基层严重产科并发症审评方法建立和应用

目的:为提高基层产科服务质量,通过借鉴国际经验,根据我国产科服务现状和孕产妇保健体系,制定了适合我国国情的严重产科并发症的审评方法。方法:制定产科并发症审评方法。结果:当地产科质量的管理及服务水平有了明显进步,严重产科并发症的母婴结局有了明显改善。结论:该审评方法有其特有的优势和使用的有效性,值得进一步推广应用。     

“产科危重症审评”的做法与体会

<正>为改进产科服务质量和降低孕产妇死亡率,WHO和许多国际组织广泛的应用"产科危重症审评"方法进行探索。在发达国家,产科危重症病例审评已常规作为医疗服务质量保     

应用严重产科并发症审评方法提高基层产科服务质量

目的:探索应用严重产科并发症审评方法提高基层产科服务质量的有效性,以利于降低严重产科并发症的发生率。方法:选择重庆市孕产妇死亡率较高的一个县作为研究地点,采用整群抽样的方法,收集研究地点2004年1月~2006年3月期间所有提供助产技术服务的医疗机构救治的全部严重产科并发症病例,对其病历资料进行调查,并在2005年4月~2006年3月期间,应用严重产科并发症审评方法定期对部分典型病例的整个医疗过程进行审评。对审评前后产科服务质量的提高情况进行效果评价。结果:审评前,严重产科并发症的发生率为12.79‰(74例),其中严重产科出血、重度子痫前期和子痫、子宫破裂的发生率分别为8.47‰、4.32‰、0.17‰;审评后,严重产科并发症的发生率为14.17‰(64例),其中产科出血、重度子痫前期和子痫、子宫破裂的发生率分别为8.41‰、6.42‰、0.00‰。审评前后比较发现,审评后产后出血、妊娠高血压综合征的规范化管理明显加强(P<0.001);严重产科并发症病例的围产儿死亡率由189.26‰降至53.57‰(P<0.01);严重产科并发症孕产妇例数与孕产妇死亡例数之比由19∶1升至32∶1,产科服务质量有了明显提高。结论:应用严重产科并发症审评方法定期对所发生病例进行审评,有助于提高产科服务质量。     

危重症孕产妇评审在产科质量安全管理中的应用价值研究

目的 研究危重症孕产妇评审在产科质量安全管理中的应用价值。方法 根据2020年上半年院级危重症孕产妇评审结果,本院于2020年7月对院内危重症孕产妇输血流程进行了规范和优化管理。本次研究选择本院2019年1月-2021年12月有产后出血输血史的110例危重症孕产妇,设2019年1月-2020年6月的54例危重症孕产妇为对照组,2020年7月-2021年12月的56例危重症孕产妇为干预组,通过对这110例研究对象实施回顾性危重症孕产妇评审,对比在优化输血流程前后危重症孕产妇输血和住院情况。结果 对照组输红细胞悬液的平均输血量为（11.47±1.02）U,干预组为（10.28±0.96）U,显著低于对照组（P<0.05）;干预前危重症孕产妇ICU进入率为24.07%(13/54)、新生儿进入NICU率为18.52%(10/54),干预后分别为8.93%(5/56)、5.36%(3/56),显著低于干预前（P<0.05）;对照组的ICU停留时间为(3.6±0.4)d、总住院时间为(8.4±0.9)d,干预组分别为(2.9±0.3)d、(7.2±0.7)d,均显著短于对照组（P&l...     

妊娠期高血压疾病产科服务质量研究现状

妊娠高血压疾病是一种妊娠期最常见的、严重危害母婴安全的产科疾病,是目前造成孕产妇和围产儿死亡的主要原因之一。提高产科服务质量能有效降低其严重程度和死亡率。妊娠高血压疾病的产科服务质量在产前检查、转诊、入院管理等方面都存在各种各样的问题。本文就该病产科服务质量的相关问题进行综述。     

孕产妇危重症评审方法干预效果研究

目的探讨孕产妇危重症评审方法在改善产科服务质量,减少医院内孕产妇危重症的发生和减少孕产妇死亡的效果。方法 2006-2007年在河南某县和重庆某县医疗机构开展了为期两年的干预研究。干预组使用孕产妇危重症评审方法,对照组不使用该方法。干预前后两组均采用同一调查表对孕产妇危重症病例进行回顾性调查,以评估评审效果。结果干预组孕产妇危重症例数与死亡数之比由干预前的76：1上升到干预后的196：1,孕产妇死亡指数也由干预前的0.026下降到干预后的0.010;干预组的孕产妇危重症发生率从干预前的21.2‰下降到干预后的18.0‰,而对照组从16.0‰上升到22.2‰;干预组各类孕产妇危重症的规范化处理满分率在评审后均有显著上升。结论孕产妇危重症评审方法可以改善产科质量,减少孕产妇危重症发生,有必要进一步推广。     

