Collecting Data for Collecting Data for Fetal and Infant Mortality Fetal and Infant Mortality

ReviewsReviews

Dani Noell ARNP/RNCDani Noell ARNP/RNC

Christine E. Lynn College of Christine E. Lynn College of NursingNursing

Florida Atlantic University Florida Atlantic University

Program Description Program Description

Collecting Data for Fetal and Infant Mortality Collecting Data for Fetal and Infant Mortality Reviews (FIMR) was developed as a final Reviews (FIMR) was developed as a final graduate project for the masters degree of graduate project for the masters degree of nursing at Christine E. Lynn College of nursing at Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Nursing, Florida Atlantic University, Boca Raton, Florida by Danielle Noell, ARNP/RNC, Raton, Florida by Danielle Noell, ARNP/RNC, under the direction of Marilyn Parker, PhD, under the direction of Marilyn Parker, PhD, RN, FAAN, Project Advisor and Kathleen RN, FAAN, Project Advisor and Kathleen Buckley, CNM/MSN, Project Chair. Buckley, CNM/MSN, Project Chair.

Dani Noell is a neonatal nurse practitioner with over a Dani Noell is a neonatal nurse practitioner with over a decade of experiences abstracting records for fetal, infant, decade of experiences abstracting records for fetal, infant, child and maternal mortality review projects. She has been child and maternal mortality review projects. She has been a nurse for 30 years and believes very strongly in the Fetal a nurse for 30 years and believes very strongly in the Fetal and Infant Mortality Review (FIMR) process as a way to and Infant Mortality Review (FIMR) process as a way to improve systems of care for communities. Ms. Noell has improve systems of care for communities. Ms. Noell has abstracted hundreds of cases, provided training to FIMR abstracted hundreds of cases, provided training to FIMR data abstractors in Florida, presented at national FIMR data abstractors in Florida, presented at national FIMR conferences regarding data abstraction and has traveled to conferences regarding data abstraction and has traveled to several states to provide data abstraction training to new several states to provide data abstraction training to new FIMR projects. Ms. Noell wrote the chapter on data FIMR projects. Ms. Noell wrote the chapter on data abstraction in the abstraction in the National Fetal and Infant Mortality Review National Fetal and Infant Mortality Review Manual (NFIMR): A Guide for Communities Manual (NFIMR): A Guide for Communities and was a and was a coauthor for coauthor for FIMR: A Guide for Home Interviewers. FIMR: A Guide for Home Interviewers.

Fetal and Infant Mortality Fetal and Infant Mortality ReviewReviewFetal and Infant and Mortality Review (FIMR) projects Fetal and Infant and Mortality Review (FIMR) projects

are community based efforts to learn more about are community based efforts to learn more about the factors and issues associated with fetal and the factors and issues associated with fetal and infant deaths and to make recommendations and infant deaths and to make recommendations and take action to improve system of care. The National take action to improve system of care. The National Fetal and Infant Mortality Review Program (NFIMR) Fetal and Infant Mortality Review Program (NFIMR) is a collaborative effort between the American is a collaborative effort between the American College of Obstetricians and Gynecologists and the College of Obstetricians and Gynecologists and the Maternal and Child Health Bureau, Health Maternal and Child Health Bureau, Health Resources and Service Administration. Beginning in Resources and Service Administration. Beginning in the 1980’s with under 10 projects, today there are the 1980’s with under 10 projects, today there are over 200 nationwide, with more starting each year. over 200 nationwide, with more starting each year. There is also international interest in starting these There is also international interest in starting these review projects. review projects.

Who is this training for?Who is this training for?

This training is for beginning FIMR This training is for beginning FIMR abstractors and project coordinators abstractors and project coordinators who are interested in learning more who are interested in learning more about how data is collected for the about how data is collected for the

FIMR review process. FIMR review process.

ObjectivesObjectives

By the end of this presentation the learner will By the end of this presentation the learner will be able to: be able to:

• Discuss ways to organize abstraction Discuss ways to organize abstraction materialsmaterials

• Describe methods to access data sourcesDescribe methods to access data sources• Discuss barriers to abstractionDiscuss barriers to abstraction• Recall importance maintaining confidentiality Recall importance maintaining confidentiality

protocolsprotocols• Identify method to summarize case.Identify method to summarize case.• Discuss role of abstractor caring for self.Discuss role of abstractor caring for self.

