Clinical Quality Measures: Measuring and monitoring clinical quality measures in practice fusion
Rbf clinical quality
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Aspects of Quality of Clinical Care in Labor & Delivery
Stephan Brenner
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Rationale• Obstetric complications intra- & postpartum
phase.
• Timely initiation & organization of EmOC ability of SBAs to detect high-risk pregnancies.
• early identification & prevention of obstetric complications routinely in every pregnancy.
Quality of Care Focus:
• Evidence-based routine care processes in L&D1. Screening for early signs of complications.
2. Monitoring for signs of complications.
3. Preparedness to timely intervene once complications occur.
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Objectives
1) Early Identification of emergencies:– Screening processes Danger Signs, risk factor
assessments, APGAR, etc.– Monitoring processes partograph, early
postpartum observation
2) Prevention of emergencies:– Infection maternal/neonatal sepsis– Hemorrhage AMSTL
3) Preparedness in emergencies:– Anticipation of need for neonatal resuscitation
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Methods• Observational checklists:
– Routine processes performed by providers during labor & delivery care
– Basic equipment, supplies related routine labor & delivery care
– Information on facility type
• Sampling:– Convenience samples
• Analysis:– Descriptive summary of frequencies of
performed routine processes– Composed scores
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Distribution of Observations
District
Balaka Dedza Mchinji Ntcheu Total
Faci
lity
leve
l BEmOC 11 10 14 10 45
CEmOC 10 8 5 14 37
Total 21 18 19 24 82
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27.5
32.5
20
5
2.5
5
7.5
24.24
21.21
12.12
9.091
21.21
6.061 6.061
05
10
15
20
25
30
35
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
BEmOC CEmOC
Pe
rcen
t
ScreenScore4Graphs by facility type
Screening: Initial assessment Danger Signs & risk factors (Hx)
Score components:
• Vaginal bleeding
• Abdominal pain
• Breathing difficulties
• Fever
• Headache
• Convulsions
• HTN
• Diabetes______________________________
Max score: 8
• Only approx. 7% of cases assessed for all 8 medical history components.• About 1/4 of cases no history on risk factors or Danger Signs was obtained. • Most commonly asssessed risk factors: „vaginal bleeding“ (62%) and „abd. pain“ (51%).
(n = 40) (n = 33)
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Screening: Initial assessment vital signs (PE)
Score components:
• Pulse
• BP
• RR
• Temp
• FHR______________________________
Max score: 55.714
31.43
5.714
14.29
25.71
17.14
3.226
22.58
6.452
16.13
32.26
19.35
05
10
15
20
25
30
35
0 1 2 3 4 5 0 1 2 3 4 5
BEmOC CEmOC
Pe
rcen
t
ScreenScore1Graphs by facility type
• In about 5% of all cases no vital signs taken during initial assessment.• In only about 18% of cases all 5 vital sign parameters were assessed.• Most commonly performed assessment was “fetal heart rate” (94%)• least commonly performed assessment was “respiratory rate” (27%)
(n = 35) (n = 31)
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2.439
7.3174.878
75.61
9.756 8.571
85.71
5.714
01
02
03
04
05
06
07
08
09
0
0 1 2 3 4 0 1 2 3 4
BEmOC CEmOC
Pe
rcen
t
ScreenScore7Graphs by facility type
Screening: Focused assessment of Newborn (PE)
Score components:
• APGAR 1 min
• APGAR 5 min
• Temp
• weight______________________________
Max score: 4
• Only 10% / 6% of cases assessed for all 4 components.• Approx. 80% of cases assessed for 3 components most commonly omitted
assessment was “Temperature check” (8%)
(n = 40) (n = 35)
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Vital signs vs. Equipment availability
Blood Pressure:• In 58% cases without initial BP check a functional BP-
cuff and stethoscope available.
Heart and Respiratory Rates:• In 89% cases without initial pulse check, and • in 93% cases without initial respiratory rate check a
functional clock/watch available.
Body temperature:• In 90% maternal (93% neonatal) cases without initial
temperature check a functional thermometeravailable.
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43.33
20
3.333 3.333
13.33
16.67
53.57
3.571
7.143 7.143 7.143
14.29
7.143
01
02
03
04
05
06
0
0 1 2 3 4 5 6 0 1 2 3 4 5 6
BEmOC CEmOC
Pe
rcen
t
MonitorScore2Graphs by facility type
Prevention: Partograph documentation (S1L) Partograph used in only 67% / 76% of cases
Score components:
• FHR Q 30 min
• Contractions Q 60 min
• Heart rate Q 60 min
• BP Q 60 min
• Fetal descent Q 60 min
• Temp Q 4 hrs______________________________
Max score: 6
• Only approx. 12% of cases complete stage 1 monitoring documented.• In 43% / 54% of cases no documentation of stage 1 monitoring.• Most frequently documented parameter “FHR Q 30 min” (41%).
