinical picture of theatient that must be considered andiscussed.Despite the efforts of a few organiza-

ions’ attempts to improve teamworknd communication surrounding the in-erpretation of fetal heart tracings, thisommunications component of care haseen largely unaddressed. The essentialissing link centers on the process of ef-

ective communication between healthare professionals that will eventuallyead to a consensus-based managementlan that results in the best outcome forhe mother and her fetus. Recognition ofatterns, the decision to call the patient’srovider, the nature of the call and theenor of the conversation, reaching con-ensus of interpretation, and finally

tal heart rate monitoring was accepted at avelopment consensus conference in 2008.on strategies that enhance teamwork andls. Communications is a complex 2-way

factual information. P.U.R.E. (purposeful,rsations in Obstetrics is an acronym thaterinatal care. P.U.R.E. stands for purpose-P.U.R.E. Conversations approach involves

with delivering the message, delivery of thests for action, attention to relationships and, and real-time assessment of the effec-w electronic monitoring nomenclature is

ol, one could expect to see a reduction inrse perinatal outcomes.

nitoring, liability in obstetrics, patient safety

poseful, unambiguous, respectful, and effective)ing consensus and collaboration. Am J Obstet

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f the communication process that isecessary for appropriate care.There have been some reasonable at-

empts to codify some components ofhis process by linking certain fetal heartatterns to the requirement that the phy-ician is needed at the bedside.7 An addi-ional relatively new layer of safety in ob-tetrical care, the introduction of thebstetric hospitalist or laborist, has madehe need for accurate communicationetween multiple practitioners evenore essential.The purpose of this essay is to focus

ttention on the need to address thisommunication process between profes-ionals associated with the NICHD ter-

inology and to make recommenda-ions of how individual labor andelivery units can implement, encultur-te, and hardwire these communicationtrategies.

It is important to recognize that com-unication is a complex 2-way process,ith a number of factors that can lead

o miscommunication, or the lost-in-ranslation effect. Miscommunicationan result from the choice of languageade by the person sending the message

nd from the interpretation of the mes-age by the receiver, both being steps inhe communication process in which

ore than the words themselves (theacts) are attached to the actual materialeing transferred.Said in another way, “Communica-

ion is often not simply about conveyingactual information but often also con-ains components of self-revelation (anxpression of the sender), the relation-hip between the sender and receiver, andn appeal aimed at influencing the re-eiver” (italics added).8

.U.R.E. (purposeful, unambiguous,espectful, and effective)onversations in obstetrics:framework for enhancing

ommunications on the perinatal unittructured communication as a way to im-rove the transfer of information between

ndividuals is not new to health care and, inarticular, perinatal medicine. One popu-

ar form of structured communication, sit-

ation, background, assessment, and rec- a

mmendation (SBAR), has been widelyntroduced in the perinatal arena.9

P.U.R.E. Conversations was devel-ped as a tool to enhance structuredommunications between health carerofessionals in the perinatal unit.10 Therinciples of P.U.R.E. Conversations areeant to complement and enhance any

ther form of structured communica-ion that might be in use. The P.U.R.E.onversations approach to communica-

ion seeks to refine the mental process ofetermining a purpose for the conversa-ion; delivering the message in an un-biguous manner; making sure that thenterchange is respectful (safe, balanced,nd nonintimidating); and measuring,n real time whether the conversation isffective in determining the plan ofction.

As a complement to the SBAR tech-ique of structured communication,.U.R.E. Conversations takes into ac-ount relationships of the individuals asell as allowing for an ongoing evalua-

ion of the progress and eventual successf the interaction. P.U.R.E. Conversa-ions is a particularly useful tool to helprevent miscommunications regarding

etal monitoring interpretation, clearlyne of the most frequent, high-risk con-ersations that occur in labor andelivery.We advocate using the P.U.R.E. Con-

ersations approach that incorporatesICHD definitions, terminology, and

ategory determination. Many of theonversations about category I and IIIracings will be straightforward with re-pect to management; it is the broad def-nition and varied approaches to cate-ory II tracings that will require the mostffective communication practices.

P.U.R.E. Conversations addresses theature and structure of the communica-

ion that must take place between mem-ers of the perinatal team, be it nurses,idwives, residents, obstetricians, fam-

ly medicine physicians, or maternal-fe-al medicine specialists. In most cases,he communication begins with theurse at the bedside and is directed to-ard house staff or the patient’s attend-

ng physician or midwife. Even in situa-ions in which the fetal heart tracing is

vailable for viewing by all parties

NOVEMBER 2010 Americ

hrough a number of alternate technolo-ies, the elements of interpretation andubsequent management still requireonsensus to be reached by the patient’surses and physicians. It is the success of

his communication component that isecessary to gain consensus and subse-uent action, if necessary, based on theppearance of the fetal monitoring stripnd the clinical status of the mother.

