W H Y? Measu rements...Early initiation of breast feeding in Labour room in uncomplicated vaginal...
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Early initiation of breast feeding in Labour room in uncomplicated vaginal delivery Department of G&O Medical college Kolkata. India Background Context & Problem Statement • Early initiation of breast feeding in LRO is done in 40% of newborn during 12 hours of day shift and 15% of newborn during 12 hours of night shift following uncomplicated vaginal delivery (baby weight >2 kg) • Following delivery mothers are shifted on a trolley from labour table after episiotomy repair, cleaning and changing gown and observed for one hour in LRO. No earmarked bed in LRO for breast feeding. • Babies are kept in a baby room inside LRO after initial procedures (drying, cord tie, injections and documentation) • Nurses are busy in other scheduled work and cant stand beside trolley for a long time to assist the mothers, otherwise the babies might fall from the trolley. X QI team of G&O dept MCH Kolkata • Dr. Somajita-leader • Dr. Mallika-analyser • Sister in charge (LR) sister Aparna-communicator • Sister Parna-analyser • Sister Soma-communicator • Sister Mita-communicator • Co-opted member Msc nursing tutor- M/s Manasi X Aim Statement • We, (QI team of G&O) MCH Kolkata, aim to improve early initiation of breast feeding (within 1 hour) in labour room in all newborn (weighing >2kg) delivered vaginally (uncomplicated) during Night shift From15% to 80% by 30.4.2017. Date:1.2.2017 X Change Idea(s) & PDSAs X • Increase awareness of junior residents on early initiation of breast feeding by showing NSSK protocol video • One earmarked bed for mother , inside LRO -baby room for breast feeding . Mother s are shifted to that bed from labour table , initiate feeding and after that shifted to the trolley. • One female attendant to be allowed inside LRO after delivery beside the trolley of the mother and keep an eye on the baby to avoid any fall from the trolley Measurements X • Outcome measures:-1.Percentage of new born weighing >2kg and delivered by uncomplicated vaginal delivery had early initiation of breast feeding in LRO • Process measures:-1. Percentage of new born weighing>2kg delivered by uncomplicated vaginal delivery initiated SSC in LRO 2.Percentage of earmarked bed in LRO for BF • Balancing measures:-1.Percentage of outside people present in LRO at 12 am and 6am Analysis & Tools Used X • Flow chart of delivery and newborn care in LRO • Fish bone analysis • Pareto chart • 5 why X Flow chart of delivery process in labour room Delivery Baby on mother’s abdomen Drying of baby with pre- warmed sterile towel Delayed cord clamping Baby shifted to radiant warmer Change towel, cord tie, give inj vit K, Hepa B Baby shifted to baby room mother- repair of episiotomy Uncomplicated Complicated Immediate 1-2 min 2-3 min 1 min 5 min 15 mins from birth Mother and baby shifted to the ward after 1 hour 1 hour Baby given to mother just before shifting to ward absent in induction training have not seen NSSK video Process Policy Procedure Place early initiation of breast feeding not done in LRO in uncomplicated vaginal birth baby weight >2 kg Problem Statement lack of awareness among JRs few nurses sp. During night shift other works to be done in busy schedule Can not stand beside trolley and supervise feeding Otherwise the bwby might fall from the trolley baby not given to mother after delivery by nurse mother in labour table >30 minutes delay in repair of episiotomy by JR mother in labour table>30 minutes delay in cleaning of mothers and gown changing by aya inadequate number of curtains beside trolley to maintain privacy no separate feeding room in LRO baby kept in a baby room inside LRO mothers are shifted on a trolley after delivery and the baby might fall from the trolley ROOT CAUSE ANALYSIS –FISH BONE X WHY? Why the baby is not given to the mother by nurse? • Sisters are fewer in number, especially in night shift and hence busy in other work. Mothers need supervision while breastfeeding which cannot be provided by the busy sisters. In 8am to 8pm shift, supervision is provided by additional staff like trainee sisters. Why do the mothers need supervision? • After cleaning and changing gown, mothers are placed on an unrailed trolley. Hence the baby might fall. Why the mothers are on trolley? • Because there is no earmarked bed for breastfeeding. early initiation of