Criterion based audit on clinical management of critically ill mothers admitted to the High Dependency Unit, Labour Ward, Mulago Hospital

Abstract

Introduction: MMR still remains unacceptably high and is a major global health challenge. To achieve MDG5 targets by 2015 will require not only sustained and urgent emphasis on improved pregnancy and delivery care throughout the developing world, but also care of the critically ill mothers in the postpartum period. HDU cares for patients who are critically ill with potentially recoverable obstetric related complications who can benefit from more continuous observation that cannot be provided safely on an ordinary ward. CBA is being used in the developed world to identify gaps in practice and thus reduce mortality among the critically ill. It is not in general use in Africa where the MMR is still high particularly in the postpartum period. Objective: To improve the management of critically ill patients admitted to HDU through the development of recommendations after comparing the levels of adherence against the guidelines and standards for the management of critically ill patients and to assess their impact by an evaluation of the quality of care after implementation of the recommendations. Methods: It was a CBA conducted within HDU Mulago Hospital which is a large teaching hospital in which more than 25,000 deliveries are conducted annually. HDU is a semi autonomous unit under labour suite that cares for patients who are critically ill with potentially recoverable obstetric related complications. Existing guidelines for the management of critically ill mothers admitted to HDU were reviewed. Management practices were evaluated against the set standards by evaluating case files. Results of the audit were then presented to those offering care and recommendations developed and implemented. A re-audit of management practices was done 2 weeks later for a period of one month to assess whether there was an improvement. Results: The initial audit showed that a majority of the standards were rarely achieved. Consequently, upon presentation of the results to the department, a number of recommendations were made and changes implemented. The midwives and doctors were briefed on the new guidelines. The guidelines were then written and pasted within the HDU notice board as well as the postgraduate room notice board. There were improvements in all fronts; review of patients prior to transfer to HDU rose from 1.7% to 34.4% (risk ratio 0.154;95% CI [0.053-0.444] p<0.001 ) The complete HDU team reviewing patients at least twice a day improved from 5.7% to 64%( 0.231 CI [ 0.133-0.402] p<0.001 ).Each patient having an intravenous access line in place, a catheter in situ and a fluid balance chart initiated on admission was maintained at a perfect 100% record in both audits. Observation charts initiated on admission improved from 89.3% to 100%. (0.764 CI [0.672-0.869] p<0.028).Urine output measurement improved remarkably from 0% to 92%. Administration of antihypertensive therapy improved from 74.1% to 95% (0.775 CI [0.66-0.911] p<0.03]).Urine protein analyzed within 24 hours improved from 24.7% to 33.3%. (0.907 CI [0699-1.18] p< 0.426). CBC done within 24 hours improved from 42.1% to 91 %.( 0.66 CI [0.526-0.817] p<0.001). LFTs and RFTs done within 24 hours rose from 40.8% to 71.4% (0.793 CI [0.645-0.978] p<0.013). The administration of magnesium sulphate given as maintaince dose improved from 22.4% to 81%. (0.534 CI [0.379-0.752] p< 0.001). Monitoring of vitals every 15 minutes for the first 2 hours improved from 5.7% to 17.2%. (0.646 CI [0.345-1.212] p< 0.056). Monitoring the vitals every hour for the next 4 hours improved from 14.8% to 55.2%. (0.526 CI [0.348-0.795] p< 0.001). Monitoring the vitals every 4 to 6 hours for the next 18 hours improved from 12.5% to 72.4% (0.38 CI [0.234-0.616] p<0.001 ).Lastly patients transfused in less than an hour upon request rose from 9% to 80.6%.. Conclusion: This study demonstrated how an audit helped to improve the quality of care for patients admitted to HDU through practical recommendations that could easily be implemented by health workers in low resource limited settings . It was useful in opening locally available avenues for improvement in the management of critically ill patients.