APACHEⅡ评分在产科ICU危重患者中的应用价值分析

目的 评估急性生理与慢性健康状况评分（APACHEⅡ）预测产科ICU患者病情危重程度及预后的价值。方法 收集2019年8月至2020年8月入住四川大学华西第二医院ICU超过24 h的孕产妇相关数据进行回顾性分析,采用受试者操作曲线（ROC）曲线下面积（AUC）评估APACHEⅡ评分预测产科危重症的能力。结果 研究期间共有19 438名孕产妇入院分娩,378例入住ICU,研究纳入352例,290例发生产科危重症,发生率为14.92/1 000;死亡2例,死亡率为1.03/10 000。产科ICU患者APACHEⅡ评分总体偏低,总体中位数为4（2,6）,危重症组高于非危重症组（P <0.001）。随着APACHEⅡ评分的增加,患者ICU住院时间延长（P <0.001）,使用呼吸机、持续肾脏替代治疗（CRRT）、体外膜肺氧合（ECMO）的比例增加（P<0.05）。APACHEⅡ评分的AUROC为0.697 （95%CI,0.629～0.764）,当截断值为10分时,预测产科危重症的敏感度为10.34%（95%CI,7%～14%）,特异度为98.39%（95%CI,91%～1...     

加中孕产妇规范管理提高产科质量

桐乡市通过加强三级网建设，加强人才培养，提高业务素质，高目标，严要求，措施配套等措施配套等措施，强化了孕产妇规范管理，提高了产科质量，降低孕产妇和围产儿死亡率。     

103例产科失血性休克患者诊治分析

目的:回顾分析产科出血失血性休克患者诊治经过及对孕产妇及胎儿结局的影响。方法:将2007年1月～2011年8月九江市妇幼保健院收治的103例失血性休克患者按发生失血性休克时是否在九江市妇幼保健院住院分为转入组(48例)与住院组(55例),分析、比较两组孕产妇及围产儿预后。另外按休克患者是否进入孕产妇危重症抢救流程分为流程组(62例)与对照组(51例),分析行之有效的抢救流程对休克抢救效果及孕产妇预后的影响。结果:转入组与住院组主要病因比较差异无统计学意义;而转入组孕妇失血量、并发症发生率、孕产妇死亡率以及围产儿不良结局明显高于住院组,差异有统计学意义(P<0.01);流程组疗效好于对照组,差异有统计学意义(P<0.05)。结论:加强高危孕产妇分级管理,提前住院待产、应用孕产妇危重症抢救流程抢救产科失血性休克可改善孕产妇及胎儿结局。     

加强孕产妇规范管理 提高产科质量

桐乡市通过加强三级网建设；加强人才培养，提高业务素质；高目标，严要求，措施配套等措施，强化了孕产妇规范化管理，提高了产科质量，降低了孕产妇和围产儿死亡率。     

Severe maternal morbidity from direct obstetric causes in West Africa: incidence and case fatality rates

Data on maternal morbidity make it possible to assess how many women are likely to need essential obstetric care, and permit the organization, monitoring and evaluation of safe motherhood programmes. In the present paper we propose operational definitions of severe maternal morbidity and report the frequency of such morbidity as revealed in a population-based survey of a cohort of 20,326 pregnant women in six West African countries. The methodology and questionnaires were the same in all areas. Each pregnant woman had four contacts with the obstetric survey team: at inclusion, between 32 and 36 weeks of amenorrhoea, during delivery and 60 days postpartum. Direct obstetric causes of severe morbidity were observed in 1215 women (6.17 cases per 100 live births). This ratio varied significantly between areas, from 3.01% in Bamako to 9.05% in Saint-Louis. The main direct causes of severe maternal morbidity were: haemorrhage (3.05 per 100 live births); obstructed labour (2.05 per 100), 23 cases of which involved uterine rupture (0.12 per 100); hypertensive disorders of pregnancy (0.64 per 100), 38 cases of which involved eclampsia (0.19 per 100); and sepsis (0.09 per 100). Other direct obstetric causes accounted for 12.2% of cases. Case fatality rates were very high for sepsis (33.3%), uterine rupture (30.4%) and eclampsia (18.4%); those for haemorrhage varied from 1.9% for antepartum or peripartum haemorrhage to 3.7% for abruptio placentae. Thus at least 3-9% of pregnant women required essential obstetric care. The high case fatality rates of several complications reflected a poor quality of obstetric care.     