breast fedding of vaginally born newborn wt >2 kg initiation of SSC in LRO Baby given to the mother immediately after changing mother’s gown initiate SSC FOR BABY >2 KG uncomplicated vaginal delivery 1. percentage of baby wt >2k in uncomplicated vaginal birth has SSC 2. percentage of outsider in LRO at 12 am and 6 am one female relative allowed inside LRO after shifting the mother to trolley (8pm-8am) allow one female relative for night shift after delivery and cleaning feeding area with privacy in LRO curtain beside trolley arrange curtains beside trolley bed for breast feeding earmarked bed for breast feeding Driver Diagram Primary driver Secondary driver awareness of JRs on early initiation of BF new flow chart for delivery display new flow chart for delivery 1. percentage of JRs can correctly tell the flow chart of delivery 2. percentage of JRs watched NSSK video NSSK video to JR s show NSSK video to JRs 1. percentage of trolley had curtain beside 2. percentage of bed in LRO earmarked for BF Change Ideas measures The aim of this change: EIBF in all vaginally delivered newborn wt >2kg Change flow chart. 1.Do not shift the baby to baby room 2.Give baby to mother immediately after shifting to trolley 3.JR to check initiation of BF before sending mother to ward 1. JR to note BF in mother sending Register 2.MSC Nurse to note the number of baby had BF in LRO on next morning at post natal ward 3. Analysis of data on every Wednesday by the QI team Changed flow chart X Flow chart of delivery process in labour room Delivery Baby on mother’s abdomen Drying of baby with pre- warmed sterile towel Delayed cord clamping Baby shifted to radiant warmer Change towel, cord tie, give inj vit K, Hepa B Baby shifted to baby room mother- repair of episiotomy Uncomplicated Complicated Immediate 1-2 min 2-3 min 1 min 5 min 15 mins from birth Mother and baby shifted to the ward after 1 hour 1 hour Mother shifted to trolley. Give baby to the mother and help her to initiate breast feeding. The aim of this change: EIBF in all vaginally delivered newborn wt >2kg 1. Placement of two beds in the place of trolleys . The mothers will be shifted to these beds after delivery and cleaning. 2. The beds are just in front of the nursing station. sisters help the mothers for EIBF. 1. Number of mothers did EIBF in LRO X The aim of this change: EIBF in all vaginally delivered newborn wt >2kg 1. Number of mothers did EIBF in LRO 1. Original baby room abolished. Convert a small ante room with an out gate to feeding room so number of total BF beds 4/14 =28.5% 2. Tie a red tape on mother’s wrist by sister after giving BF. Msc nurses to check the tape next morning X C OR R I D OR TO M C H H U B CORRIDOR…………………………………………………………………CORRIDOR………… LDR 3 LDR 2 DOCTORS ROOM NURSES ROOM E N T R Y S T A F W A S H T T C C G R D AUT OCLA VE Feeding room PATIENT ENTRY/EXIT LDR 1 NBC C NBC C B ST O R E T T CAB W T W T C A B C A B N N NS N S W N S GLASS W C A B NS SN CU X PNC WARD X Final measurements X • 1. Percentage of caregiver can tell the flowchart of delivery correctly=100% • 2.Percentage of bed in LR earmarked for EIBF= 28.5% • 3. Percentage of outsider in LR at 12 midnight and 4 am- not applicable , as the staff nurses could provide support to ALL mothers for EIBF X 0 10 20 30 40 50 60 70 80 90 100 1 6 11 16 21 26 31 36 41 46 51 56 percentage of mother had EIBF in day shift Rns Median 100 X 0 10 20 30 40 50 60 70 80 90 100 1 6 11 16 21 26 31 36 41 46 51 56 percentage of mother had EIBF at night Median 81.5 X Day shi 18.7 23.7 28.7 33.7 38.7 percentage of mother had EIBF in day shi Column1 percentage of mother had EIBF in day shi 5.43 15.43 25.43 35.43 45.43 55.43 65.43 75.43 1 2 3 4 5 6 Run Chart Period PDSA 1 26.63 46.63 66.63 86.63 106.63 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Run Chart Period PDSA2 72.5 77.5 82.5 87.5 92.5 97.5 102.5 1 3 5 7 9 11 13 15 17 19 21 23 25 27 Run Chart Period PDSA 3 Night shi 10.6 15.6 20.6 25.6 30.6 1 2 3 4 5 6 percentage of mother had EIBF at night night percentage of mother had EIBF at night -10 10 30 50 70 90 110 7 8 9 10 11 12 Run Chart 7 - 12 PDSA 1 14.42 34.42 54.42 74.42 94.42 114.42 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 Run Chart 13 - 33 PDSA 2 69.2 74.2 79.2 84.2 89.2 94.2 99.2 104.2 34 36 38 40 42 44 46 48 50 52 54 56 58 60 Run Chart 34 - 60 PDSA 3
Transcript of W H Y? Measu rements...Early initiation of breast feeding in Labour room in uncomplicated vaginal...
