Using Guidelines to Assure Clinical Quality and Patient Safety

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Using Guidelinesto AssureClinical Quality and
Patient Safety

• Dr. Evita Fernandez

HOSPITAL
Hyderabad, INDIA www.fernandezhospital.com
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Patient safety has always been a prime concern of
the clinician
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Hospital Admissions

• 1 in 10 Adverse event
• 1 in 300 Death

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Harm to an Individual

• 1 in 1,000,000 Air travel
• 1 in 300 Healthcare

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Why Use Guidelines ?

• 1. Standardizes care
• 2. Improves quality of care
• 3. Improves patient safety
• 4. Cost effective
• 5. Facilitates audits

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Standardize Medical Care
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• 12 Consultants - 40 other clinicians
• Nursing staff comfortable
• Coordinated teamwork
• Patient comfort
• Institutionalizes care

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Improve Quality of Care
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• Evidence based practice
• Algorithm / protocols

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WHO Partogram

• Overall improvement
• Differentiates normal / abnormal progress
• Identifies women requiring intervention

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• Its use in all labour wards
  is recommended

Lancet, 1994
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All women should have support throughout labour
and birth.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C.

Continuous support for women
during childbirth.
Cochrane
Database of Systematic Reviews 2007
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Research Findings

• The need for analgesics
• Rate of Oxytocin
• Instrumental deliveries
• Caesarean sections
• 5 min APGAR Score of lt 7

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• Continuous support in labour
• increased the chance of a
• spontaneous vaginal birth, had no harm,
• and women were more satisfied.

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Improve Quality of Care

• Protocols

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Protocols
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Improves Patient Safety
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Clinical Risk Management
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Fernandez Hospital CRM Committee
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Reporting Form
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Incident Evaluation Form
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The CRM Box in Labour Ward
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Not focusing on who was the person
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The key question is not who blundered but how and
why the defenses failed
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Oxytocin Infusion Regime
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Aim at the System not the Individual

• Standardize processes
• and equipment

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• TERBUTALINE FOR HYPERSTIMULATION
• More than 5 contractions in 10 minutes with FHR
  changes
• Stop syntocinon infusion. Start plain RL drip.
• Observe CTG over next 15 minutes.
• Vaginal examination to determine the progress.
• Draw the contents of the entire ampoule into the
  syringe provided in the kit
• Use the volume side of the syringe to determine
  the dose.
• Inject 0.5 ml subcutaneously.
• Continue CTG monitoring
• If no change repeat dose (the remainder of drug
  in the syringe) after 15 min.
• If no change in CTG pattern over the next 15 min
  despite second dose
• ? for C. Section.

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Learning from Mistakes

• Human error seen as a consequence not as a course
  of failure
• The best people can often make the worst mistake
• Errors usually fall into a recurrent pattern

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High Risk Management PlanSheet
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Checklist for Correct Patient / Site / Surgery
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Monthly Meets

• Perinatal Mortality Meet
• CTG Meet
• CRM Interaction
• Anesthesia interaction
• Neonatologist interaction

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Cost Effective
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Enemas during labour (review)
Reveiz L, Gaitán HG, Cuervo LG, Cochrane
Database of Systematic Reviews 2007, updated in
2010
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Variables Evaluated

• Neonatal infections
• 1. Any infection
• 2. Umbilical infection
• 3. Ophthalmic infection
• 4. Skin infections
• 5. Respiratory tract infections
• 6. Intestinal infections
• 7. Meningitis
• 8. Sepsis
• 9. Need for systemic antibiotics

• Puerperal infections
• 1. Episiotomy dehiscence
• 2. Urinary tract infection
• 3. Pelvic Infections
• 4. Vulvovaginitis
• 5. Endometritis
• 6. Myometritis
• 7. Vulvovaginitis
• 8. Other puerperal infections
• 9. Need for systemic antibiotics

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• These findings speak against the routine
• use of enemas during labour
• therefore, such practice should be
• discouraged.