Using the P.U.R.E. Conversationstructure, a typical approach to the com-

unication process regarding a given fe-al heart tracing would entail the follow-ng factors:

: purpose. The nurse (or whoever is at the bed-

side) would make a clear determina-tion of the elements of the tracingbased on the NICHD terminology.Using a mental or a written checklistformat, baseline rate, variability, thepresence or absence of decelerationsor accelerations, the type of decelera-tions defined, and the characteristicsof uterine activity would be noted.

. The next step would be to put this in-formation together in a SBAR format.SBAR is a form of structured commu-nication that has been widely intro-duced in many professional settingsas a method to organize, prioritize,and deliver information that is to becommunicated.

. Before the call is placed, the mentalprocess of determining the purpose ofthe call should be formulated. Thepurpose of the call may be to ask thepatient’s physician to come to thebedside, to give a progress report, orto ask for a medication change or ad-dition, but the purpose of the callshould be clear in the caller’s mindbefore the call is made. Without aclearly established purpose, it is diffi-cult to construct the necessary ele-ments of the conversation and evenmore difficult to evaluate the successof the interaction.

: unambiguous

. The call should be made and thetransfer of information and requestfor action should be presented in an

unambiguous manner with respect to

an Journal of Obstetrics & Gynecology 440.e2

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the following issues: first would comean SBAR report as to the nature of thetracing; second would be a requestfrom the caller to the recipient to viewthe tracing, if available, off site (home,office, or celluar device) during the dis-cussion. Third, there should be a clearstatement of whether the physician isrequested to come to the bedside. Thislatter point, on occasion, especially atnight, may produce resistance, negoti-ation, and even anger when the requestto come to the bedside is hesitant, am-biguous, or unsupported by evidencefrom the tracing.

. Because many studies have shownthat there is never going to be 100%agreement in monitor tracing inter-pretation, there should be a unit pol-icy that addresses when the physicianshould come to the hospital. This pol-icy might address the following:a. When the physician must come.

For example,i. If the nurse is not sure about

the tracing or the conditions ofthe mother or fetus.

ii. If the doctor is not sure aboutthe tracing or the conditions ofthe mother or fetus.

iii. If the nurse and doctor can notagree about the tracing, thecategory or the plan of care.

iv. If the category is clearly II orIII.

b. What the physician is expected todo when he or she comes to theunit:

i. Write a progress note in thepatient’s record.

ii. Have a minibriefing to estab-lish the category of the fetaltracing, the plan of care, or thenext check-in point.

c. Have a method to resolve any con-flicts or disagreements that mightoccur. (See additional discussionin the following text regarding theevaluation of the effectiveness ofthe conversation.)

. When requesting the physician tocome to the hospital, an unambigu-ous request might be, “I would likeyou to come to the hospital now to

evaluate the fetal tracing.” This ●

40.e3 American Journal of Obstetrics & Gynecolo

should be followed by the question,“When can I expect you to arrive?”

: respectful. It is well established in the literature

that disruptive and intimidating be-havior is a potent inhibitor of com-munication.11 There is also ample ev-idence that this behavior is associatedwith a significant proportion of nearmisses and adverse outcomes.12

. It should be clear to the professionalson the entire unit that there is a zerotolearance for unprofessional behav-ior, and there should be policies andprocedures that are effectively de-signed to deal with such behaviors.These policies should stress the im-portance of reporting such behaviorsand, as importantly, address the pro-hibition of retaliation when unpro-fessional behavior is reported.

. The “R” in P.U.R.E. Conversationsstanding for respect is unique as anadjunct to the concept of structuredcommunication because it focuses onthe relationship of the individualswho are communicating with eachother. An example that occurred atour institution was as follows: a nursecalled a physician with what shethought was a well-structured SBARreport of a situation. The physicianwas not satisfied with the style and thecontent of the report and remarked,“You call that an SBAR?!” By utilizingthe principle of respect during the re-sponse to the SBAR message, thecomment from the physician wouldhave been different, and the overalleffectiveness of the conversation interms of what was needed for the pa-tient would have most likely beenenhanced.

: effective. As part of the real-time evaluation andebriefing of the communication pro-ess, the parties should ask themselvesnd/or each other where applicable:Was the preparation adequate?Were the data correct?Was the information reported in anSBAR format?

Was the right person contacted? f

gy NOVEMBER 2010

Were the requests clear and under-stood?Was the response reasonable? Re-spectful?Were other measures necessary to helpresolve conflicts that arose from theconversation? What techniques wereused and how effective were they?2. Part of the communication training

rocess for staff on any perinatal unithould be dedicated to conflict resolu-ion. There are a number of tools to assistith this training. A particularly effective

ool is the TeamSTEPPS program devel-ped by the Department of Defense inonjunction with the Agency for Health-are Research and Quality.13

3. To have a successful communica-ion strategy, it is critical for the entireepartment to agree on a prescribed ap-roach for conflict resolution. The use ofcripts, key phrases, elevation policies tohe chain of command, implementationf a 2-challenge approach to stop the

ine, second opinion teams, and depart-ental leadership can all provide effec-

ive tools and personnel to help resolveonflicts, should they occur.

