Quality Improvement: Intrapartum Maternal and Neonatal Mortality Assignment

Quality Improvement: Intrapartum Maternal and Neonatal Mortality Assignment

Quality Improvement: Intrapartum Maternal and Neonatal Mortality Assignment

The problem that my quality improvement project seeks to explore is the high rates of intrapartum maternal and neonatal mortality. This is a problem because it points to possible issues in the obstetrics process that increase the risk of complications. The common complications that occur during the intrapartum process include hemorrhage, high blood pressure, amniotic fluid embolism, and intraamniotic infection. Most of the complications during intrapartum are preventable through quality care and early detection, which should start from the antenatal period. According to Khanam et al. (2018), effective antenatal care that involves early identification and management of complications is one of the strategies for reducing the risk of complications during labor. Additionally, effective emergency obstetric care also contribute to the reduction in complications during labor, subsequently reducing the risks of preventable maternal and neonatal deaths. Similarly, a study by Alyahya et al. (2019) reveals that proper antenatal care is critical for the health of the mother and baby throughout the obstetric period including preventing intrapartum complications.

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Further evidence shows that adequate obstetrics care during labor is essential for reducing the risks of complications encountered during the intrapartum period. The identified common care activities during this period that increase the risks of complications include continuous electro-fetal monitoring, bed rest and restriction of free movement, limiting oral intake during labor, frequent vaginal checks, amniotomy, induction, enema, ineffective pushing, and regional anesthesia (Akyıldız et al., 2021). Hence, to promote effective and quality obstetrics care, clinicians must avoid making these care mistakes that put both the mother and baby in danger. Furthermore, the knowledge and expertise of the obstetrics team also play a critical role in preventing complications during labor. According to Tenaw et al. (2018), obstetrics practitioners who are skilled and knowledgeable in the third stage of labor ensure proper management of labor and care, which reduces the risk of complications.

Prevalence and Scope

According to statistics, 300,000 die annually around the time of delivery from preventable causes. Another study investigated deliveries between 2015 and 2020 and reported a maternal mortality ratio of 129.34 per 100,000 live births (Sitaula et al., 2021). The main causes associated with the high mortality ratio were sepsis, hemorrhage and hypertensive disorder. Another study evaluating the prevalence of intrapartum stillbirths showed that out of 4,476 women, 136 had stillbirths (Wrammert & Ewald, 2018). The associated risk factors for stillbirth were obstetric complications during labor, inadequate antenatal care, hemorrhage, preterm birth, and inadequate monitoring of heart rate (Wrammert & Ewald, 2018). According to, the global stillbirth rate is 13.9 per 1000 births and 42·3% of these are due to intrapartum issues, which can be prevented by timely, quality, and responsive obstetrics care (Hug et al., 2021). The problem of high mortality rates during the intrapartum period affects the entire obstetric process right from the first session of antenatal care to postnatal care.

Impact and the Affected Population

Intrapartum complications are problematic because they also impact the outcomes of postpartum care. For example, complications during labor and delivery increase the risk of postpartum hemorrhage, perinatal hypoxia, and general poor health outcomes for the mother and the baby (Wrammert & Ewald, 2018). Additionally, the issue impacts on safety and quality of the obstetrics process. The problem affects the obstetrics population, including pregnant women, unborn babies, new mothers, and neonates.

References

Akyıldız, D., Çoban, A., Gör Uslu, F., & Taşpınar, A. (2021). Effects of Obstetric Interventions During Labor on Birth Process and Newborn Health. Florence Nightingale J Nurs. , 29(1):9-21. https://doi.10.5152/FNJN.2021.19093. PMID: 34263219;.

Alyahya, M., Khader, Y., & Batieha, A. (2019). The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study. BMC Health Serv Res, 19, 425. https://doi.org/10.1186/s12913-019-4232-9.

Hug, L., You, D., & Alkema, L. (2021). Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. The Lancet, https://doi.org/10.1016/S0140-6736(21)01112-0.

Khanam, R., Baqui, A., Syed, M., Harrison, M., Begum, N., Quaiyum, A., . . . Ahmed, S. (2018). Projahnmo Study Group in Bangladesh. Can facility delivery reduce the risk of intrapartum complications-related perinatal mortality? Findings from a cohort study. J Glob Health. , 8(1):010408. https://doi.10.7189/jogh.08.010408.

Sitaula, S., Basnet, T., & Agrawal, A. (2021). Prevalence and risk factors for maternal mortality at a tertiary care centre in Eastern Nepal- retrospective cross sectional study. BMC Pregnancy Childbirth , 21, 471. https://doi.org/10.1186/s12884-021-039.

Tenaw, Z., Yohannes, Z., & Amano, A. (2018). Obstetric care providers’ knowledge, practice and associated factors towards active management of third stage of labor in Sidama Zone, South Ethiopia. BMC Pregnancy Childbirth , 17, 292. https://doi.org/10.1186/s12.

Wrammert, J., & Ewald, U. (2018). Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study. Reprod Health , 13, 103. https://doi.org/10.1186/s12978-016-0226-9.

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Discussion 11.1: Best Practice Evidence
Value: 15 points
Discussion Guidelines
Initial Post

DNP-prepared nurses are committed to the use of evidence to guide and facilitate change. Once problems are identified, then more questions are generated. As a leader for your QI project team, you will need to improve your knowledge regarding the problem/practice issue you are addressing. Select three recent (published within the past five years) scholarly articles addressing the problem your QI team is trying to address. Within your discussion, describe the context of the problem. Answer the questions:

Why is it a problem?
What is the prevalence and scope of the problem?
What impacts or influences the problem?
What population is affected by the problem?

