OBI Data Variables and Definitions
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OBI Data Variables and Definitions APRIL RICHMOND, BSN, RN SARAH EVILSIZER, BSN, RN OBSTETRICS INITIATIVE DATA MANAGERS [email protected] Module Objectives • Become familiar with the OBI Data Manual (v2) • Explore the different OBI data sections and associated variables • Identify additional resources and support OBI Program Manual 2019 Data Collection Manual v2 obstetricsinitiative.org/data-abstraction Important Documents • Section: OBI Data Variables and Definitions Demographics Neonatal Outcomes Labor Management Maternal Outcomes Delivery Post Discharge Events Cesarean Delivery Arrest Disorders DEMOGRAPHICS Demographics • Hospital Name • Ethnicity • Patient Last Name • Race • Patient First Name • Patient Postal Zip Code • Medical Record Number • Patient Insurance Type • Maternal Birthdate Demographics ● Mouse Minnie 1234 01/01/1990 ✔ 48888 ✔ LABOR MANAGEMENT Labor Management • Admission • Maternal Comorbidities Present on Admission • Planned Mode of Delivery • Admission with Labor for Planned Vaginal Birth • Pain, Discomfort, and Coping During Labor • Labor Support Admission Date & Time • Record the date and time the patient was admitted to L&D Unit for care • Become familiar with your hospital’s admitting processes Examples: – IF inpatient admission orders are placed right before or at time of birth THEN use the time patient was placed in labor room or unit – IF the patient is in observation status during workup for HTN to determine whether or not to admit THEN use date/time patient was placed in labor room or unit Admitting Provider and Nurse Provider Admitting Patient to L&D • Focus on the provider who made the decision to move the patient to the next level of care Select the Attending Physician or CNM from the drop down in the registry – If provider is not found in the list, follow instructions in the manual to add a new provider. Admitting Nurse • L&D Nurse receiving the patient from triage The admitting RN will most likely be the Nurse completing the admission intake assessment Free Text Field, enter as: Last Name, First Name Gravidity and Parity on Admission • OBI only includes nulliparous patients (P0) If parity is documented as 1 or more then re-review the OBI case selection criteria for inclusion! • Make sure you are reviewing G&P status BEFORE delivery as this status will update following delivery Maternal Height & Weight • Height entered as inches or centimeters • Weight entered as pounds or kilograms Admission weight: The most recent weight prior to delivery Pre-Pregnancy weight: The last pre-pregnancy weight (up to 12 weeks gestation) Prenatal Care • Determine if the patient received prenatal care If prenatal care is not discussed in the EMR, select “Unable to Determine” • If Yes is selected, enter the date (or estimated date) prenatal care started If the month is known, but not the exact te day, use the 15th of that month If you can not reasonably estimate the start of prenatal care, leave it blank Comorbidities Medical • Pre-Pregnancy Diabetes Hx of diabetes prior to pregnancy • Gestational Diabetes Developed for the first time during pregnancy • Pre-Pregnancy Hypertension Chronic Htn diagnosed on or before 20 weeks • Gestational Hypertension Gestational Htn, pre-eclampsia, eclampsia, HELLP syndrome during pregnancy • Asthma Comorbidities Substance Use • Alcohol use anytime during pregnancy • Tobacco use before or during pregnancy If yes, record quit smoking status • Opioid use during pregnancy See Appendix D for a reference list of Opioids For MAT therapy, select the appropriate Medication used as part of the program Planned Mode of Delivery What was the planned mode of delivery AT TIME OF ADMISSION? • Admission with labor for planned Planned vaginal birth Labor for • Pain, discomfort, and coping Vaginal Delivery during labor • Labor Support Delivery Section Planned • Primary Indication for Planned Cesarean Cesarean Delivery Planned Vaginal Birth Labor Status at Admission • Determine if the patient was admitted for Induction vs Spontaneous Onset of Labor and membranes status • If being admitted for induction, determine primary reason Secondary reasons will be entered in separate field Planned Vaginal Birth Ripening Prior to Admission • Outpatient methods prior to admission Transcervical Catheter – Balloon Catheter, Foley Balloon, Cook Catheter Prostaglandins – Cervidil, Misoprostol Planned Vaginal Birth Ripening/Induction Interventions During Admission • Determine all interventions utilized Transcervical Catheter intended to be used simultaneously with a medication should be captured as combined interventions Individual Interventions Combined Interventions • Amniotomy • Transcervical catheter and oxytocin as • Cervidil