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Using Guidelines to Assure Clinical Quality and Patient Safety. Dr. Evita Fernandez. HOSPITAL. Hyderabad, INDIA www.fernandezhospital.com. Patient safety has always been a prime concern of the clinician. Hospital Admissions. 1 in 10 : Adverse event 1 in 300 : Death.

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using guidelines to assure clinical quality and patient safety

Using Guidelinesto AssureClinical Quality and Patient Safety

Dr. Evita Fernandez

HOSPITAL

Hyderabad, INDIA

www.fernandezhospital.com

hospital admissions
Hospital Admissions

1 in 10 : Adverse event

1 in 300 : Death

harm to an individual
Harm to an Individual

1 in 1,000,000 : Air travel

1 in 300 : Healthcare

why use guidelines
Why Use Guidelines ?

1. Standardizes care

2. Improves quality of care

3. Improves patient safety

4. Cost effective

5. Facilitates audits

standardize medical care

1

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

2

Improve Quality of Care
  • Evidence based practice
  • Algorithm / protocols
who partogram
WHO Partogram
  • Overall improvement
  • Differentiates normal / abnormal progress
  • Identifies women requiring intervention
slide10

“Its use in all labour wards is recommended”

Lancet, 1994

all women should have support throughout labour and birth
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

research findings
Research Findings

The need for analgesics

Rate of Oxytocin

Instrumental deliveries

Caesarean sections

5 min APGAR Score of < 7

slide13

Continuous support in labour

increased the chance of a

spontaneous vaginal birth, had no harm,

and women were more satisfied.

aim at the system not the individual
Aim at the System not the Individual

Standardize processes

and equipment

slide27

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.
learning from mistakes
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
monthly meets
Monthly Meets
  • Perinatal Mortality Meet
  • CTG Meet
  • CRM Interaction
  • Anesthesia interaction
  • Neonatologist interaction
enemas during labour review
Enemas during labour (review)

Reveiz L, Gaitán HG, Cuervo LG,

Cochrane Database of Systematic Reviews 2007, updated in 2010

variables evaluated
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

slide35

These findings speak against the routine

use of enemas during labour;

therefore, such practice should be

discouraged.

active versus expectant management for women in the third stage of labour review
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.

recommendations on active management of the third stage of labour
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
slide38

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

obstetric anal sphincter injury oasi
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

changes in practice
Changes in Practice
  • Training of Doctors
  • Perineal repair workshop
  • Protocols, Follow up
  • Clinical attachment with Dr. Abdul Sultan
  • Perineal Repair Clinic
concept of a car dashboard
Concept of a Car Dashboard

Current status of fuel, speed, temperature, battery, seat belts and so on

maternity dashboard1
Maternity Dashboard
  • Clinical activity
  • Workforce
  • Clinical outcome
  • Risk incidents / complaints / patient satisfaction
determining the traffic lights
Determining the Traffic Lights
  • Green – within desired limits
  • Amber – alert zone
  • Red – urgent action
methodology
Methodology
  • Prospective study
  • July 2010 – Jan 2011
  • Fernandez Hospital
  • Tertiary perinatal referral
  • 5000 births / year
  • 120 bedded Perinatal unit
slide70

Measurement, however,

plays an important part in

improving the quality of care

and promoting beneficial

changes.

Departments to select quality indicators