Perinatal audit – what is the purpose?

1. Mölndals Sjukhus March 2017 Perinatal audit – what is the purpose? Michael Robson The National Maternity Hospital Dublin, Ireland Mrobson@nmh.ie

2. Key issues in the Maternity Services Safety, consistency and quality

3. Key issues in the Maternity Services How do we assess quality in the Maternity Services?

4. Assessing Quality Structure (resources) Building Equipment Staff

5. Assessing Quality Processes (guidelines)

6. Assessing Quality Organisation Philosophy Leadership Truly multidisciplinary approach Good communication Key decision making Fail safe mechanisms

7. Assessing Quality Outcome Events and outcomes (including complications) Complaints, adverse events, medico-legal cases (incidents) Professionals knowledge of information Ability to respond and change as a result of information Ability to perform and continuously reassess information

8. Assessing Quality Women, healthcare professionals and governments are interested in safety and quality Safety and quality are ultimately related to outcome and outcome guides processes

9. Perinatal Audit- what is the purpose? The first measure of quality in any organisation is knowing what your results are

10. Perinatal Audit- what is the purpose? Safety and quality of care provided by a labour and delivery unit should be assessed in terms of available validated perinatal audit and only then ultimately in appropriate outcomes when all the necessary information is available

11. Perinatal Audit- what is the purpose? The second measure of quality is enabling the ability to understand the results, compare them with other delivery units and use them to improve quality of care

12. Evidence based medicine Competing Philosophies Process driven (Randomised trials) Outcome driven (Perinatal audit)

14. Randomised trials depend on relative outcomes over a limited period of time while perinatal audit concentrates on absolute outcomes over an indefinite period of time

15. As randomised trials continue to ascend in the evolution of evidence based medicine, we must recognise and respect their limitations when examining complex phenomena in heterogeneous populations Andrew Kotaska BMJ 2004

16. Perinatal Audit- why is it so difficult? Not recognised as an entity, specialist area or even at all useful (poor relation of randomised controlled trials) Collection of routine quality data is resource dependent, requiring total organisational commitment No accepted classification, principles or training programmes

17. Perinatal Audit- what is the purpose? In theory at least, it should be simpler to standardise measurement of outcomes rather than processes

18. Perinatal Audit- what is the purpose? If standardising measurement of outcome is established and accepted, a greater degree of comparison, learning and communication can and will take place It might then be reasonably expected that processes would gradually merge over time

19. Perinatal Audit- what is the purpose? Embrace different ways of care and rather than concentrating on standardising processes standardise the way we carry out perinatat audit so greater learning and comparison can take place between delivery units

20. Perinatal Audit– collection of routine quality data is resource dependent, requiring total organisational commitment Few delivery units, regions, countries have committed to routine quality data collection

21. Perinatal Audit– collection of routine quality data is resource dependent, requiring total organisational commitment Perinatal audit starts at the individual unit level with The Clinical Report

26. Perinatal Audit The current challenges Routine data collection Classification of data

27. The Maternal and Newborn Clinical Managment System (MN-CMS)- routine data collection A means of clinical communication Concept of a virtual record and clinical care Storage of information Access to and the use of additional resources to improve care Information available for analysis

28. Perinatal Audit- classification of data Unless we classify data in a systematic and consistent way the more confused we will become

29. Perinatal audit– no accepted classification, principles or training We need to classify all perinatal outcome so that objective comparisons can be made of fetal and maternal outcomes over time in one unit and between different units both nationally and internationally

30. But to do that We need a consistent, objective and overarching structure (classification) within which we can examine fetal and maternal outcomes

31. Labour and delivery events and outcomes (including “interventions” and complications) Events Any intrapartum event, on its own insignificant to the mother, midwife, obstetrician or neonatologist but may influence one of the labour outcomes Outcomes Any outcome thought by the mother, midwife, obstetrician or neonatologist to affect the health and satisfaction of either mother or baby Robson MS. Labour Ward Audit. In: Management of Labour and Delivery. Ed. R.Creasy, 1997 Blackwell Science pp. 559-570

32. Is a Caesarean Section an event or an outcome?

33. Principles of Perinatal Audit Overall rates of any events or outcomes are on their own meaningless

34. Principles of Perinatal Audit No perinatal event or outcome (including CS) should be considered in isolation from other events, outcomes and organisational issues

35. No perinatal event or outcome should be considered in isolation from other eventsand outcomes Risk-Benefit Calculus Perinatal morbidity and mortality Maternal morbidity and mortality Labour and delivery events and outcomes Complaints, adverse incidents and medico-legal cases Maternal satisfaction and staff satisfaction

36. Perinatal Mortality Rate NMH 2005-2014(88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies)

37. HIE NMH 2005-2014(88,005 deliveries >24/40 and/or weighing >500g including congenital anomalies)

38. Principles of Perinatal Audit Classification must be able to incorporate other variables related to perinatal events and outcome

39. Classification must be able to incorporate other variables related to perinatal events and outcome Significant epidemiological factors Age, BMI, Fetal weight, Casemix Data collection must be aligned Organisational systems Staff and infrastructure resources Economics of childbirth

40. Principles of an ideal classification system Simple, easy to implement, informative and useful Robust, self validating and universal Prospectively determined, clinically relevant, identifiable, totally accountable and replicable The groups must be objectively not subjectively defined, mutually exclusive and totally inclusive Remove variables, but interpret accordingly

41. Classifying Perinatal Events and Outcome – the 10 Groups, Obstetrical Concepts and their Parameters

42. The 10 Group Classification- and the advantage of standardisation Any differences in sizes of groups or events and outcomes in the groups are either due to Poor data quality Differences in significant epidemiological factors Differences in practice

43. Philosophy of the 10 Group Classification Based on the premise that all information (epidemiological, maternal and fetal events, outcomes, cost and organisational) will be more clinically relevant by stratifying them using the 10 groups

45. Perinatal Audit- what is the purpose? To record and understand what we do in order to improve maternity care

46. Quality of maternity care Will not improve until we all continuously audit events and outcomes in a standardised way and understand their relationships MRobson@nmh.ie

47. Classifying Perinatal Outcome – the 10 Group classification system (TGCS) The Ten Groups Have Been Created From the Previous Obstetric Record, Course, Category and Gestation Robson MS. Classification of Caesarean Sections. Fetal and Maternal Review 2001; 12:23-39. Cambridge University Press

48. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015

49. National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015 Total number of caesarean sections over the overall total number of women Number of caesarean sections over the total number of women in each group

50. Size of each group is the total number of women in each group divided by the overall total number of women National Maternity Hospital, Dublin Caesarean Sections - the 10 Groups 2015