Bi-Weekly Multidisciplinary Prenatal Rounds North of 60
The Beaufort Delta Health & Social Services Authority (BDHSSA) serves the 7,500 residents of the Beaufort-Delta Region in the Northwest Territories - a land of dramatic landscapes, abundant wildlife, fascinating history, and accessible cultural encounters. The Inuvik Regional Hospital offers acute care services in the 14 in-patient bed unit, 3 special care unit beds, 4 day surgery beds and 2 birthing room beds. A compliment 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, and quality care. Our physician compliment consists of 9 full time positions, of which only 1 is filled by a permanent physician. Therefore, the BDHSSA physician compliment is staffed by 89% Locum Physicians.
Pregnant women in outlying and satellite communities come to Inuvik for confinement at 37 weeks. Historically, if the client was low risk, only at time of confinement was the Inuvik Regional Hospital OBS physicians made aware of this client. Due to the inconsistent physician population mentioned above, the MOREOB Core Team noted that recurrently patients would present in labor 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 putting all disciplines on the same page. A few common occurrences were RH negative women were not treated at 28 weeks, obstetrical histories were poorly completed, dating was often incorrect which all increased the risk to both mother and newborn. As well, Group B status was rarely confirmed resulting in unnecessary use of antibiotics. There was no established reporting system or sign over system amongst the locum physicians who provided prenatal care when they would leave. As MOREOB Program maintains open communication, increased trust and respect amongst all members of the team results in improved maternal and neonatal outcomes and reductions in harmful events.
The MOREOB Core Team wanted to develop a formal communication tragedy amongst obstetrical care providers for the prenatal patients within the BDTISSA.
The MOREOB Core Team decided to call a meeting with its participant group, and locum physicians present at this time in January, 2011 to brainstorm solutions to address the lack of consistent, complete and safe prenatal care. All parties decided that a formal process of review of prenatal patients by those involved in their care must be established. Working closely with the Co-Medical Directors it was decided that a formal review of prenatal patients at 36 weeks gestation and over, as well as any patient deemed high risk would occur weekly.
This weekly Multidisciplinary Prenatal Rounds had its launch on February 3, 2011. The initiative has enhanced over the past 21 months, and at this current time it involves the OBS physician for the week having scheduled time on Monday mornings for chart reviews and request clinic appointment bookings for all patients on the standardized prenatal list (Appendix 1). The patients are booked that week with the OBS physician on call. Each Monday and Thursday, all staff involved in prenatal care including but not limited to: Team Leader for Acute Care and Emergency, Manager of Hospital Nursing Units, Medical Director, OBS Locum Physicians, visiting GYNE/OB Specialist, Medical Students, Medical Residents, Nurse Practitioners, Prenatal Nutritionist, Manager of Clinics and Anesthesia take part in a round table multidisciplinary prenatal round. It involves a complete review the patients current status including but not limited to: gestation confirmation and method, gravita and para review, Group B status, RH status and treatment, Blood Type and Antibody review, 3rd trimester hemoglobin, 3rd trimester Chlamydia and Gonorrhea screen, Body Mass Index (pre-pregnancy and at term), risk factors, date last seen in clinics and any other relevant medical or psychosocial history. The OBS physician for that week verbalizes each patient's condition and relevant scheduled follow up and the multidisciplinary team actively plans for a safe delivery.
As the MOREOB Program asserts, when an interprofessional team works together, it creates a community of practice. This will result in team members sharing a common interest and recognizing that reflective learning results in shared knowledge. All team members must be empowered to speak up and identify what might be getting in the way of patient care and safety. With this initiative, The Manager of Nursing Units discussed the MOREOB Core Team concerns regarding inconsistent prenatal care that often did not align with the MOREOB Standards, and the lack of communication amongst service providers for the prenatal women in the BDHSSA, with the Medical Directors. The Manager of Nursing Units presented to Senior Management Team the MOREOB Core Team suggestion of a formalized prenatal rounds. It was supported by the Senior Management Team and the Quality and Risk Manager.
After this approval, the MOREOB Core Team decided to call a meeting with its participant group, and locum physicians present at this time in January, 2011 to share the proposed solution to the identified problems. The participants played and continue to play an active and essential role to the success of this initiative. Once a week, one of the members of the participant group 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. This is the list that the obstetric physician works from on Monday to complete chart reviews and present each patient at the multidisciplinary obstetrical rounds. The MOREOB Core and Participant inembers 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 whether it is achieving its objectives effectively, economically and efficiently. Module 2 enhanced the BDHSSA staff and management's knowledge of the functional components of auditing. Through audits completed, 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 now are proud to report that 100% of our RH negative patients receive the standard of care.The audit reports and successes have been shared to our stakeholders. Namely Accreditation Canada, our territory referral centers, Quality and Risk management, to the public via our Annual General Report, Senior management and last but not least, our dedicated obstetrical staff.
At its current status, the bi-weekly multidisciplinary prenatal rounds is well established, and the MOREOB Team has been very successful in changing the culture to one that values communication and a common and informed voice for all team members. The multidisciplinary rounds have improved patient outcomes by first of all indentifying a growing population of women with Body Mass Index (BMI) of greater than 45. This has lead to the BDHSSA developing a guideline which requires an anesthesia consults pre delivery for any women with a EMI greater than 45, and in one case a transfer to tertiary center for delivery. It has also ensured that a patient with a cardiac condition (Supra Ventricular Tachycardia treated with Veraprimil) had proper supports like additional trained personal for both neonatal resuscitation and advanced cardiac life support present at delivery. Finally, for patients choosing adoption there now is support plans put in place, involving Social Programs to ease the transition. There are countless benefits for patient outcome improvements and staff education via this initiative that are too many to mention.
In conclusion, our MOREOB Core Team of a mere 7 members and participants team of 10 are a dynamic team that is often faced with the challenges of a diverse culture, dramatic landscape and inconsistent staff. Despite the obstacles, this team has consistently raised the bar in patient care, and has created a culture of safety that is apparent. I am proud to be a part of such a group of change champions, leaders and patient care advocates. I highly recommend them for this honor.
Director of Client Services
Inuvik Regional Hospital
Inuvik, Northwest Territories