IntroductionsIntroductions

Entering the Project Entering the Project

ResourcesResources

• National Fetal and Infant Mortality National Fetal and Infant Mortality Review ProgramReview Program

• Materials: publications, technical Materials: publications, technical assistance, electronic resourcesassistance, electronic resources

• FIMR Projects: about 200 in local and FIMR Projects: about 200 in local and state levelsstate levels

• Email: nfimr@acog.orgEmail: nfimr@acog.org

FIMR ProcessFIMR Process

DefinitionsDefinitions• Fetal death: a death prior to delivery if the 20th week Fetal death: a death prior to delivery if the 20th week

of gestation has been reached and fetus does not of gestation has been reached and fetus does not breathe or show any other evidence of life such as breathe or show any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.  definite movement of voluntary muscles. 

• Infant death: any death of an infant from birth up to Infant death: any death of an infant from birth up to (but not including) one year of age. (but not including) one year of age.

• Neonatal: death of a live born infant before 28 days of Neonatal: death of a live born infant before 28 days of life. life.

• Post neonatal: death of an infant after 28Post neonatal: death of an infant after 28thth day up to day up to (but not including) one year of age.(but not including) one year of age.

FIMR DataFIMR Data

• Vital statistics Vital statistics

• Maternal Maternal interviewsinterviews

• Medical recordsMedical records

• Social servicesSocial services

Vital StatisticsVital Statistics

STRENGTHSSTRENGTHS

• Traditional/well Traditional/well establishedestablished

• AvailabilityAvailability

• Community specific/Community specific/

Population based Population based datadata

• Helps with FIMR Helps with FIMR focusfocus

WEAKNESSWEAKNESS

• Limitations Limitations

• Accuracy Accuracy

Medical RecordsMedical Records

STRENGTHSSTRENGTHS

• AvailabilityAvailability

• Glimpse system Glimpse system carecare

• Fetal, neonatal and Fetal, neonatal and maternal maternal informationinformation

• In patient and In patient and outpatient records outpatient records

WEAKNESSWEAKNESS

• TechnicalTechnical

• Lack psychosocial Lack psychosocial datadata

• Time consumingTime consuming

• Poor imaging on Poor imaging on computerized computerized recordsrecords

Maternal InterviewMaternal Interview

STRENGTHS:STRENGTHS:

• Community voice Community voice

• Powerful Powerful informationinformation

• Consumer Consumer perspectiveperspective

• Bereavement follow Bereavement follow up and referralsup and referrals

• Cultural focusCultural focus

WEAKNESSESWEAKNESSES

• Can be hard to Can be hard to locatelocate

• Conflicting Conflicting informationinformation

Social Service RecordsSocial Service Records

• ReferralsReferrals

• Support servicesSupport services

• EducationEducation

• WICWIC

• Case managementCase management

• OtherOther

Starting the ProcessStarting the Process

• Community picks Community picks focusfocus

• Identify data toolsIdentify data tools

• Identify FIMR Identify FIMR abstractor/intervieabstractor/interviewerwer

• Identify legal Identify legal information information

NFIMR FormsNFIMR Forms

• ComprehensiveComprehensive

• Multi-systemMulti-system

• FreeFree

• RevisedRevised

• History of useHistory of use

AbstractorAbstractor

• FlexibleFlexible

• Knowledge baseKnowledge base

• TransportationTransportation

• Computer and Computer and people skillspeople skills

• Unbiased Unbiased storytellerstoryteller

FIMR Legal IssuesFIMR Legal Issues

• Know your statutes/immunity Know your statutes/immunity

• Institutional Review Board (IRB)Institutional Review Board (IRB)

• Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA) Accountability Act (HIPAA)

• Confidentiality protocolsConfidentiality protocols

• Accessing records/limitationsAccessing records/limitations

• Storing informationStoring information

• Child abuse reporting lawsChild abuse reporting laws

HIPAAHIPAA

• Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA) of 1996: Accountability Act (HIPAA) of 1996: to protect privacy and security of to protect privacy and security of exchange of health information.exchange of health information.

