RSSA MALANG

Despite significant progress in recent years, maternal and Neonatal mortality rates in Indonesia remain unacceptably high

Significant number of Maternal and Neonatal emergencies die shortly after arrival to the hospital.

Why?1. Delay in seeking medical advice?2. People refrain from seeking medical advice?3. Delay in referring critical patients from private

sector?4. Un-safe patient transfer system and

substandard pre-hospital phase?5. Sub-optimal initial management ?

Substandard medical care is a major cause of avoidable morbidity and mortality particularly in the area of emergency care.

There is no policy to standardize initial management of obstetric & neonatal emergencies even within the same district.

Hospitals have wide variations in personnel, infra-structure and equipment resources.

Competency in Resuscitation skills is variable among physicians and nurses of Obstetric and Neonatal departments

Recent assessment in several hospitals has shown

No Obstetric nor Neonatal doctors in-hospital after 2pm. Patients are shifted to Obst and Neonatal units where no adequate resuscitation equipment available, No resuscitation expertise and no standing orders. with subsequent threat to life of mother and fetus.

Develop Implementation plan of MNERC at the region of Malang as a model for regionalization of the ER strengthening activities .

Reproducible Model

Work within the system is easier than re-inventing the wheel

Strengthen the existing potential recourses

Adopt a strategic approach: i.e do the simplest interventions that are likely to

produce the largest impact on the service(focused training on ABC /General Emergency

live Support of major killers)

Identify points of weakness and Strengths in both Managerial and Clinical performance so that specific support can be provided on priority basis.

The clinical supervisory visits should cumulate in helping the hospital to

develop their own self improvement plan. This is based on identifying the problems and putting a realistic time

framed plan with nomination of person/persons responsible for the

decided action

ImprovemImprovement ent

Category Category NumberNumber

Description of problem Description of problem causing non-compliancecausing non-compliance

(deficiency/improvements (deficiency/improvements needed)needed)

Action to be taken Action to be taken

Responsible Responsible PersonPerson

Due Due datedate ConstraintsConstraints

11

Clinical performance:Clinical performance:There is a low There is a low exposure of ED staff exposure of ED staff (doctors and Nurses (doctors and Nurses to Critical patients to Critical patients (P1), which will result (P1), which will result in a long learning in a long learning curve to reach curve to reach competency in competency in MNERCMNERC

Arrange for a rotational Arrange for a rotational Clinical attachment Clinical attachment program that allows one program that allows one physician and one nurse physician and one nurse to get attached to The to get attached to The busy ED of RSSA for 2 busy ED of RSSA for 2 weeks on rotational weeks on rotational basis. Focused training basis. Focused training on ABCon ABC

Dr Ari with Dr Ari with Hospital Hospital directors directors approvalapproval

Start Start nownow

Only Only administrative administrative approvalsapprovals

22

Non-adherence to Non-adherence to MNERC policy.MNERC policy.No Obstetric nor No Obstetric nor Neonatal doctors in-Neonatal doctors in-hospital after 2pm. hospital after 2pm. Patients are shifted Patients are shifted to Obst and Neonatal to Obst and Neonatal units where no units where no adequate adequate resuscitation resuscitation equipment available equipment available and No resuscitation and No resuscitation expertise.expertise.

1.1.Either, a trained Obst Either, a trained Obst and Neonatologist stay and Neonatologist stay in-housein-house2.2.Or, Critical patients Or, Critical patients stay in ED under care of stay in ED under care of the ER senior physician the ER senior physician until Obst/Neonatologist until Obst/Neonatologist arrive and escort pt to arrive and escort pt to Obs/Neonatal units. A Obs/Neonatal units. A midwife may do the midwife may do the Obst assessment in ER.Obst assessment in ER.3.3.stable patients may be stable patients may be shifted to the ward and shifted to the ward and ER physician may be ER physician may be called if deterioration called if deterioration occursoccurs

Hospital Hospital DirectorDirector

ED ED DirectorDirector

Head of Head of Obst.Obst.

Head of Head of Ped.Ped.

