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audit of the monitoring of obstetric patients in theatre recovery

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audit of the monitoring of obstetric patients in theatre recovery

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    1. Audit of the Monitoring of Obstetric Patients in Theatre Recovery Dr Gareth Roberts, Ysbyty Gwynedd Dr Haitem Maghur, Ysbyty Gwynedd

    3. Audit objectives To find out what: Recovery training has been provided for midwives to enable them to undertake this role Observations are documented on obstetric patients recovering from anaesthesia Facilities are present in the obstetric theatre recovery bay

    4. Audit standards The obstetric theatre recovery bay must meet the AAGBI minimum national standards for recovery facilities All women should have at least the AAGBI recommended set of minimum observations recorded on a dedicated recovery chart at least every 15 minutes All recovering women should not be left alone at any time

    5. There should be a protocol for discharge from recovery and all women should meet these criteria before leaving the area All recovering women should be recovered by a member of staff (nurse or midwife) who has undergone recovery training and recovers patients on a regular basis All recovering women should have the presence of trained recovery staff giving them 1:1 care

    6. Method 3 part audit : 1st part was a questionnaire sent to all midwives on labour ward 2nd part was a retrospective analysis of cases notes of patients being recovered following Caesarean Section 3rd part was an audit of the facilities present in obstetric theatre recovery compared against AAGBI minimum standards

    7. PART 1 Prospective Questionnaire sent to all 70 midwives working at Ysbyty Gwynedd

    8. Questions asked about : 1. Recent training in recovery skills 2. Basic life support training 3. Frequency of recovering patients 4. Confidence level when recovering patients 5. Criteria for discharge from recovery 6. Training in use of invasive monitoring 7. Ability to give intravenous drugs

    9. Results 25 questionnaires completed (35% response rate)

    10. I have received the following formal training in recovery skills within the last 3 years None 5 (20%) Day release to main recovery 20 (80%) Other 0

    11. I have passed a BLS course within the pastyear Yes 22 (88%) No 3 (12%)

    12. How often do you recover patients following surgery?

    13. I feel confident in recovering patients after: GA 21(84%) Spinal 25 (100%) Epidural topup 25 (100%)

    14. Criteria for discharge

    15. How often do you care for a patient in Obstetric HDU?

    16. Have you received formal training in the use of an arterial line? Yes 4 (16%) No 21(84%)

    17. Have you received formal training in the use of a central line? Yes 4 (16%) No 21 (84%)

    18. Are you able to give drugs intravenously? Yes 23 (92%) No 2 (8%)

    19. PART 2 Retrospective 45 case notes of patients recovered from elective and emergency Caesarean Section in obstetric theatres audited Sampling period between 1st January and 31st August 2008 3 groups of 15 cases audited based on the type of anaesthetics, GA, Spinal, Epidural topup ‘AAGBI minimum monitoring requirements in recovery’ parameters audited in these 45 recovered patients

    20. AAGBI minimum obstetric recovery observations should include: 1. Haemoglobin oxygen saturation 2. Respiratory rate 3. Heart rate and rhythm 4. Blood pressure 5. Temperature 6. Level of consciousness 7. Pain score 8. Sensory level of regional block 9. Blood loss from wound, vagina and drain

    21. Results

    22. Spinal

    23. GA

    24. Epidural topups

    25. Part 3 Prospective Assessment of recovery facilities including staffing carried out. Compared against The AAGBI checklist of minimum nationally recommended recovery facilities which include: Oxygen outlet Ambu Bag Electrical Sockets 4. Pulse oximeter

    26. 5. ECG monitor 6. Suction Unit 7. NIBP monitoring 8. Telephone / emergency buzzer 9. 1:1 staff to patient ratio 10. Breast feeding facilities 11. IV cannulas 12. Tape 13. Blood test bottles and forms 14. IV fluid and giving sets 15. Defibrillator 16. Emergency drug box 17. Intubation equipment

    27. Results 100% of recovery facilities found to be present Midwives however provide 1:2 care due to having to care for the newborn baby and recover the mother simultaneously Midwife occasionally needing to leave recovering patient due to newborn duties No obstetric recovery discharge protocol in existence for the midwifes to use

    28. Conclusions Although most midwives have received a day of recovery training in the past 3 years this is probably insufficient training to meet current national standards for obstetric recovery care Although midwives feel confident in recovering patient following regional and general anaesthesia they do not recover patients often enough to maintain experience Very poor documentation of patient’s vital signs, pain score and sensory block level in recovery.

    29. Midwifes are not always able to be with patient for whole of recovery period due to additional newborn duties Obstetric theatre recovery facilities fully meet minimal national requirements

    30. Recommendations We recognise the valuable contribution that midwives have played in the recovery of obstetric patients over the years However, as shown by this audit, to meet current national standards for the recovery of obstetric patients, their recovery at Ysbyty Gwynedd should in the future only be undertaken by trained recovery nurses Midwives require formal training in the use of invasive monitoring (arterial & CVP line management) to make them more effective in caring for the sick parturient To establish an Obstetric recovery discharge protocol with well defined criteria to aid in the decision of discharging patients back to the ward.

    31. Future audits Audit length of stay of patients in obstetric recovery against national standard Audit obstetric HDU monitoring, staffing and facilities Re audit in 12 months.

    32. References Association of anaesthetists of Great Britain and Ireland. Immediate postanaesthetic recovery. AAGBI London 2002 Association of anaesthetists of Great Britain and Ireland. The Anaesthesia Team. AAGBI London 2005 Association of anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery. AAGBI London 2007 Confidential Enquiry into Maternal and Child Health. Saving Mother’s Lives 2003-2005. CEMACH, London 2007

    33. Thank you… Questions?

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