Maternal and Neonatal Emergency Room Care Activities Indonesia REGIONAL STRATEGIES

1. Maternal and Neonatal Emergency Room Care Activities Indonesia REGIONAL STRATEGIES RSSA MALANG

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

3. Story Significant number of Maternal and Neonatal emergencies die shortly after arrival to the hospital. Why? • Delay in seeking medical advice? • People refrain from seeking medical advice? • Delay in referring critical patients from private sector? • Un-safe patient transfer system and substandard pre-hospital phase? • Sub-optimal initial management ?

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

5. Findings • 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

6. Rationale 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.

7. Strategy • Develop Implementation plan of MNERC at the region of Malang as a model for regionalization of the ER strengthening activities . • Reproducible Model

8. Approach • 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)

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

10. Facility Self Improvement Plan 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

11. Emergency Department Self Improvement Plan

12. Emergency Department Self Improvement Plan

13. Emergency Department Self Improvement Plan

14. Emergency Department Self Improvement Plan

15. Steps • 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)

16. Steps (cont.) • 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

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

18. ER Materials Package (cont) • Monitoring tools • Clinical performance monitoring (departmental performance and Individuals log books) • Managerial performance monitoring • Reporting system tools • Clinical supervision (Clinical – Challenges solved/unsolved) • Regional quarterly reports

19. Training strategy • 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

20. Training strategy • 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.

21. Training strategy • 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)

22. Training strategy • 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).

23. Training strategy • 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

24. Sustainability Plan • 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)

25. Major Causes of Maternal Mortality presenting to EDs: • Vaginal Bleeding • before 20 weeks, • Antepartum, • postpartum • Eclampsia and Pre-Eclampsia • Trauma in Pregnancy • Post-partum sepsis

26. Major Causes of Neonatal Mortality presenting to EDs: • Neonatal Resuscitation • Respiratory distress • Circulatory Failure • Hypo and Hyperglycemia • Thermo-regulation • Neonatal Seizures

27. Major Causes of Mortality in Maternal and Neonatal Topics presenting to EDs: Cardiac Arrest • CPR in Pregnancy • CPR in Neonates • CPR Equipment

28. Policies regulating Obstetric and Neonatal Emergencies • Initial Management of Obstetric Emergencies in ER • Initial Management of Neonatology Emergencies in ER

29. Initial Management of Obstetric 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).

30. 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.

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

32. Procedures: • 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.

33. 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.

34. 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

35. Conditions to apply the policy: • 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.

36. Regional MNERC model

37. Regional Malang ? Kota Pasuruan bangil Kota Probolinggo Kediri Kota Malang Probolinggo Batu Tulungagung wlingi Lumajang Malang Blitar

38. Result • 6 months program ( ideally 2 year program ) • As pilot project

39. Result OJT 9 District Hospitals

40. Average OJT compliance scores for nine district hospitals

41. Average OJT compliance scores by category for 9 district hospitals

42. Average OJT compliance scores by category for 9 district hospitals

43. Clinical Practices

44. Clinical practice indikators for emergency medical services

45. Average clinical practice compliance scores by category for 9 district hospitals

46. Average clinical practice compliance scores for nine district hospitals

47. Recommendations 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

48. Recommendations 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

49. Recommendations Communication skill: • upgrading of communication skills is essential for all staff working in ED

50. Future plans • Pre-hospital, Ambulance service • EMT • Private sectors • Nursing training • Community activities • Increase awareness with risk factors • Seek medical advice early • Change the current image