Start Start nownow

Emergency Department Self Improvement Plan

ImprovemeImprovement nt

Category Category NumberNumber

Description of problem Description of problem causing non-causing non-compliancecompliance

(deficiency/(deficiency/improvements improvements

needed)needed)

Action to be Action to be taken taken

Responsible Responsible PersonPerson

Due Due datedate ConstraintsConstraints

33

IV General IV General Anesthesia is given Anesthesia is given in the OR attached in the OR attached to the delivery to the delivery room. It is not room. It is not equipped with equipped with Anesthesia Machine Anesthesia Machine and no adequate and no adequate resuscitation resuscitation facilities. This facilities. This results in unsafe results in unsafe clinical practiceclinical practice

Ensure safe GA Ensure safe GA setup is setup is available with available with all resuscitation all resuscitation facilities facilities

ED director ED director Head of Head of Anesthesia Anesthesia (to put (to put specs)specs)

Hospital Hospital director for director for approvalapproval

44

All Crash Carts need All Crash Carts need to have a standard to have a standard arrangement and a arrangement and a check list every check list every shiftshift

Follow the Follow the policy on Crash policy on Crash cart in ER cart in ER Clinical Clinical ProtocolsProtocolsUse breakable Use breakable lockslocks

ED director ED director and Dr Ari and Dr Ari

Head nurse Head nurse ERER

1 1 weekweek

Emergency Department Self Improvement Plan

Improvement Category

Number

Description of problem causing non-compliance

(deficiency/improvements needed)

Action to be taken

Responsible Person

Due date

Constraints

5

Deficiency in equipment:Number of sphygmomanometer is not enough

Different BP.cuff sizes not available

Laryngoscopes with different blade sizes from Neonate and adult

3 more sphygmomanometer with full range of cuff sizes

2 sets of Laryngoscope with full range of blade sizes

ED director Hospital director for approval

To be decided by hospital director

6 Deficiency in suppliesBuy missing items (see check list 7th July 2010)

ED director Hospital director for approval

To be decided by hospital director

Emergency Department Self Improvement Plan

Improvement

Category Number

Description of problem causing non-

compliance(deficiency/

improvements needed)

Action to be taken

Responsible Person

Due date

Constraints

7

OJT materials: Trainee log book Clinical Supervisor

trip report Master trainer’s

hospital training Matrix

To Develop:To complete:

Dr Khamis. Askar, Ari

Clinincal supervisors

Dr Ari

1 week

8have no Equipment maintenance plan

Use the Equipment maintenance plan in ER service standard

ED director

Emergency Department Self Improvement Plan

strengthen and support the regional Training Center at RSSA (TOT, clinical protocols, training materials, training methodology….etc)

Perform initial assessment of the district hospitals and identify points of weakness and strengths

Assist in developing Facility Self Improvement Plan (priority based)

Perform clinical and managerial monitoring

Establish a feed-back reporting system from the district hospitals to the regional Teaching hospital

Provide data and reporting system to the Governorate Health Authorities

Sustainability plan

Revise and upgrade clinical protocols ED policies and procedures Physicians hand book Standing orders Didactic training (modules, PP…etc) OJT Rotational Clinical attachment

Monitoring tools1. Clinical performance monitoring

(departmental performance and Individuals log books)

2. Managerial performance monitoring Reporting system tools

1. Clinical supervision (Clinical – Challenges solved/unsolved)

2. Regional quarterly reports

OJT strategy The Maternal and Neonatal Emergency Care

Package should be a separate course so that focused training is achieved in an area which represents an obvious weakness in General Emergency Training.

The primary target group is the ER physicians and nurses as they are the first and many cases the only available team to meet maternal and Neonatal Emergency Cases.

Obstetric and Neonatology Staff must participate both as trainers and as trainees so a team approach to this important task can be achieved

The focus of training is ABCs of resuscitation, with a special reference to differences in Neonatal and Pregnancy form the other population

The individual trainees are assessed as they progress in competency based training using log book (see attachment) for each trainee.

The trainee should reach mastery in each competency of the list (see attachment) of the major causes of Maternal and Neonatal mortalities presenting to ER.

The instructor should identify points of weakness and discuss them with the candidate each visit.

Managerial performance deficiencies that influence clinical performance must be addressed and discussed with the appropriate level of hospital administration.

Methods used to assess progression of clinical performance are Observation (best method if cased are present) Retrospective (record review) Case Scenarios ( if no cases)

In hospitals with low flow of P1 patients the learning curve to reach mastery of the different skills will be very slow. To use Case scenarios as the sole method is not recommended. Accordingly, doing rotational clinical attachment to a busy high flow ED as in RSSA is an acceptable alternative.

The objective of clinical attachment is to acquire competencies and mastering skills on the job in the busy environment of the referral hospital. This will shorten the OJT time considerably. The trainee will be exposed to a large variety and much larger work load compared to his hospital ( low patient work load and limited varieties).

