Availability and use of emergency obstetric care services in four districts of West Bengal, India

Process indicators have been recommended for monitoring the availability and use of emergency obstetric care (EmOC) services. A health facility-based study was carried out in 2002 in four districts of West Bengal, India, to analyze these process indicators. Relevant records and registers for 2001 of all studied facilities in the districts were reviewed to collect data using a pre-designed schedule. The numbers of basic and comprehensive EmOC facilities were inadequate in all the four districts compared to the minimum acceptable level. Overall, 26.2% of estimated annual births took place in the EmOC facilities (ranged from 16.2% to 45.8% in 4 districts) against the required minimum of 15%. The rate of caesarean section calculated for all expected births in the population varied from 3.5% to 4.4% in the four districts with an overall rate of 4%, which is less than the minimum target of 5%. Only 29.9% of the estimated number of complications (which is 15% of all births) was managed in the EmOC facilities. The combined case-fatality rate in the basic/comprehensive EmOC facilities was 1.7%. Major obstetric complications contributed to 85.7% of maternal deaths, and pre-eclampsia/eclampsia was the most common cause. It can be concluded that all the process indicators, except proportion of deliveries in the EmOC facilities, were below the acceptable level. Certain priority measures, such as making facilities fully functional, effective referral and monitoring system, skill-based training, etc., are to be emphasized to improve the situation.     

优质护理服务在产科的实施与成效

目的探讨优质护理服务在产科的实施效果。方法自2010年3月起在产科实施优质护理服务,于实施前后对患者、医生、护士的满意度进行问卷调查,对科室护理工作质量进行考核,并将实施前后调查考核的结果进行比较。结果开展优质护理服务后,医生、患者、护士满意度及护理工作质量明显提高。结论在产科开展优质护理服务,有利于提高护理质量和医、护、患满意度。     

《母婴护理》教学中护生关怀照护意识的培养

探讨母婴护理教学中加强护生关怀照护意识培养的必要性,从加强教师关怀照护意识的培养、创造开放的交流环境和实验室人文环境、优化考试方法方面提出了具体设想.     

产科急症子宫切除58例临床分析

目的：探讨产科急症子宫切除的发生率及相关高危因素。方法选择北京妇产医院近12年间分娩总数126959例,回顾性分析其中58例急症子宫切除术病例的临床资料。结果行产科急症子宫切除术的病例占分娩总数的0．046％,其中阴道分娩11例,剖宫产47例。手术指征中胎盘因素占44．83％,其中20例（76．92％）因剖宫产史合并胎盘异常。其次为子宫收缩乏力（32．76％）。产科急症子宫切除与分娩次数、分娩方式、剖宫产史、孕周、多胎妊娠显著相关（χ^2值分别为151．785、22．568、200．694、114．547、37．084,均P＜0．01）。结论产科急症子宫切除术是挽救孕产妇生命的有效手段,应严格掌握剖宫产指征,降低剖宫产率,可减少产科急症子宫切除率。     

Restoring dignity: Social reintegration after obstetric fistula repair in Ukerewe,Tanzania

Abstract

This study explores barriers and facilitating factors women experience re-integrating into society after treatment of an obstetric fistula in rural Tanzania. A total of 71 women were interviewed in the Mwanza region of Tanzania, including a community control group. The majority of the women who received successful surgical repairs reported that, over time, they were able to resume many of the social and economic activities they engaged in prior to the development of a fistula. Familial support facilitated both accessing repair and recovery. For 60% of the women recovering from an obstetric fistula, work was the most important factor in helping them feel ‘normal again’. However, physical limitations and other residual problems often hampered their ability to continue working. All of the treated women expressed interest in follow-up discussions with health care providers regarding their health and concerns about future pregnancies. Special attention is needed for women who are not completely healed and/or for those who experience other related medical or emotional problems after repair, especially if they lack a social network.     

Planning and studying improvement in patient care: the use of theoretical perspectives

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.     