(n = 30) (n = 28)
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35
2.5
20
12.5
25
2.5 2.5
44.44
16.67
13.89
22.22
2.778
01
02
03
04
05
0
0 1 2 3 4 5 6 7 8 9 10111213141516 0 1 2 3 4 5 6 7 8 9 10111213141516
BEmOC CEmOC
Pe
rcen
t
MonitorScore5Graphs by facility type
Monitoring: maternal 1st hour postpartum 2-hr postpartum observation in only 68% / 69% of cases
Score components:
• Uterus tone Q 15 min (4x)
• Vaginal bleeding Q 15 min (4x)
• BP Q 15 min (4x)
• Heart rate Q 15 min (4x)
______________________________
Max score: 16
• No case with recommended minimum monitoring checks.• 35% / 44% of cases were not monitored during the 1st hour postpartum.• Approx . ½ of cases had “vaginal bleeding” and “BP” checked only once within
the 1st hour postpartum.
(n = 40) (n = 36)
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82.5
2.52.5
12.5
83.33
11.11
2.7782.778
01
02
03
04
05
06
07
08
09
0
0 1 2 3 4 5 6 7 8 9 10111213141516 0 1 2 3 4 5 6 7 8 9 10111213141516
BEmOC CEmOC
Pe
rcen
t
MonitorScore7Graphs by facility type
Monitoring: neonatal 1st hour postpartum 2-hr postpartum observation in only 68% / 69% of cases
• None of the cases received the recommended minimum monitoring checks. • 83% of cases were not monitored during the 1st hour of life.• “responsiveness” was the most common parameter monitored within 1st hour
of life (17%).
Score components:
• Respiratory rate Q 15 min (4x)
• Heart rate Q 15 min (4x)
• Responsiveness Q 15 min (4x)
• Temp Q 15 min (4x)
______________________________
Max score: 16
(n = 40) (n = 36)
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Monitoring vs. Equipment availability
Stage 1 Labor Monitoring:
• In 84% cases without partograph use partograph forms available.
Postpartum Monitoring:
• In 67% of cases without early postpartum monitoring at least one dedicated recovery bed available in maternity unit.
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3.226 3.226
22.58
16.13
12.9
25.81
16.13
3.333 3.333
6.667
23.33
30
20
13.33
05
10
15
20
25
30
35
0 1 2 3 4 5 6 0 1 2 3 4 5 6
BEmOC CEmOC
Pe
rcen
t
PrevScore1Graphs by facility type
Prevention: Infection prevention during assessment and delivery
• Most commonly omitted processes were “hand hygiene vaginal exam” (61%) and “hand hygiene” ( 55%).
• Most frequently performed processes were the use of sterile gloves for vaginal exam (79%) and stage 2 labor (83%).
Score components:• Hand hygiene
physical exam• Hand hygiene S2L• Sterile gloves
vaginal exam• Sterile gloves S2L• Perineal cleansing
vaginal exam• Perineal cleansing
S2L______________________________
Max score: 6
(n = 31) (n = 30)
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7.692
38.46
53.85
2.778
11.11
30.56
55.56
01
02
03
04
05
06
0
0 1 2 3 4 0 1 2 3 4
BEmOC CEmOC
Pe
rcen
t
PrevScore4Graphs by facility type
Prevention: Hemorrhage (use of oxytocin)
• 97% of all cases received oxytocin.• In only about ½ of all cases oxytocin was given according to the recommended
standard actions.• Ruling out twin pregnancy prior to oxytocin administration was the most
omitted action.
Score components:
• Setting up oxytocin
• Rule out twin pregnancy
• Inform patient
• Oxytocin administration
______________________________
Max score: 4
(n = 39) (n = 36)
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2.5
10
2.5 2.5
37.5
45
2.778
16.67
19.44
61.11
01
02
03
04
05
06
07
0
0 1 2 3 4 5 6 0 1 2 3 4 5 6
BEmOC CEmOC
Pe
rcen
t
PrevScore5Graphs by facility type
Prevention: Hemorrhage (delivery of placenta)
• Overall, in about 82% of all cases all or 5 actions were performed.• Most frequently omitted action was “estimation of total blood loss”
Score components:• Place cord-clamp
proximally• Transabdominal
pressure on uterus• Downward cord
traction during contraction
• Ensure completeness of placenta
• Massage uterus• Estimate blood loss______________________________
Max score: 6
(n = 40) (n = 36)
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Infection prevention vs. Supplies
Hand Hygiene:
• In 92% of cases during physical exam and
• In 85% of cases during newborn delivery without provider performing some form of hand hygiene some source of water plus soap available.
• In 19% of cases during physical exam and
• In 86% of cases during newborn delivery without provider performing some form of hand hygiene hand desinfectant available.
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Preparedness: neonatal complications
• Overall, in about 31% of all cases all or 5 devices were set up prior to delivery.• “oxygen source” and “oxygen delivery system” were not prepared in 2/3 of
cases.
Score components:
• Resuscitaire
• Ambu-bag
• Suction device
• Oxygen source
• Oxygen delivery system
______________________________
Max score: 513.89
25 25
2.778 2.778
30.56
44.44
8.333 8.333
5.556
2.778
30.56
01
02
03
04
05
0
0 1 2 3 4 5 0 1 2 3 4 5
BEmOC CEmOC
Pe
rcen
t
PrepScore1Graphs by facility type
(n = 36) (n = 36)
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Preparedness vs. Equipment
• In 32% of cases without oxygen set-up prior to delivery oxygen source and delivery system available.
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Steps ahead…
• Analysis of ANC observation data.
• Analysis of provider knowledge assessment data.