Peer Review Monthly: Case studies in peer review

Dear medical staff leaders and professionals,

Dr. Jon Burroughs and I are just completing entitled Peer Review Best Practices: Case Studies and Lessons Learned, which will be published later this fall. Dr. Burroughs wrote the case presented below.
 
The goal of the book is to help train physicians on how make peer review less biased and more efficient. The 20 case studies presented in the book are real cases that illustrate some important lessons. Although this column does not allow for the reproduction of the complete case study, we hope this except is helpful.

Clinical scenario: An 18 year old prima-gravida female presents in active labor at full term with no pre-natal risk factors. She does well until the second stage of labor when the nurse mid-wife notes a lack of beat-to-beat variability on the fetal monitoring strip and occasional periods of fetal bradycardia (P 90-100). The OB/GYN attending is consulted and decides to use the vacuum extractor and cut a medio-lateral episiotomy to deliver the baby expeditiously. A six-pound baby girl is delivered with adequate APGAR (appearance, pulse, grimace, activity, respiration) scores and her mother does fine except for a fourth-degree vaginal tear that requires four-layer repair and closure. Mother and baby are discharged home after two days of observation. The mother does not experience urinary or fecal incontinence but does report a moderate amount of pain from her vaginal tear during intercourse for several months.

Criteria for review: The fourth degree vaginal tear is an unexpected complication of delivery and referred by the OB department.

Using a generic indicator like “unexpected complication” opens a plethora of opportunities for case review, most of which individually will not yield significant opportunities for improvement. Confining review indicators to specific high-risk issues and using rate indicators for frequency issues will significantly decrease a peer review committee’s work load while equally increasing the opportunities for improvement.

Nurse screener review: The nurse feels that the fourth-degree vaginal tear is probably the result of the medio-lateral episiotomy and is thus an “unexpected complication.” He asks the physician reviewer as to whether the episiotomy was indicated, and if so, if the fourth-degree tear could have been avoided.

Initial physician findings: The physician agrees that an episiotomy was indicated in light of fetal distress during the second stage of labor. She feels that the fourth-degree laceration may have been avoided by performing a medio-lateral episiotomy at a slightly greater angle away from the midline. She rates the overall physician care as appropriate and suggests that the episiotomy could be made at a sharper angle away from the midline.

Committee findings: The committee agrees with the initial reviewer but also wants to commend the OBGYN attending for delivering a baby in obvious fetal distress so expeditiously. They send a letter of commendation to the attending and decide to “track and trend” fourth degree vaginal tears to see if there are any outliers in the OB department.

Lesson learned: Tracking and trending individual outcomes (fourth-degree tear) is not likely to improve overall care. Monitoring the rate of non-indicated episiotomies over time utilizing pre-determined targets is more efficient for the committee and fairer to the physician. The peer review committee only needs to be involved if a pre-set threshold rate is exceeded.

It is not rare for a case to be reviewed that represents exemplary performance. Recognizing this by giving positive feedback to the physician has a profound impact on the medical staff culture.

Best,
Robert Marder, MD, CMSL
The Greeley Company