In other words, you will need to convince the administrative team that the problem is worth exploring.
Response Post(s)

Respond to at least two classmates’ posts.

Follow the RISE Model for Meaningful Feedback (PDF)Links to an external site. when writing your response posts.
Submission

Post your initial and follow up responses on the Discussion 11.1: Best Practice Evidence page.

Assignment 11.1: Problem Validation and Project Aim

Value: 30 points
Introduction

The purpose of objective data is to identify quality concerns and to describe problems, gaps, trends, patterns, etc. Baseline data is critical to determine a need for change or improvement. Think back to your stakeholder interviews. Did the stakeholders indicate if there was data present to validate the problem exists? If so, this data needs to be explored further, or what additional data is needed to further validate the problem exists? Data is a powerful tool to gain new knowledge, engage stakeholders, and strengthen buy-in. Leadership may have a difficult time investing time and resources in a QI project that is not supported by evidence and objective data. Data paints a clear picture of the current performance and can generate support for change among a diversity of stakeholders.

Example of Measurement Plan: Delayed Discharge in the SICU
WHAT?

What is being measured? What type of data/variables?
HOW?

How will the data be obtained? (electronic report, national report, manually [data collection sheet])
WHEN?

What period of time will the data be obtained from? (5-year trend, 1-year trend, monthly)
WHERE?

On which unit, area, or department will the data be collected?
WHO?

Who is responsible for obtaining the data? (unit manager, data analytic dept., risk/quality & safety dept.)
Data is obtained (Y/N)

If yes, enter data outcomes
Length of stay (LOS) EPIC report 1 year of data Surgical ICU SICU nurse manager and Data Analytics Dept. Request for data has been submitted by the nurse manager
Time of ICU discharge entry (all service lines) EPIC report 1 year of data Surgical ICU Data Analytics Dept. Median time of discharge order entry by service line:

CV: 4:12 pm
Neuro: 5:10pm
General: 2:25 pm
ENT: 12:15 pm
Ortho: 3:35 pm

Once your QI project team knows your current state and performance levels, you need to determine your desired state. Steps of a gap analysis:

Gap Analysis Example

Example of Gap Analysis: Blood Culture Draw Technique

Depending on your QI project and problem, your QI team may have identified several gaps. This is an example of how one gap may be addressed. Be sure to support the best practice with recent, evidence-based resources. If the current state meets best practice standards, it may not be a practice gap, but a process (workflow) gap or staff compliance issue.
Current State

(What is happening?)
Best Practice *Cite the resources to support

(What is different?)
Desired State

(What should it look like?)
Practice Gap (Y/N)

No policy in the NICU
No specialized training for RNs
No consistency of practice on neonates throughout the hospital (NICU, Newborn Nursery, Pediatric ED, General Pediatrics Unit)

Culture drawn by specially trained phlebotomy team. (Strength of evidence: moderate)

Significant decrease in contamination rates with dedicated, specially trained teams (*cite reference)
Phlebotomy teams becoming more common (70% cultures obtained by teams in teaching hospitals, 85% in non-teaching hospitals; *cite reference)
Part of bundle demonstrated decrease in contaminated blood culture rate in Pediatric ED (*cite reference)

Culture drawn by specially trained phlebotomy team. Yes

Addressed in NICU policy
Monthly compliance audit by Infection Control Dept. meeting benchmark

Hand hygiene prior to blood culture draw N/A No

Finally, the QI project team will develop QI project aims. Remember in Week 1, the 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, outlined six aims for healthcare: safe, effective, patient-centered, timely, efficient, and equitable.

Safe: Avoid injuries to patients from the care that is intended to help them.
Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care.
Patient-Centered: Honor the individual and respect choice.
Timely: Reduce waiting for both patients and those who give care.
Efficient: Reduce waste.
Equitable: Close racial and ethnic gaps in health status.

Many organizations use the six IOM aims to develop their QI project aims. The aim is what the QI team suggests to do about the problem. The aim states what the team is hoping to accomplish by how much and over what period of time. The aim statement does not state how the team is going to achieve the aim.

A good aim statement is written in SMART format: Specific, Measurable, Achievable, Realistic, and Timely.

SMART Example

Example of project aim in SMART format:

We will improve ED provider (nurse, physician) percentage compliance of 45% with the SEP-1 bundle in patients >18 years old identified with a sepsis diagnosis, to the current average academic center performance of 72% within 3 months.
Professor’s Tips

Professor’s Tips

Be sure you obtain proper permissions to access data at the QI project site. Even if you are an employee, you may need special access permission in your role as a student. If you are not an employee, you cannot access charts or private health information; you will only be able to obtain secondary data sets.
Assignment Guidelines

Identify the objective baseline data that will be used as indicators for performance improvement. Use the Week 11 Worksheet (Word)Links to an external site. as a tool to determine how best to obtain data that will link to your problem statement and project aim. If you currently have data, use the worksheet to identify the specifics of how the data was obtained.

Develop your gap analysis using the Week 11 Worksheet (Word)Links to an external site.. To determine key indicators for improvement, visit the Guide to Data, Tools, and Statistics for many resources containing data sets and statistics or review Chapter 7, “Leading with Quality Metrics,” in your textbook.

You will need to provide the evidence to support the best practice. Chapters 13 and 14 in your textbook are good reviews of how to search the literature for evidence to support project initiatives.

Finally, write at least one project aim written in SMART format with the template provided. Depending on your QI project and problem, your QI team may have multiple project aims.
Submission

Submit your completed worksheet on the Assignment 5.1: Problem Validation and Project Aim page.