Early initiation of breast feeding in Labour room in uncomplicated vaginal deliveryDepartment of G&O Medical college Kolkata. India
Background Context & Problem Statement
• Early initiation of breast feeding in LRO is done in 40% of newborn during 12 hours of day shift and 15% of newborn during 12 hours of night shift following uncomplicated vaginal delivery (baby weight >2 kg)
• Following delivery mothers are shifted on a trolley from labour table after episiotomy repair, cleaning and changing gown and observed for one hour in LRO. No earmarked bed in LRO for breast feeding.
• Babies are kept in a baby room inside LRO after initial procedures (drying, cord tie, injections and documentation)
• Nurses are busy in other scheduled work and cant stand beside trolley for a long time to assist the mothers, otherwise the babies might fall from the trolley.
X
QI team of G&O dept MCH Kolkata
• Dr. Somajita-leader
• Dr. Mallika-analyser
• Sister in charge (LR) sister Aparna-communicator
• Sister Parna-analyser
• Sister Soma-communicator
• Sister Mita-communicator
• Co-opted member Msc nursing tutor- M/s Manasi
X
Aim Statement
• We, (QI team of G&O) MCH Kolkata, aim to improve
early initiation of breast feeding (within 1 hour) in labour room in all newborn (weighing >2kg) delivered vaginally (uncomplicated) during Night shift
From15% to 80% by 30.4.2017.
Date:1.2.2017
X
Change Idea(s) & PDSAs X
• Increase awareness of junior residents on early initiation of breast feeding by showing NSSK protocol video
• One earmarked bed for mother , inside LRO -baby room for breast feeding . Mother s are shifted to that bed from labour table , initiate feeding and after that shifted to the trolley.
• One female attendant to be allowed inside LRO after delivery beside the trolley of the mother and keep an eye on the baby to avoid any fall from the trolley
MeasurementsX
• Outcome measures:-1.Percentage of new born weighing >2kg and delivered by uncomplicated vaginal delivery had early initiation of breast feeding in LRO
• Process measures:-1. Percentage of new born weighing>2kg delivered by uncomplicated vaginal delivery initiated SSC in LRO
2.Percentage of earmarked bed in LRO for BF
• Balancing measures:-1.Percentage of outside people present in LRO at 12 am and 6am
Analysis & Tools UsedX
• Flow chart of delivery and newborn care in LRO
• Fish bone analysis
• Pareto chart
• 5 why
X Flow chart of delivery process in labour room
Delivery
Baby on
mother’s
abdomen
Drying of baby
with pre-
warmed sterile
towel
Delayed cord
clamping
Baby shifted
to radiant
warmer
Change towel,
cord tie, give
inj vit K, Hepa
B
Baby shifted to
baby room
mother- repair
of episiotomy
Uncomplicated
Complicated
Immediate 1-2 min
2-3 min
1 min 5 min
15 mins from birth
Mother and
baby shifted
to the ward
after 1 hour
1 hour
Baby given to
mother just
before shifting to
ward
absent in induction training
have not seen NSSK video
ProcessPolicy
ProcedurePlace
early initiation of breast feeding not done in LRO in uncomplicated vaginal birth baby weight >2 kg
Problem Statement
lack of awareness among JRs
few nurses sp. During night shift
other works to be done in busy schedule
Can not stand beside trolley and supervise feeding Otherwise the bwby might fall from the trolley
baby not given to mother after delivery by nurse
mother in labour table >30 minutes
delay in repair of episiotomy by JR
mother in labour table>30 minutes
delay in cleaning of mothers and gown changing by aya
inadequate number of curtains beside trolley to maintain privacy
no separate feeding room in LRO
baby kept in a baby room inside LRO
mothers are shifted on a trolley after delivery and the baby might fall from
the trolley
ROOT CAUSE ANALYSIS –FISH BONEX
WHY?
Why the baby is not given to the mother by nurse?
• Sisters are fewer in number, especially in night shift and hence busy in other work. Mothers need supervision while breastfeeding which cannot be provided by the busy sisters. In 8am to 8pm shift, supervision is provided by additional staff like trainee sisters.
Why do the mothers need supervision?
• After cleaning and changing gown, mothers are placed on an unrailed trolley. Hence the baby might fall.
Why the mothers are on trolley?