Medicalization and obstetric care: An analysis of developments in Dutch midwifery

The Dutch system of obstetric care is often recommended for midwife-attended births, the high number of home deliveries, and the low rate of intervention during pregnancy and labour. In this contribution, the question is addressed whether processes of medicalization can be demonstrated in the Dutch midwife practice. Medicalization of pregnancy and childbirth is often criticized because it creates dependency on the medical system and infringement of the autonomy of pregnant women. It is concluded that medicalization is present in the practice of Dutch independent midwives, however it is less clear and outspoken than in hospital policies. This revised version was published online in July 2006 with corrections to the Cover Date.     

Patients’ experiences and views of an emergency and urgent care system

Background Surveys of patients’ experiences and views of health care usually focus on single services. During an unexpected episode of ill health, patients may make contact with different services and therefore experience care within an emergency and urgent care system. We developed the Urgent Care System Questionnaire and used it to describe patients’ experiences and views of an emergency and urgent care system in England. Methods A market research company used quota sampling and random digit dialling to undertake a telephone survey of 1000 members of the general population in July 2007. Results 15% (151/1000) of the population reported using the emergency and urgent care system in the previous 3 months. Two thirds of users (68%, 98/145) contacted more than one service for their most recent event, with a mean of 2.0 services per event. Users entered the system through a range of services: the majority contacted a daytime GP in the first instance (59%, 85/145), and 12% (18/145) contacted either a 999 emergency ambulance or an emergency department. Satisfaction with all aspects of care diminished when four or more services had been contacted. Conclusions This is the first study to describe patients’ experiences and views of the emergency and urgent care system. The majority of patients experienced a system of care rather than single service care. There was an indication that longer pathways resulted in lower levels of patient satisfaction. Health care organisations can undertake similar surveys to identify problems with their system or to assess the impact of changes made to their system.     

'Emerge': Benchmarking of clinical performance and patients' experiences with emergency care in Switzerland.

OBJECTIVE: To assess the effects of uniform indicator measurement and group benchmarking followed by hospital-specific activities on clinical performance measures and patients' experiences with emergency care in Switzerland. DESIGN: Data were collected in a pre-post design in two measurement cycles, before and after implementation of improvement activities. Trained hospital staff recorded patient characteristics and clinical performance data. Patients completed a questionnaire after discharge/transfer from the emergency unit. SETTING: Emergency departments of 12 community hospitals in Switzerland, participating in the 'Emerge' project. SUBJECTS: Eligible patients were entered into the study (18 544 in total: 9174 and 9370 in the first and second cycles, respectively), and 2916 and 3370 patients returned the questionnaire in the first and second measurement cycles, respectively (response rates 32% and 36%, respectively). MAIN OUTCOME MEASURES: Clinical performance measures (concordance of prospective and retrospective assessment of urgency of care needs, and time intervals between sequences of events) and patients' reports about care provision in emergency departments (EDs), measured by a 22-item, self-administered questionnaire. RESULTS: Concordance of prospective and retrospective assignments to one of three urgency categories improved significantly by 1%, and both under- and over-prioritization, were reduced. The median duration between ED admission and documentation of post-ED disposition fell from 137 minutes in 2001 to 130 minutes in 2002 (P < 0.001). Significant improvements in the reports provided by patients were achieved in 10 items, and were mainly demonstrated in structures of care provision and perceived humanity. CONCLUSION: Undertaken in a real-world setting, small but significant improvements in performance measures and patients' perceptions of emergency care could be achieved. Hospitals accomplished these improvements mainly by averting strong outliers, and were most successful in preventing series of negative events. Uniform outcomes measurement, group benchmarking, and data-driven hospital-specific strategies for change are suggested as valuable tools for continuous improvement. Several hospitals have already implemented the developed measures in their internal quality systems and subsequent measurements are projected.     

The MOMENTUM study: Putting the ‘Three Delays’ to work to evaluate access to emergency obstetric and neonatal care in a remote island community in Western Kenya

ABSTRACT

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The ‘Three Delays’ model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the ‘Three Delays’. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the ‘Mfangano Health Navigation’ programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes.     

Policymaker use of quality of care information.

