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Background:  Though electronic fetal monitoring (EFM) is the most common obstetric procedure (ACOG, 2005), failure to interpret FHM tracings and provide appropriate interventions plays a role in poor neonatal outcomes.  Clinician failure to recognize an abnormal FHR pattern may be due to lack of knowledge, lack of training, or lack of skills assessment by the employer or credentialing body (Miller 2005). Abruzzese (1992) defines competency as the assessment of an individual’s demonstrated ability to achieve expected behaviors as outlined in performance standards. As part of a unit based EFM competency, documentation of recognition of late fetal heart rate decelerations and targeted nursing interventions were measured using a peer review audit process.

Method:  Interrater reliability was established between auditors. Each month 40 charts; 20 labor inductions and 20 pitocin augmentations are audited by a team of staff nurses who are AWHONN FHM Instructors, along with the OB Informatics nurse. Audits target nurses’ documentation of recognition and appropriate interventions for late decelerations.  When the auditor disagrees with the case’s recognition or intervention, the case is forwarded to one of two APNs.  The APNs perform a second review and collaborate with unit management for any identified learning needs. Educational in-services were held on the new NICHD terminology from Sept to Dec. of 2008.  Updates are emailed to staff with issues identified in the audits, for example uterine tachysystole management.  Monthly results are posted and nurses that demonstrate excellence are recognized.

Results:  The measure was calculated as the percentage of auditor agreement with the case’s EFM documentation.  From the July 2008 baseline of 54% agreement, a steady improvement has been noted:  Aug, 64%, Sept, 43%, Oct, 08 63%, Nov, 75%, Dec, 81%.  Results for 2009 include:  Jan, 78%, Feb, 81%, Mar, 82%, Apr, 89%, May, 81%, June, 74 %.  Another result has been a change in culture: keener awareness of patient safety and collegial discussions of FHM tracings.  Adoption of the new NICHD FHM categories occurred quickly.  The need for multidisciplinary FHM education and further mentoring of newer nurses was reinforced.  Cases of concern are now forwarded to a multidisciplinary team for physician peer review.  

Discussion:.  This measure of EFM competence was dependent on nursing documentation of their actions.  In certain cases where late decelerations were documented we believed that interventions had probably been provided, but not documented. In a few instances, 2 or 3 reviewers disagreed on a difficult tracing, highlighting the challenges of FHM Interpretation.  Auditors noted how much easier it is to recognize subtle changes in the tracing in retrospect when the outcomes were known.  The value of a multidisciplinary clinical documentation system integrated with electronic FHM was evident throughout this project.

Conclusion:  Validation of EFM competence must be incorporated into all labor and delivery units’ EFM practice, and bedside providers should be closely engaged in this process.  Clinicians deserve ongoing support and education to create a culture of safety and excellence.  Additional research is needed to identify factors that may interfere with recognition, intervention and documentation of nursing EFM practice.