- Background and overview
The Beaufort-Delta Health and Social Services Authority (BDHSSA) serves the 7,500 residents of the Beaufort-Delta region in the Northwest Territories. The Inuvik Regional Hospital offers acute care services in the fourteen in-patient bed unit, three special care unit beds, four day surgery beds, and two birthing room beds. A complement of registered nurses and licensed practical nurses provide 24/7 care. The acute care department has access to diagnostic testing and laboratory services in the hospital. Seriously ill or injured patients needing intensive care beyond the scope of services available at Inuvik Regional Hospital are transferred to Yellowknife or Edmonton. There are approximately 150 births per year at the Inuvik Regional Hospital. Our primary care team has a patient- and client-focused approach to service delivery, striving to provide competent, evidence-driven, quality care. Our physician complement consists of nine full-time positions, of which only one is filled by a permanent physician. Therefore, the BDHSSA physician complement is staffed by 89 percent locum physicians.
- Problem statement
Pregnant women in outlying and satellite communities come to Inuvik for confinement at 37 weeks. Historically, if a woman was low risk, only at the time of confinement was the Inuvik Regional Hospital obstetric (OBS) physician made aware of this patient. Due to the inconsistent physician population mentioned above, the moreOB Core Team noted that often patients would present in labour on the acute care unit without standard prenatal care. There was a lack of the moreOB Module One goals, especially the development of quick wins by having all disciplines on the same page. A few common occurrences included RH negative women who were not treated at 28 weeks, poorly completed obstetrical histories, and incorrect dating, all of which increased the risk to mother and newborn. As well, group B strep bacteria status was rarely confirmed, resulting in unnecessary use of antibiotics. There was no established reporting system or sign-over system among the locum physicians providing prenatal care. As the moreOB Program maintains open communication, increased trust and respect among all members of the team resulted in improved maternal and neonatal outcomes and reductions in harmful events.
The moreOB Core Team wanted to develop a formal communication strategy among
obstetrical care providers for the prenatal patients within the BDHSSA.
The moreOB Core Team met with its participant group and locum physicians in January 2011 to brainstorm solutions to address the lack of consistent, complete, and safe prenatal care.
All parties agreed on a formal process of review of prenatal patients by those involved in their care. Working closely with the co-medical directors, it was decided that a weekly review would occur for prenatal patients at 36 weeks gestation and over, as well as for any patient deemed high risk. Weekly multidisciplinary prenatal rounds were implemented in February 2011 and subsequently enhanced. The OBS physician scheduled time on Monday mornings for chart reviews and to request clinic appointment bookings for all patients on the standardized prenatal list. Patients are booked that week with the on-call OBS physician. Each Monday and Thursday, staff involved in prenatal care (including the team leader for acute care and emergency, manager of hospital nursing units, medical director, OBS locum physicians, visiting gynecology/obstetrics specialist, medical students and residents, nurse practitioners, prenatal nutritionist, manager of clinics and anaesthesia) take part in a prenatal round table. This involves a review of the patient’s current status, including gestation confirmation and method, gravida and para review, group B status, RH status and treatment, blood type and antibody review, third trimester hemoglobin, third trimester chlamydia and gonorrhea screen, body mass index (BMI), risk factors, date last seen in clinics, and any other relevant medical or psychosocial history. The obstetrics physician for that week discusses each patient’s condition and relevant scheduled follow-up, and the multidisciplinary team actively plans for a safe delivery.
- Formalized prenatal rounds
The moreOB Program asserts that when an interprofessional team works together, it creates a community of practice. Team members share a common interest and recognize that reflective learning results in shared knowledge. All team members must be empowered to speak up and identify what might be negatively affecting patient care and safety. With this initiative, the manager of nursing units discussed the moreOB Core Team’s concerns regarding inconsistent prenatal care that often did not align with the moreOB standards as well as the lack of communication among prenatal care service providers with the medical directors. The manager of nursing units presented the moreOB Core Team’s suggestion of formalized prenatal rounds to the senior management team, and this was supported by the senior leaders and the quality and risk manager.
After this approval, the moreOB Core Team met with its participant group and locum physicians to share the proposed solution. The participants play an essential role in this initiative. Once a week, one of the group members reviews all prenatal records in the family clinics and adds every woman at 36 weeks to the list with her relevant medical/obstetrical history and information. The OBS physician completes chart reviews and presents each patient at the multidisciplinary obstetrical rounds on Mondays. The moreOB Core Team and participant members have been the change champions behind this initiative. They have often rallied to ensure it stayed on track in its infancy.
A performance audit can be helpful to review a program and determine whether it is achieving its objectives effectively and efficiently. Module 2 enhanced the BDHSSA staff and management’s knowledge of the functional components of auditing. Through completed audits, we were able to identify that 25% of our RH negative women were not treated as per moreOB standards at 28 weeks gestation prior to the implementation of the prenatal reviews. We are now proud to report that 100% of our RH negative patients receive the standard of care. The audit reports and successes have been shared with our stakeholders, including Accreditation Canada, territory referral centres, quality and risk management, the public via the annual general report, senior management, and our dedicated obstetrical staff.
The bi-weekly multidisciplinary prenatal rounds are well established and the moreOB team has been successful in changing the culture to one that values communication and that has a common and informed voice for all team members. The multidisciplinary rounds have improved patient outcomes by identifying a growing population of women with a BMI greater than 45. This has led to the BDHSSA developing a guideline that requires an anaesthesia consult pre-delivery for any woman with a BMI greater than 45. In one case, this led to a transfer to the tertiary centre for delivery; in another, it ensured a patient with a cardiac condition (supra ventricular tachycardia treated with Verapamil) had proper supports such as additional trained personnel at delivery for both neonatal resuscitation and advanced cardiac life support. Finally, for patients choosing adoption, there now are support plans involving social programs to ease the transition. There are countless benefits for patient outcome improvements and staff education via this initiative.
In conclusion, our moreOB Core Team of seven members and participant team of ten members are often faced with the challenges of a diverse culture, harsh landscape, and inconsistent staffing patterns. Despite the obstacles, the team has consistently raised the bar in patient care, and has created a culture of safety that is apparent. I am proud to be part of such a group of change champions, leaders, and patient care advocates.