OBJECTIVE: This study describes public policymakers' experiences with the feasibility of using information from quality of care assessment activities. The objective is to improve the ability to match quality evaluation tools with policymakers' information needs. DESIGN: US state administrative policymakers were interviewed about use of quality of care information and knowledge, attitudes, and experiences with information from specific types of measures. PARTICIPANTS: A purposive sample of 82 key informants from Medicaid program administrations in 48 states. MAIN MEASURE: Users of information from each of eight targeted types of quality of care measurement methods were compared with non-users based upon their levels of knowledge, perceived characteristics of quality of care information, and perceived characteristics of the policy situation. RESULTS: Participants indicated that some types of quality measurement methods have been useful, whereas others have not. Extent of quality assessment information use, and the measurement methods utilized, varied widely. Two factors were associated with the use of information from particular quality assessment methods: information needs of the policymakers and their perceptions of the characteristics, including strengths and weaknesses, of particular measurement methods. CONCLUSIONS: These policymakers had positive attitudes about quality assessment, were knowledgeable about types of methods, and had a variety of potential uses for quality-related information. Yet, perceptions and experiences with different types of measurement methods varied. We describe a set of quality assessment methods with complementary characteristics that could provide a relatively inclusive picture of quality of care and better address policymaker information needs.     

Inappropriate use of emergency ambulance services and the implications for primary health care in Japan

The number and per-capita emergency transports by public ambulancesand the percentage of transports of patients with non-emergencyconditions has been increasing in Japan, especially in urbanareas. Public ambulance services are, of course, essential fortransporting patients with crucial health problems. However,inappropriate ambulance use by patients who do not need emergencytreatment, but who need primary health care, means that thesepatients cannot get suitable health care, and diminishes theeffectiveness and efficiency of emergency medical-care servicesystems. The purposes of this study were to identify the factorsrelating to usage of public ambulance services in urban areas,to determine how to make these services more effective and moreefficient, and to discuss how to provide primary health-careservices so as to reduce the inappropriate use of public ambulanceservices. We investigated the accessibility of primary health-careservices, the characteristics of public ambulance service utilization,and the potential needs of the elderly for emergency-care servicesin two Tokyo wards: Edogawa andSetagaya. There were less healthresources, such as clinics, hospital beds and physicians, percapita in Edogawa than in Setagaya. Both the percentage of ambulancetransports of patients suffering from mild problems and thepercentage of ambulance transports on Sundays were higher inEdogawa than in Setagaya. Our survey showed that the percentagesof the elderly who would call for ambulances for each of threespecific health problems (fever, chest pain and ankle sprain)were all higher in Edogawa than in Setagaya. In both wards,elderly people living with their children and/or grandchildrenwere more likely to choose different health resources accordingto the specific problem being experienced than were elderlypeople living with other aged persons but without young people.The insufficient development of primary healthcare resourcesand systems increased the inappropriate use of high-cost emergencyambulance services by the elderly living in urban areas, wherefamily support is weakening. Health systems therefore need tobe reoriented so as to enhance accessibility to primary healthcareservices.     

Quality management in Australian emergency medicine: translation of theory into practice.

OBJECTIVES: The primary objective was to describe the current level of implementation of quality management (QM) structures and practices with Australian emergency departments. The secondary objective was to describe the level of association between the presence of QM structures and processes and the achievement of associated improvements. DESIGN: Data were collected by mail-out of a structured survey instrument to all Australian emergency departments accredited for postgraduate training by the Australasian College for Emergency Medicine. PARTICIPANTS: Director of Emergency Medicine or delegate in each surveyed department. MAIN OUTCOME MEASURES: The presence of specific structure and process indicators of QM and the achievement of QM linked improvements. RESULTS: A response rate of 63% was achieved. Designation of a hospital quality improvement (QI) physician was reported by 40% of institutions, an emergency department (ED) QI physician by 40%, and an ED QI nurse by 67%. A structured system for QM indicator analysis was present in 67% of the departments; in 45% of the departments public reporting of performance occurred. There was a significant association between QM process indicators and the presence of (i) a hospital QI physician (P=0.02), (ii) an ED QI nurse (P=0.02), (iii) presence of a system for data analysis and reporting (P=0.01), and (iv) presence of a QM component to postgraduate education (P= 0.05). There was a significant relationship between the presence of QM process indicators and the achievement of QM linked improvements (P= 0.003). CONCLUSIONS: Demonstration of the links between QM structures, its indicators of activity (in structure and process), and the achievement of outcome improvement is fundamental to quality improvement methodology. These links are demonstrated within the context of Australian emergency medicine, providing support for the effectiveness of this approach in promoting change and performance improvement.     