At this time, preliminary data arevailable regarding the effectiveness ofsing P.U.R.E. Conversations. After

raining sessions with physicians andurses practicing the principles of struc-

ured communication, immediate par-icipant satisfaction was high. For exam-le, of 121 participants in one system’series of workshops, 121 of 121 found theraining useful and rated the importancend quality of the subject matter and theaterials at 4.8 of 5. For many it was the

rst time that physicians and nurses ac-ually practiced talking with each other.

Additional data obtained 6 months af-er the training reflected that 81% of par-icipants felt that they used the principlesf P.U.R.E. Conversations in their dailyractice, 83% felt that communicationsere improved on their perinatal unit,9% felt that the unit had hardwired.U.R.E. Conversations and the culturef the unit had changed, and 61% felthat the changes in communicationractices were permanent rather thanemporary.

Fetal monitoring is more than identi-

ying elements of the tracing with the
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www.AJOG.org Obstetrics Clinical Opinion

ppropriate terminology. The criticalhase of care involves the care plan andhe actions that result from the monitortrip interpretation and subsequent inte-ration of the elements of the tracingith the clinical status of the patient. If

ommunications are inadequate in anyf the elements described in the afore-entioned text, without purpose, am-

iguous, disrespectful, and ineffective,here is a good chance that the patientill not receive the safest care that she

hould. Combining proper understand-ng of the NICHD terminology withommunications policies and training inhe utilization of a structured communi-ation tool will benefit patients and in-rease satisfaction among members ofhe perinatal team. f

EFERENCES. American College of Obstetricians and Gyne-ologists. Intrapartum fetal heart rate monitor-

ng: nomenclature, interpretation, and generalanagement principles. ACOG practice bulletin

o. 106. Obstet Gynecol 2009;114:192-202. 2

. Macones GA, Hankins GD, Spong CY, Hauth, Moore T. The 2008 National Institute of Childealth and Human Development Researchorkshop report on electronic fetal heart rateonitoring. Obsetet Gyneocl 2008;112:661-6.. American College of Obstetricians and Gyne-ologists. ACOG refines fetal heart rate moni-oring guidelines. Office of Communications,une 22, 2009. Available at: www.acog.org.ccessed Nov. 1, 2009. Updated resource pro-ides electronic. Association of Women’s Health, Obstetricnd Neonatal Nurses. Fetal heart monitoringuidance, AWHONN press release May 25,009. Available at: www.awhonn.org. Ac-essed Nov. 1, 2009.. For examples, see the following web sites.dvanced Practice Strategies, Advanced fetalssessment and monitoring. Available at: www.ps-web.com. Accessed Nov. 10, 2009, and GEealthcare. Available at: www.gehealthcare.om/usen/perinatal/clinical_ed/elecfetheart_on.html. Accessed Nov. 10, 2009.. Pettker CM, Thung SF, Norwitz ER, et al. Im-act of a comprehensive patient safety strategyn obstetric adverse events. Am J Obstet Gy-ecol 2009;200:492.e1-8.. Parer JT, Ikeda T. A framework for standard-

zed management of intrapartum fetal heart rateatterns. Am J Obstet Gynecol 2007;197:

6.e1-6.

NOVEMBER 2010 Americ

. Key principles of effective communication, aearning module by Marinita Schumacher,nowledge Board web page. Available at:ttp://www.knowledgeboard.com/item/2697

referring to Schulz von Thun, Friedemann,001). Miteinander reden 1. Allgemeine psy-hologie der kommunikation. Reinbek beiamburg: Rowohlt Taschenbuch Verlag. Avail-ble at: http://www4.uwm.edu/cuts/bench/ommun.htm. Accessed Oct. 15, 2009.. Dixon JF, Larison K, Zabari M, Skilled com-unication: making it real. AACN Advancedritical Care. 2006;17:376-82.0. Veltman L, Larison K. PURE Conversations

n obstetrics: a process to enhance structuredommunications and teamwork on the perinatalnit. Journal of Healthcare Risk Management.007;27:2, 41-44.1. Veltman LL. Disruptive behavior in obstet-ics: a hidden threat to patient safety. Am J Ob-tet Gynecol 2007;196:587.e1-5.2. Rosenstein AH, O’Daniel M. Disruptive be-avior and clinical outcomes: perceptions ofurses and physicians. Am J Nurs 2005;05:54-64.3. TeamSTEPPS. Available at: www.teamstepps.hrq.gov (for complete description). Accessed Oct.0, 2009.

an Journal of Obstetrics & Gynecology 440.e4