• Because there is no earmarked bed for breastfeeding.
early initiation of breast fedding of
vaginally born newborn wt
>2 kg
initiation of SSC in LRO
Baby given to the mother
immediately after changing mother’s
gown
initiate SSC FOR BABY >2
KG uncomplicated
vaginal delivery
1. percentage of baby wt >2k in uncomplicated
vaginal birth has SSC 2. percentage of
outsider in LRO at 12 am and 6 am
one female relative allowed inside LRO
after shifting the mother to trolley
(8pm-8am)
allow one female relative for night shift after delivery and cleaning
feeding area with privacy in
LRO
curtain beside trolley
arrange curtains beside trolley
bed for breast feeding
earmarked bed for breast feeding
Driver Diagram
Primary driver
Secondary driver
awareness of JRs on
early initiation of
BF
new flow chart for delivery
display new flow chart for delivery
1. percentage of JRs can correctly
tell the flow chart of delivery
2. percentage of JRs watched NSSK
video NSSK video
to JR sshow NSSK video to JRs
1. percentage of trolley had curtain beside
2. percentage of bed in LRO earmarked for BF
Change Ideas
measures
The aim of this change: EIBF in all vaginally delivered newborn wt >2kg
Change flow chart. 1.Do not shift the baby to baby room 2.Give baby to mother immediately after shifting to trolley 3.JR to check initiation of BF before sending mother to ward
1. JR to note BF in mother sending Register 2.MSC Nurse to note the number of baby had BF in LRO on next morning at post natal ward 3. Analysis of data
on every Wednesday by the QI team
Changed flow chartX
Flow chart of delivery process in labour room
Delivery
Baby on
mother’s
abdomen
Drying of baby
with pre-
warmed sterile
towel
Delayed cord
clamping
Baby shifted
to radiant
warmer
Change towel,
cord tie, give
inj vit K, Hepa
B
Baby shifted to
baby room
mother- repair
of episiotomy
Uncomplicated
Complicated
Immediate 1-2 min
2-3 min
1 min 5 min
15 mins from birth
Mother and
baby shifted
to the ward
after 1 hour
1 hour
Mother shifted to trolley.
Give baby to the mother
and help her to initiate
breast feeding.
The aim of this change: EIBF in all vaginally delivered newborn wt >2kg
1. Placement of two beds in the place of trolleys . The mothers will be shifted to these beds after delivery and cleaning.
2. The beds are just in front of the nursing station. sisters help the mothers for EIBF.
1. Number of mothers did EIBF in LRO
X
The aim of this change: EIBF in all vaginally delivered newborn wt >2kg
1. Number of mothers did EIBF in LRO
1. Original baby room abolished. Convert a small ante room with an out gate to feeding room so number of total BF beds 4/14 =28.5%
2. Tie a red tape on mother’s wrist by sister after giving BF. Msc nurses to check the tape next morning
XCORRIDORTOMCHHUB
CORRIDOR…………………………………………………………………CORRIDOR…………
LDR3
LDR2
DOCTORSROOM NURSESROOM
ENTRYSTAF
WASH
T
T
C
C
GRD
AUTOCLAVE
Feedingroom
PATIENTENTRY/EXIT
LDR1
NBCC
NBCC
B
STOR
E
T
T
CAB
W
T
W
T
CAB
CAB
NNNSNS
W
NS
GLASS
GLASSS
W
GLASSS
CAB
NS
SNCU
X
PNC WARDX
Final measurementsX
• 1. Percentage of caregiver can tell the flowchart of delivery correctly=100%
• 2.Percentage of bed in LR earmarked for EIBF= 28.5%
• 3. Percentage of outsider in LR at 12 midnight and 4 am- not applicable , as the staff nurses could provide support to ALL mothers for EIBF
X
0
10
20
30
40
50
60
70
80
90
100
1 6 11
16
21
26
31
36
41
46
51
56
percentage of mother had EIBF in day shift
Rns
Median 100
X
0
10
20
30
40
50
60
70
80
90
100
1 6 11
16
21
26
31
36
41
46
51
56
percentage of mother had EIBF at night
Median 81.5
X
Dayshi
18.7
23.7
28.7
33.7
38.7
percentageofmotherhadEIBF
indayshi
Column1
percentageofmotherhadEIBFindayshi
5.43
15.43
25.43
35.43
45.43
55.43
65.43
75.43
1 2 3 4 5 6
RunChart
Period
PDSA1
26.63
46.63
66.63
86.63
106.63
12 3 456 7 8 9101112131415161718192021
RunChart
Period
PDSA2
72.5
77.5
82.5
87.5
92.5
97.5
102.5
1 3 5 7 9 11 13 15 17 19 21 23 25 27
RunChart
Period
PDSA3
Nightshi
10.6
15.6
20.6
25.6
30.6
1 2 3 4 5 6
percentageofmotherhadEIBF
atnight
night
percentageofmotherhadEIBFatnight
-10
10
30
50
70
90
110
7 8 9 10 11 12
RunChart
7-12
PDSA1
14.42
34.42
54.42
74.42
94.42
114.42
131415161718192021222324252627282930313233
RunChart
13-33
PDSA2
69.2
74.2
79.2
84.2
89.2
94.2
99.2
104.2
34 36 38 40 42 44 46 48 50 52 54 56 58 60
RunChart
34-60
PDSA3