a concurrent intervention • Membrane Stripping • Transcervical catheter and misoprostol • Misoprostol Alone as a concurrent intervention • Oxytocin Alone • Transcervical Catheter Alone Planned Vaginal Birth Cervical Exam at Time of Admission • Select Yes if: Cervical exam was done 30 minutes before or after admission Cervical exam was done in clinic within 4 hours prior to admission – When Yes is selected *Abstraction Tips: Enter details about dilation, station, and effacement Dilation • Round to the nearest 0.5 cm • Closed = 0 cm • Complete = 10 cm Effacement • Thick = 0% Effaced Station • High = -5 Station Planned Vaginal Birth Fetal Monitoring Type Ordered at Admission • Intent is to identify what type of fetal monitoring was planned/ ordered upon admission Review Admission Orders and H&P to determine the initial plan for fetal monitoring If plans change and actual monitoring type differs from orders, still only capture what was ordered Planned Vaginal Birth Rupture of Membranes • Determine if ROM occurred spontaneously or via amniotomy • Record date and time of ROM, if unknown check “Not Documented” • Record cervical dilation at time of ROM Use the exam closest to, but within 60 minutes before or after ROM Round to the nearest 0.5 cm Planned Vaginal Birth Oxytocin • Determine if Oxytocin was administered prior to delivery for induction or augmentation • If Yes is selected in the workstation, additional questions will populate: Planned Vaginal Birth Active Labor! Planned Vaginal Birth Fetal Monitoring Used for Active Labor • Actual fetal monitoring type(s) used during active labor Continuous Electronic Fetal Monitoring Intermittent Auscultation – Doppler Checks – Intermittent Monitoring Not Documented Planned Vaginal Birth Nurse Supporting Active Labor • Free Text Field, enter as: Last Name, First Name • Provider Supporting Active Labor • Physician or CNM at the time of the first exam describing dilation of 6 cm or more Select the Attending Physician or CNM from the drop down in the registry – If provider is not found in the list, follow instructions in the manual to add a new provider. Planned Vaginal Birth Clinical Chorioamnionitis • Suspected intrauterine infection based on clinical assessment during labor Assisted Delivery • Forceps or Vacuum extraction were attempted to assist with vaginal delivery If either method is attempted, determine if the attempt led to the outcome of vaginal delivery (successful) or not (unsuccessful). Pain, Discomfort, Coping During Labor Methods Used to Assess Pain, Discomfort, and Coping Capture all assessment methods used during labor Pain Management Techniques Capture all pain management methods used during labor Pain, Discomfort, Coping During Labor Regional Anesthetic used during labor • Determine if regional anesthesia was used for labor management, NOT as part of a cesarean procedure Labor Support Shared Decision Making Discussion with patient about preferences specific to labor and delivery – Birthing Plan – Labor Partnership – Discussion about birthing preferences Labor Support Person Doula Support Person DELIVERY Delivery • Complete Dilation and Pushing • Provider and Nurse at Birth • Mode of Delivery • Delivery Outcomes Complete Dilation and Pushing • Date and time of Complete Cervical Dilation If the patient did not reach complete dilation then select not applicable • Date and Time Patient Started Pushing If the patient did not start pushing then select not applicable Delivering Provider and Nurse at Birth • Delivering (Attending) Provider - Provider who was present and providing hands on delivery care Select the Attending Physician or CNM from the drop down in the workstation. – If provider is not found in the list, follow instructions in the manual to add a new provider • Delivering RN – RN providing maternal care at time of delivery Free Text Field, enter as: Last Name, First Name Actual Mode of Delivery • Select the actual mode of delivery This may be different that the planned mode of delivery Selecting a cesarean mode will populate the Cesarean Delivery Section Lacerations • Episiotomy • Third Degree Laceration • Fourth Degree Laceration CESAREAN DELIVERY Cesarean Delivery • Cervical Dilation at Cesarean Delivery Use the cervical exam closest to the Cesarean • Primary Indication for Cesarean Delivery Review the Op Note to determine the primary indication of cesarean – Secondary Indications will be entered in a subsequent field The following primary indications will prompt Labor Arrest Disorder section: – Latent Phase Arrest of Dilation – Arrest of Descent- First Stage – Active Phase Arrest of Dilation – Arrest of Descent- Second Stage LABOR ARREST DISORDERS Labor Arrest Disorders • Latent Phase Arrest (Less than 6 cm) Refers to patients in spontaneous labor Induced