Improving Emergency Obstetric Care through CriterionBased Audit

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Improving Emergency Obstetric Care through
Criterion-Based Audit

• Managing Complications in Pregnancy and Childbirth

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Definition of an Audit

• The systematic and critical analysis of the
  quality of medical care, including the procedures
  used for diagnosis and treatment, the use of
  resources and the resulting outcome and quality
  of life for the patient.
• Crombie et al 1997

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Areas to Be Audited

• Technical Clinical care patients receive
• Managerial Management (or organization) of the
  health facility
• Human rights aspects of medical care

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Why Conduct an Audit?

• To improve practices
• To enhance rational use of limited resources
• To improve staff morale and motivation
• To increase utilization of services
• To increase met need for emergency obstetric care
• To improve case fatality rates

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Types of Medical Audits

• Case reviews and case-note presentations
• National-level confidential enquiries
• Criterion-based audits

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Criterion-Based Audit

• Criterion-based audit compares current practices
  against written and agreed upon criteria
• Criteria are based on standards of evidence-based
  care
• Criteria are measurable activities that are
  appropriate for the setting in which they are
  used

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Resources for Standards and Quality

• Enkin et al. 2000. Cochrane Collaboration A
  Guide to Effective Care in Pregnancy and
  Childbirth.
• World Health Organization (WHO). 2000. Managing
  Complications in Pregnancy and Childbirth A
  Guide for Midwives and Doctors.
• American College of Nurse-Midwives. 1998. Life
  Saving Skills for Midwives.
• WHO guidelines for rational use of blood, sharps
  disposal and infection control
• National standards and guidelines

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Audit Cycle
  Data collection    
Initial situation assessment or evaluation
Analysis
Recommendations implemented  
Recommendations formulated
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Advantages of Criterion-Based Audits

• Process is objective Problem identification is
  easier and less threatening because the criteria
  and standards for assessing a practice were
  agreed upon in advance by the participants of
  the audit process case reviews often place
  blame
• Allow measurement of change
• Address whole process of care or just parts of it
• Non-medical personnel may be able to extract data

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Steps in the Audit ProcessStep 1 Form an Audit
Team

• Team should have people with
• A desire to examine current practice
• Enough knowledge to identify criteria
• Willingness to implement change

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Steps in the Audit ProcessStep 2 Choose Your
Topic

• Local relevance
• Problem is amenable to change

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Steps in the Audit ProcessStep 3 Define Your
Cases Clearly

• Adverse outcomes
• Deaths, near misses or severe obstetric
  complications
• All cesarean section deliveries
• All blood transfusions
• All referrals
• All emergency hysterectomies

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Steps in the Audit ProcessStep 4 Set Your
Criteria

• Criteria should be essential (not optional)
• Evidence should support criteria
• Patient records need to exist for auditing
• Practices realistically can be changed

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Example Criteria-Setting for Clinical Case

• Clinical management of ruptured uterus
• Patient treated for shock with IV blood
  replacement before laparotomy
• Ampicillin 2 g IV or cefazolin 1 g IV was given
  before surgery
• Oxytocin 20 units in 1 L of IV fluids was infused
  after newborn and placenta were delivered

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Example Criteria for Evaluating Referral
Procedures

• Referral slip included
• Patient stabilized prior to referral
• What drugs or procedures were given
• Reason(s) for referral
• Patient history

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Steps in the Audit ProcessSteps 57

• 5. Identify information sources
• 6. Design a data extraction sheet
• 7. Data collection

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Steps in the Audit Process Step 8 Analysis
Wagaarachchi et al 2001.
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Steps in the Audit ProcessSteps 911

• 9. Recommendations formulated
• 10. Implementation of the recommendations
• 11. Repeat the audit cycle

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How Auditing Human Rights May Differ from
Clinical Topics

• Standards of evidence-based care may not come
  from randomized clinical trials
• Definitions of cases and of criteria may require
  more participation of audit team
• Patient records unlikely to provide the necessary
  information patients themselves may be
  interviewed

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References
Crombie I et al. 1997. The Audit Handbook.
Improving Health Care Through Audit. John Wiley
Sons New York. Wagaarachchi P et al. 2001.
Holding up a mirror Changing obstetric practice
through criterion-based clinical audit in
developing countries. Int J Gyn Obstet 74
119130.