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Active versus expectant management for women in
the third stage of labour (Review)
Begley CM, Gyte GML, Murphy DJ, Devane D,
McDonald SJ, McGuire W. Cochrane Database of
Systematic Reviews 2010, Issue 7. Art. No.
CD007412. DOI 10.1002/14651858.CD007412.pub2.
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Recommendations on active management of the
third stage of labour

• Active management of the third stage
• Use of oxytocin
• Dose 10 IU by intramuscular injection

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• Active management of third stage reduced the risk
  of haemorrhage greater than 1000 ml in an
  unselected population

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Facilitates an Audit
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Obstetric Anal Sphincter Injury(OASI)

• 1 of all vaginal deliveries
• Anal incontinence
• Recognized sphincter disruption 0.6 9
• Occult injury 36 after vaginal delivery

The Obstetrician Gynecologist, 2003
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Audit on Vaginal DeliveriesAugust September
2007
Type of Vaginal Delivery Epidural (142) Non Epidural (118)
Spontaneous 77.4 94
Assisted 32.6 6
Forceps 18.3 2.5
Ventouse 2.1 0.8
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Audit on Vaginal DeliveriesAugust September
2007
Type of Vaginal Delivery Epidural (142) Non Epidural (118)
Episiotomy 50 26.2
Severe Perineal Injury 2.1 0.8
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Protocol and Documentation
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Follow up
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Changes in Practice

• Training of Doctors
• Perineal repair workshop
• Protocols, Follow up
• Clinical attachment with Dr. Abdul Sultan
• Perineal Repair Clinic

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Maternity Dashboard
Monitoring Health Care with
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Concept of a Car Dashboard
Current status of fuel, speed, temperature,
battery, seat belts and so on
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Maternity Dashboard

• Clinical activity
• Workforce
• Clinical outcome
• Risk incidents / complaints / patient satisfaction

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Determining the Traffic Lights

• Green within desired limits
• Amber alert zone
• Red urgent action

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Clinical Activity Indicators
Goal Red Flag
Births 4000 (336) 370/month
Bookings 4324 (360) 500/ month
AVD 10 - 15 lt5 or gt20
Group 1 Robsons CSR lt 20 gt 25
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Workforce Indicators
Goal Red Flag
Consultant cover (hours per wk) 168 (24X7) 144 (24X6)
Nurse birth ratio 12 14
Daya birth ratio 12 14
Education session attendance - nurses gt90 lt70
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Clinical Outcome Indicators
Goal Red Flag
Eclampsia lt 6 cases in any two month period gt 8 cases in any two month period
ICU Admission lt 6 cases in any two month period gt 8 cases in any two month period
Blood transfusion lt 6 cases in any two month period gt 8 cases in any two month period
Postpartum hysterectomy lt 6 cases in any two month period gt 8 cases in any two month period
Meconium aspiration syndrome lt 6 cases in any two month period gt 8 cases in any two month period
HIE 3 or 4 grade lt 6 cases in any two month period gt 8 cases in any two month period
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Risk Incidents / Complaint Indicators
Goal Red Flag
Failed instrumental delivery lt 1 3
Massive PPH gt 2000 ml blood loss lt10 / month gt 15 / month
Shoulder dystocia lt 6 / month gt 10 / month
3rd or 4th degree perineal tear lt 6 / month gt 10 / month
No of complaints lt 3 / month gt 6 / month
Wound infection lt 1 / month gt 2 / month
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Methodology

• Prospective study
• July 2010 Jan 2011
• Fernandez Hospital
• Tertiary perinatal referral
• 5000 births / year
• 120 bedded Perinatal unit