• See sample letters in See sample letters in FIMR: HIPAA FIMR: HIPAA Privacy RegulationsPrivacy Regulations

Confidentiality is key.Confidentiality is key.

AbstractAbstract

(ab.strakt”) v.t. to separate (ab.strakt”) v.t. to separate from; remove, summarize; from; remove, summarize;

reducereduce

AccessAccess

• (ak’.ses)n. a (ak’.ses)n. a coming to the coming to the means or way of means or way of approach: approach: admission; admission; entrance; attack; entrance; attack; fit.fit.

Traveling from B to ATraveling from B to A

Abstraction MethodologyAbstraction Methodology

• Organization of Organization of casescases

• Accessing sources Accessing sources

• Identification of Identification of barriersbarriers

• Communication Communication skillsskills

Early Organization Early Organization

• Assemble abstracting Assemble abstracting materials: fetal/infant materials: fetal/infant packet, case packet, case identifiers, legal formsidentifiers, legal forms

• Abstracting supplies: Abstracting supplies: pens/pencils, extra pens/pencils, extra abstraction formsabstraction forms

• Make a list of hospitals Make a list of hospitals and contact and contact persons/phone and persons/phone and secure fax numberssecure fax numbers

Abstraction PathwaysAbstraction Pathways

Identification of Fetal/Infant Death

Abstractor notifies Medical Records

Of request to Review

Is request approved? NO

Yes

Is education indicated?

Yes

Provide copies of statutes. letters

Abstract hospital record

No

Communication with Directors/Managers

Abstraction PathwaysAbstraction PathwaysWere providers

Identified?

Yes No

Abstractor contacts providers and

requests to abstract

Is request approved?

Completed data

Yes No

Abstract records

Ask provider to fill out forms

Yes No

Completed Data

Case is summarized including information

from maternal interview

Abstracting BarriersAbstracting Barriers

Abstracting BarriersAbstracting Barriers

• Provider refusalProvider refusal

• Lost records, incomplete misfiledLost records, incomplete misfiled

• Communication confusionCommunication confusion

• Missing contact person: Always have Missing contact person: Always have a back up persona back up person

• TravelingTraveling

Communication SkillsCommunication Skills

• Not burn bridgeNot burn bridge

• Take time to be knownTake time to be known

• Represent your projectRepresent your project

• Refusal to participate due to many Refusal to participate due to many factorsfactors

• May join with time if decreased threatMay join with time if decreased threat

• Have sensitivity to provider grief Have sensitivity to provider grief

Abstractor InterventionsAbstractor Interventions

• Abstractor not to change system by selfAbstractor not to change system by self

• Key points Key points

- Confidentiality- Confidentiality

- Ethical decision: system vs. individual- Ethical decision: system vs. individual

• Omissions/clerical errors Omissions/clerical errors

• Suspected child abuse Suspected child abuse

• Copy records for others Copy records for others

Additional Information Additional Information

• Details back of formsDetails back of forms

• Treatments and follow upTreatments and follow up

• Answer timing questions Answer timing questions

• Supportive lab information Supportive lab information

• CRT helps to evolve type info CRT helps to evolve type info neededneeded

Abstracting TipsAbstracting Tips

• Chronological order eventsChronological order events

• Don’t put in your opinionDon’t put in your opinion

• OK to present conflicting informationOK to present conflicting information

• Notation on forms if didn’t find Notation on forms if didn’t find informationinformation

• Keep forms de-identifiedKeep forms de-identified

Basic FIMR Abstracting RuleBasic FIMR Abstracting Rule

““If the information about a question is If the information about a question is not in the chart it was NOT done.”not in the chart it was NOT done.”

Summarizing The StorySummarizing The Story

•Medical/social and maternal Medical/social and maternal interviewinterview

•De-identifiedDe-identified

•Preserves mothers voice Preserves mothers voice

•Caution what eliminate/not biasCaution what eliminate/not bias

•Consistent for CRT deliberation Consistent for CRT deliberation

•Types: narrative/bulleted/italicsTypes: narrative/bulleted/italics

Caring For SelfCaring For Self

Reflections on Abstracting Reflections on Abstracting • The greater past relationship you have with a The greater past relationship you have with a

provider, the less likely they will give you access to provider, the less likely they will give you access to their records.their records.

