Using Guidelines to Assure Clinical Quality and Patient Safety

1. Using Guidelinesto AssureClinical Quality and Patient Safety Dr. Evita Fernandez HOSPITAL Hyderabad, INDIA www.fernandezhospital.com

2. Patient safety has always been a prime concern of the clinician

3. Hospital Admissions 1 in 10 : Adverse event 1 in 300 : Death

4. Harm to an Individual 1 in 1,000,000 : Air travel 1 in 300 : Healthcare

5. Why Use Guidelines ? 1. Standardizes care 2. Improves quality of care 3. Improves patient safety 4. Cost effective 5. Facilitates audits

6. 1 Standardize Medical Care • 12 Consultants - 40 other clinicians • Nursing staff comfortable • Coordinated teamwork • Patient comfort • Institutionalizes care

7. 2 Improve Quality of Care • Evidence based practice • Algorithm / protocols

8. WHO Partogram • Overall improvement • Differentiates normal / abnormal progress • Identifies women requiring intervention

10. “Its use in all labour wards is recommended” Lancet, 1994

11. 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

12. Research Findings The need for analgesics Rate of Oxytocin Instrumental deliveries Caesarean sections 5 min APGAR Score of < 7

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

14. Improve Quality of Care • Protocols

15. Protocols

16. 3 Improves Patient Safety

17. Clinical Risk Management

18. Fernandez Hospital CRM Committee

19. Reporting Form

20. Incident Evaluation Form

21. The CRM Box in Labour Ward

22. Not focusing on ‘who was the person’ …

23. The key question is not who blundered but how and why the defenses failed

24. Oxytocin Infusion Regime

25. Aim at the System not the Individual Standardize processes and equipment

27. 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.

28. 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

29. High Risk Management PlanSheet

30. Checklist for Correct Patient / Site / Surgery

31. Monthly Meets • Perinatal Mortality Meet • CTG Meet • CRM Interaction • Anesthesia interaction • Neonatologist interaction

32. 4 Cost Effective

33. Enemas during labour (review) Reveiz L, Gaitán HG, Cuervo LG, Cochrane Database of Systematic Reviews 2007, updated in 2010

34. 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

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

36. 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.

37. 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

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

39. 5 Facilitates an Audit

40. Obstetric Anal Sphincter Injury(OASI) The Obstetrician & Gynecologist, 2003 1% of all vaginal deliveries Anal incontinence Recognized sphincter disruption 0.6 – 9% Occult injury : 36% after vaginal delivery

41. Audit on Vaginal DeliveriesAugust – September 2007 HOSPITAL

42. Audit on Vaginal DeliveriesAugust – September 2007 HOSPITAL

43. Protocol and Documentation

44. Follow up

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

46. Monitoring Health Care with Maternity Dashboard

47. Concept of a Car Dashboard Current status of fuel, speed, temperature, battery, seat belts and so on

48. Maternity Dashboard • Clinical activity • Workforce • Clinical outcome • Risk incidents / complaints / patient satisfaction

49. Determining the Traffic Lights • Green – within desired limits • Amber – alert zone • Red – urgent action

50. Clinical Activity Indicators