FEATURE OBS/GYNE
2007 to guide the process of improving the quality of care for these women. The initial findings confirmed the
available evidence, demonstrating that women were questioning the need to be admitted the day before their caesarean, reporting increased anxiety due to separation from their family. Lack of continuity of care was also identified as a result of frequent bed moves from the antenatal to postnatal wards.
THE FIRST STEPS ON A NEW PATHWAY A multidisciplinary team comprised of nurses/midwives, obstetricians, anaesthetists, medical records, admissions office and bed management staff conducted a mapping exercise to establish the patient journey. Each step was analysed to identify opportunities for improvement. The problematic areas emerged as: Increased costs for the family and hospital due to the additional overnight stay, with no clinical input required
Unnecessary workload for staff due to caring for women with no clinical requirements until preparation for surgery
Separation of mother and baby in the operating theatre resulting in lack of skin to skin contact and initiation of breast feeding (now a requirement for maintaining Al Wasl as a Baby Friendly accredited hospital, awarded in 2010)
An increased risk of baby mix-up due to separation of mother and child
The need to develop practice in response to international evidence based practice
PLANNING THE CHANGE Clear communication channels were opened across all disciplines to inform about the new CS pathway initiative. Rigorous criteria were developed to ensure only uncomplicated elective CS cases with no pre-existing medical or obstetric conditions were included. It was arranged that all women suitable for the pathway attended a pre-operative anaesthetic assessment. A competency framework was
developed to ensure all nurses/midwives received training to enable them to admit the mother, accompany her and her husband to the operating theatre, receive the newborn and accompany
«Clear communication channels were opened across all disciplines to inform about the new CS pathway initiative»
the mother and father back to the unit with the baby. This included providing care and support to the mother during the siting of the spinal anaesthetic, performing catheterisation, promoting skin to skin contact between mother and baby and initiating breast feeding in the recovery area to enhance bonding. Patient information leaflets were prepared in Arabic and English to help educate women suitable for the pathway. Key performance indicators based on complications as a direct result of admission on the day of surgery and patient satisfaction were designed to monitor the process.
THE PILOT RESULTS The pilot commenced in January 2008 on one maternity ward, with one obstetric consultant. 35 women experienced the pathway in comparison to 337 women admitted the day before surgery. 17 were UAE nationals and 18 expatriots and this represented 35 less bed days due to admission on day of surgery. Patient satisfaction data scored 100% excellent on a likert scale questionnaire. These preliminary findings indicated that admission on day of operation had the potential to improve standards of care
and optimise quality of care. The decision was made to offer the pathway across all consultants and maternity wards to women booked for uncomplicated elective CS, with admission the day before the exception rather than the norm (see table 1).
WHAT NEXT – HOLDING THE GAIN?
The final stage in the FOCUS PDCA was to act to hold the gain. Following international best practice, the logical next step was to develop the admission on day of surgery initiative into a fully integrated clinical pathway called the Caesarean Birth Integrated Care Pathway (CBICP).
INTEGRATED CARE PATHWAYS (ICP) Integrated Care Pathways (ICPs) are standardised, evidence based multidisciplinary management plans, which identify the appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for a specific patient group. It is a document which is completed by all health professionals involved in care and variances to normality are assigned codes and an action plan and outcomes recorded on a variance sheet. ICPs are ideal for procedures and
conditions associated with high volume short stay admissions, high cost treatment/ care, for describing the patient journey and supporting particular treatment options – all features of the admission on day of
Tertia and Marko Albertyn with baby Max during CS Pathway
Image © Tertia and Marko Albertyn Arab Health Issue 3 2011 17
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