• The record you abstract quickly is most likely to be The record you abstract quickly is most likely to be the hardest to summarize.the hardest to summarize.

• The longer a case is discussed at a CRT meeting, the The longer a case is discussed at a CRT meeting, the more certain it is that no one has the faintest idea of more certain it is that no one has the faintest idea of what happened.what happened.

• The probability of crying is directly proportional to the The probability of crying is directly proportional to the number of cases you have abstracted.number of cases you have abstracted.

• If you can’t figure out what steps to do next in an If you can’t figure out what steps to do next in an abstraction pathway, call another abstractor. They abstraction pathway, call another abstractor. They may not have any idea either but you sure will feel may not have any idea either but you sure will feel better. better.

• The ‘success’ of the project is directly proportional to The ‘success’ of the project is directly proportional to the community’s response.the community’s response.

““The best preparation for tomorrow is The best preparation for tomorrow is to do today’s work superbly well.” to do today’s work superbly well.”

Sir William OslerSir William Osler

ReferencesReferencesBuckley, K., Koontz, A. & Casey, S. (1998). Buckley, K., Koontz, A. & Casey, S. (1998). Fetal and infant mortality review Fetal and infant mortality review

manual: A guide for communities.manual: A guide for communities. Washington, DC: American College of Washington, DC: American College of Obstetricians and Gynecologists. Obstetricians and Gynecologists.

Harmer, B. (1929). Harmer, B. (1929). Text-Book of the principles and practice of nursingText-Book of the principles and practice of nursing. New . New York: The MacMillan Company. York: The MacMillan Company.

Lauterbach, S. & Becker, P. ( 1996) Caring for self: Becoming a self-reflective Lauterbach, S. & Becker, P. ( 1996) Caring for self: Becoming a self-reflective nurse, nurse, Holistic Nursing Practice,Holistic Nursing Practice, 1010(7), 57-68.(7), 57-68.

McNeely, E. (2005). The consequences of job stress for nurses health: Time for McNeely, E. (2005). The consequences of job stress for nurses health: Time for a check up. a check up. Nursing outlook,Nursing outlook, 5353(6), 291-299. (6), 291-299.

Pellatt, G. (2003). Ethnography and reflexivity: Emotions and feelings in Pellatt, G. (2003). Ethnography and reflexivity: Emotions and feelings in fieldwork. fieldwork. Nurse Researcher,Nurse Researcher, 1010(3) pp.28-37.(3) pp.28-37.

Polit, D. & Beck, C. (2004). Polit, D. & Beck, C. (2004). Nursing research principles and methodsNursing research principles and methods. 7. 7thth ed. ed. Philadelphia, PA: Lippincott Williams & Wilkins.Philadelphia, PA: Lippincott Williams & Wilkins.

Shafer, J., Noell, D., & MCClain, M. (2002) Shafer, J., Noell, D., & MCClain, M. (2002) Fetal and infant mortality review: A Fetal and infant mortality review: A guide for home interviewsguide for home interviews. Washington, DC: American College of . Washington, DC: American College of Obstetricians and Gynecologists. Obstetricians and Gynecologists.

The fetal and infant mortality review process: The hipaa privacy regulations.The fetal and infant mortality review process: The hipaa privacy regulations. (2003) Washington, DC: American College of Obstetricians and (2003) Washington, DC: American College of Obstetricians and Gynecologists. Gynecologists.

Wise, P. & Wulff, L. (1992) Wise, P. & Wulff, L. (1992) A manual for fetal and infant mortality review.A manual for fetal and infant mortality review. Washington, DC: American College of Obstetricians and Gynecologists. Washington, DC: American College of Obstetricians and Gynecologists.

Appreciation for Don Noell for the photographs, Mike Noell for Appreciation for Don Noell for the photographs, Mike Noell for emotional and financial support emotional and financial support

and for and for

Frank Meoni at Christine E. Lynn College of Nursing Frank Meoni at Christine E. Lynn College of Nursing Florida Atlantic University for technical assistance with this Florida Atlantic University for technical assistance with this

project.project.