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Results - Activity
Goal Red Flag July Aug Sep Oct Nov Dec
Births 4000 (336) 370/ month 470 480 492 500 462 438
Bookings 4324 (360) 500/ month 620 639 622 586 694 616
AVD 10-15 lt5 -gt20 14 11 10 9 12 12
Group 1 Robsons CSR lt20 gt 25 20 22 28 34 32 28
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Results - Workforce
Goal Red Flag July Aug Sep Oct Nov Dec
Consultant cover 168 hr 144 hr 152 152 152 152 160 160
Nurse Birth ratio 12 14 13 13 12 12 12 13
Daya Birth ratio 12 14 13 13 13 13 13 13
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Results - Workforce
Goal Red Flag July Aug Sep Oct Nov Dec
Education nurses gt90 lt70 80 80 80 80 80 80
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Clinical IndicatorsMaternal Morbidity
Goal Red Flag July Aug Sep Oct Nov Dec
Eclampsia Booked lt 6 cases in any 2 month period gt 8 cases in any 2 month period 1 0 1 1 1 2
Eclampsia Referral lt 6 cases in any 2 month period gt 8 cases in any 2 month period 0 1 2 0 1 0
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Clinical IndicatorsMaternal Morbidity
Goal Red Flag July Aug Sep Oct Nov Dec
ICU Admission Booked lt 6 cases in any 2 month period gt 8 cases in any 2 month period 3 3 8 8 4 4
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Clinical IndicatorsMaternal Morbidity
Goal Red Flag July Aug Sep Oct Nov Dec
Blood transfusion Booked lt 6 cases in any 2 month period gt 8 cases in any 2 month period 4 0 0 2 0 0
Postpartum Hysterectomy lt 6 cases in any 2 month period gt 8 cases in any 2 month period 0 0 0 1 0 1
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Clinical IndicatorsNeonatal Morbidity
Goal Red Flag July Aug Sep Oct Nov Dec
MAS lt 6 cases In any 2 month period gt 8 cases In any 2 month Period 2 2 0 0 2 2
HIE - III / IV grade lt 6 cases In any 2 month period gt 8 cases In any 2 month Period 4 4 3 3 0 0
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Risk Management
Goal Red Flag July Aug Sep Oct Nov Dec
Failed AVD lt 1 gt 3 0 0 0.2 0 0 0
Massive PPH gt 2000ml lt 10 gt 15 0 1 0 0 0 0
Shoulder Dystocia lt 6 gt 10 0 0 3 0 0 0
III / IV Perineal tear lt 6 gt 10 1 6 5 7 7 4
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Clinical IndicatorsRisk Management
Goal Red Flag July Aug Sep Oct Nov Dec
No of complaints lt 3 gt 6 7 4 6 11 15 8
Wound Infection lt 1 gt 2 2.1 1.4 1.8 2.6 1.2 3.4
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The Changes Activity
Goal Red Flag July Aug Sep Oct Nov Dec Jan BG Jan HG
Births 4000 (336) 370/ month 470 480 492 500 462 438 309 64
Bookings 4324 (360) 500/ month 620 639 622 586 694 616 628 169
AVD 10-15 lt5 - gt20 14 11 10 9 12 12 14 15
CSR Group 1 Robsons lt20 gt 25 20 22 28 34 32 28 24 12
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The Changes Workforce
Goal Red Flag July Aug Sep Oct Nov Dec Jan BG Jan HG
Consultant cover 168 hr 144 hr 152 152 152 152 160 160 168 168
Nurse Birth ratio 12 14 13 13 12 12 12 13 13 11
Daya Birth ratio 12 14 13 13 13 13 13 13 13 12
Education Nurses gt90 lt70 80 80 80 80 80 80 80 80
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The Changes Risk Incidents
Goal Red Flag July Aug Sep Oct Nov Dec Jan BG Jan HG
Failed AVD lt 1 3 0 0 0.2 0 0 0 0 0
Massive PPH gt 2000ml lt 10 gt 15 0 1 0 0 0 0 1 3
Shoulder Dystocia lt 6 gt 10 0 0 3 0 0 0 0 0
III / IV Perineal tear lt 6 gt 10 1 6 5 7 7 4 4 1
No of complaints lt 3 gt6 7 4 6 11 15 8 3 0
Wound Infection lt 1 gt 2 2.1 1.4 1.8 2.6 1.2 3.4 2.9 0
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Maternity DashboardMarch 2011
NEW
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Maternity DashboardMarch 2011
NEW
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Maternity DashboardMarch 2011
NEW
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• Measurement, however,
• plays an important part in
• improving the quality of care
• and promoting beneficial
• changes.
• Departments to select quality indicators

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Documentation
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Labour Ward Documentation AssessmentJanuary
2008
In Percentages
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Consent Form Documentation Scoring January 2008
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Intelligent, data-driven decision making is the
only path to continuous improvement