The training workshop should target the physicians and nurses separately. The learning objectives for each target group is different

Continuous medical education for physicians and Nurses should be implemented. Refresher periodic courses should be planned

Training must be a continuous process not only to acquire competencies but also to maintain them

All the activities are within the system Current Bylaws Of MOH Training Centers Funding (supervisory visits, clinical

attachment ..etc) Potential funding sources (Governor- MOH- Medical Associations)

Vaginal Bleeding 1. before 20 weeks,2. Antepartum,3. postpartum

Eclampsia and Pre-Eclampsia Trauma in Pregnancy Post-partum sepsis

Neonatal Resuscitation Respiratory distress Circulatory Failure Hypo and Hyperglycemia Thermo-regulation

Neonatal Seizures

Cardiac Arrest1. CPR in Pregnancy2. CPR in Neonates3. CPR Equipment

Initial Management of Obstetric Emergencies in ER

Initial Management of Neonatology Emergencies in ER

Introduction Many Maternal and subsequently fetal

mortalities can be directly attributed to the initial management offered to patients with life threatening conditions (problem in ABC).

It is not infrequent that obstetric emergencies are directly shifted to the obstetric ward without any triage in ER and without ensuring availability of an expert help. The receiving obstetric department may frequently lack a 24 hours coverage of senior staff who is competent in ABC of resuscitation or may be occupied in other activities. Medical attendance may be delayed with subsequent threat to life of mother and fetus.

To ensure that obstetric emergencies will receive optimum initial management on their arrival to different medical facilities (regardless of the level of hospital).

All obstetric emergencies should be triaged in ER.

P1(priority I) patients with life threatening conditions should be immediately attended by senior ER physicians and resuscitation started.

Obstetrician will be called to join the resuscitation team as soon as possible.

When the patient is stabilized, the patient will be shifted to the obstetric care accompanied by the obstetrician.

Critical patients stay in ED under care of the ER senior physician until Obst arrive and escort pt to Obs units. A midwife may do the Obst assessment in ER.

In case of P2 and P3 patient (patient with no life threatening condition and non urgent stable patient may be shifted to the ward and ER physician may be called if deterioration occurs

The ER must have 24 hours coverage of a senior ER physician competent in all resuscitation skills.

The clinical guidelines “obstetric emergencies for non-obstetricians” will be applied for the clinical management of these cases.

Malangwlingi

Batu

Lumajang

Kota Probolinggo

Probolinggo

Kota Malangbangil

Kota Pasuruan

Tulungagung

Kediri

Blitar

6 months program ( ideally 2 year program )

As pilot project

OJT Scores for 9 district hospitals

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10%

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40%50%

60%

70%

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90%

Bangil

Kanjur

uhan

Blitar

Wlin

gi

Kraks

aan

Proboli

nggo

Lum

ajan

g

Pasur

uan

Batu

OJT 1

OJT 2

OJT 3

Average OJT compliance scores by category for 9 district hospitals

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OJT 1

OJT 2

OJT 3

Average clinical practice compliance scores by category for nine district hospitals

0%10%20%30%40%50%60%70%80%90%

Triage &

P3

pro

cess

Resuscitation

pro

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Observ

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patients

Tra

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patient

Docum

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Susta

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medic

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education

Support

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Case 1

Case 2

Case 3

Strategic interventions: Develop a national-level strategy and

plan for improving emergency hospital care

Focused CBT on ABC of resuscitation Focus on improving skills and

capacity in a small number of simple and effective emergency interventions

Strategic interventions: Target groups of trainees Use local trainers Clinical attachment to high flow ED Supervisory visits to predict barriers standardization of methodology of training

Apply monitoring and feed back reporting system

Communication skill: upgrading of communication skills is essential

for all staff working in ED

Pre-hospital, Ambulance service EMT Private sectors Nursing training Community activities

Increase awareness with risk factors Seek medical advice early Change the current image

Emergency Service is an integrated service which includes all the previously mentioned components. Although this project works on the hospital phase, the other phases have to be addressed at the appropriate level of heath Authorities

statistics !!Current statistics are confusing, do not reflect

the magnitude of the problem

UU No 44 tahun 2009 mengharuskan setiap RS terakreditasi. ( survey MOH 2011 only 26% )

SPM (129/Menkes/SK/II/2008 ) agar digunakan sebagai pedoman bagi Rumah Sakit dalam menjamin pelaksanaan pelayanan kesehatan. ( < 2 th sejak SK)

SK 856 /Menkes/SK /II/2009 tentang standar pelayanan IGD RS.

Surat edaran : YM.01/II/1936/2011: standar kompetensi minimal bagi dokter IGD adalah pelatihan GELS/ PPGD.

1. Ability for live saving --> 100%2. IGD/ED services --> 24 hours3. Has Certificate which still apply

(BLS/PPGD/GELS/ALS) 4. Estabish disaster team response < 1 team5. Respon time Emergency doctor < 5 minute6. Satisfaction of customers > 70%7. Mortality of unexpected death patient < 24

Jam ≤ 2/1000 (transfer to the ward at least 8 jam at ED ) 8. No down payment for any patient.

Involving MOH hospitals accreditation commission .