Development of a proxy wealth index for women utilizing emergency obstetric care in Bangladesh

There are increasing concerns regarding inequities in access to health care, and hence calls for routine data collection to improve monitoring. For many developing countries, such as Bangladesh, increasing the availability and uptake of emergency obstetric care (EmOC) is vital in improving maternal health. It is crucial, however, that women of all socio-economic status benefit from this. This paper describes the development and validation of a proxy wealth index for assessing women's socio-economic status in Bangladesh as they are admitted to hospital. Existing poverty assessment tools are unsuitable for use in this context as they are too lengthy or need to be administered at household or community level. We sought to develop a tool with a limited number of indicators to allow quick administration and avoid interference with treatment. We also aimed to develop a pragmatic tool to be able to calculate a score in the field. The steps, involving selecting and weighting indicators, assigning a proxy wealth score and validating the score, are outlined. Indicators were selected from the Bangladeshi Demographic and Health Survey (DHS) data, which allowed comparison of socio-economic status between women using EmOC and those in the wider population. The tool proved quick and easy to use and was acceptable to women and their families. The validity of the tool was established by means of factor analysis. Our comparison with DHS data suggested that women using EmOC were significantly wealthier than women in the wider population. The implications of this, as well as the strengths and limitations of the proxy wealth index, are discussed. The proxy wealth index offers potential as a pragmatic and quick means of assessing poverty status in a busy hospital setting. Such a tool may enable monitoring of equity in access to treatment and identification of those least able to afford treatment, to enable any mechanisms in place to pay for care to be applied in a timely fashion, so avoiding delays in treating life-threatening complications.     

Use of biomedical obstetric care in rural Tanzania: The role of social and material inequalities

Despite over 20 years of efforts to improve maternal health, complications of pregnancy and childbirth continue to threaten women’s lives in many countries of sub-Saharan Africa. To reduce maternal mortality levels and achieve Millennium Development Goal Five, institutions working for safe motherhood are committed to making biomedical obstetric care more available to women during childbirth. However, implementation of this strategy is not reaching women at the lower end of the socioeconomic spectrum for reasons that are not well understood. Using data from fieldwork conducted between September 2007 and June 2008, this study examines women’s use of biomedical obstetric care in two rural districts of south-central Tanzania where this care was being supplied. Specifically, it seeks to explain how social and material inequalities affect decisions and behaviors related to childbirth.     

院前急救护理中潜在的安全隐患及应对措施

目的本研究主要就院前急救护理中潜在的安全隐患以及应对措施展开分析讨论。方法选择该院2010年1月—2012年1月所接到的急救电话资料作为研究对象,对其急救护理的相关资料进行回顾性分析。结果 2011年,该院护士在综合水平的提升方面明显优于2010年,患者的满意度有了明显的提升,救护车的出车时间也明显缩短,它们之间的差异具有统计学意义,P<0.01。结论为了提高院前急救护理的质量,医院就必提高120的接听应急能力,须强化人员配备、加强急救护理人员的专业技能培训,在急救前做好充分的准备工作,这样不仅可以缩短救护车的出车时间,而且还可以提高院前抢救的成功率。     

优质护理在急诊工作中的应用

目的：探讨优质护理服务在急诊患者护理工作中的应用效果。方法：回顾性分析2013年3月-2014年3月我院收治的80例急诊患者的临床资料,将其随机均分为观察组和对照组,每组40例,对照组实施一般护理服务,观察组实施优质护理服务,观察比较两组患者的心理状态、对护理工作的满意度、护理质量及护理差错的发生率。结果：观察组患者的焦虑和抑郁状态明显减轻,对护理工作更加满意,护理质量明显提高,护理差错发生率明显降低,与对照组比较有统计学意义（P〈0．05）。结论：优质护理的实施,为患者提供了人性化、整体化、专业化的连续性优质护理服务,提高患者对护理工作的满意度,值得临床推广。