Severe acute maternal morbidity and associated deaths in conflict and post-conflict settings in Africa

Setting:

 Five hospitals in four conflict and post-conflict countries (Democratic Republic of Congo, Somaliland, Sierra Leone and Burundi).

Objectives:

 To report among hospital deliveries: 1) the proportion of severe acute maternal morbidity (SAMM), 2) the pattern of SAMM, and 3) maternal deaths according to type of SAMM.

Methods:

 An audit of data from a standardised database implemented in all the sites in the study.

Results:

 Of the 18 675 deliveries, there were 6314 (34%) known SAMM cases with 63 associated deaths, implying that for every 100 SAMM cases there was one maternal death. In descending order, the death-to-SAMM ratios per 1000 deliveries were: 1:7 for sepsis, 6 for haemorrhage 1:70 for hypertensive disorder and 1:398 for obstructed labour. A substantial proportion of deaths (38%) that occurred in hospitals could not be categorised into the standardised SAMM conditions available in the database.

Conclusion:

 As this is the first study using multi-centre data from conflict and post-conflict countries, these findings are relevant to improving maternal health in such settings. Findings, implications and possible ways forward in addressing various challenges are discussed.     

Research, audit and quality improvement

PURPOSE: The purpose of this article is to clarify the distinction between research and audit, and propose appropriate regulatory arrangements for audit and related activities. DESIGN/METHODOLOGY/APPROACH: The methods used were literature reviews and conceptual analysis. FINDINGS: Research and audit overlap in various ways, but differ in terms of their purposes and the risks likely to be encountered and distinguished, along with a third related category of activities called quality improvement. PRACTICAL IMPLICATIONS: Appropriate regulatory arrangements are proposed for audit and quality improvement activities. Using these should ensure appropriate ethical standards and risk management, while avoiding the time-consuming over-regulation that occurs when projects are unnecessarily submitted to the ethical scrutiny appropriate for research projects. ORIGINALITY/VALUE: Gives suggestions and information that could be of great value in spreading service improvement.     

Criteria for clinical audit of the quality of hospital-based obstetric care in developing countries

Improving the quality of obstetric care is an urgent priority in developing countries, where maternal mortality remains high. The feasibility of criterion-based clinical audit of the assessment and management of five major obstetric complications is being studied in Ghana and Jamaica. In order to establish case definitions and clinical audit criteria, a systematic review of the literature was followed by three expert panel meetings. A modified nominal group technique was used to develop consensus among experts on a final set of case definitions and criteria. Five main obstetric complications were selected and definitions were agreed. The literature review led to the identification of 67 criteria, and the panel meetings resulted in the modification and approval of 37 of these for the next stage of audit. Criterion-based audit, which has been devised and tested primarily in industrialized countries, can be adapted and applied where resources are poorer. The selection of audit criteria for such settings requires local expert opinion to be considered in addition to research evidence, so as to ensure that the criteria are realistic in relation to conditions in the field. Practical methods for achieving this are described in the present paper.     

The role of clinical audit in the quality improvement of health care

The aim of clinical audit is continuous improvement of the quality of care through systematic and critical review of current practice against explicit criteria and the implementation of change if necessary. The audit is a regular multidisciplinary activity by which all participants of care including doctors, nurses and other health professionals carry out a systematic review of their own practice. Data collected during the process of audit should be handled with care, and individual data concerning care-givers, patients or health professionals must be treated confidentially. Clinical audit needs realistic timeframe and necessary resources as well as tolerant culture of learning organisations. Furthermore the success of clinical audit depends on the commitment and support of the management of the organisations. Clinical audit could relatively easily be embodied into the current practice of peer-review processes and other quality improvement initiatives in Hungary. Widespread and systemic application of clinical audit may improve the quality of patient care and maintain the trust of the population. However, clinical audit should be effective and cost-effective. The recently published methodological guideline by the Ministry intends to promote good practice in clinical audit.     

Pregestational obesity,maternal morbidity and risk of caesarean delivery in a country in an advanced stage of obstetric transition

ObjectiveTo evaluate whether pregestational obesity is associated with the risk of caesarean section in pregnant women living in a country in an advanced stage of the obstetric transition.MethodsRetrospective cohort study. Data were collected from prenatal and hospital records. Pregestational obesity was defined as: body mass index, [weight(k)/height (m²)] ≥30, and caesarean sections were categorized as elective, emergency, or non-emergency/medically necessary. Biodemographic and sociodemographic characteristics, obstetric and perinatal pathologies, and maternal anthropometric variables were assessed. Chi-square and t-tests were used to compare qualitative and quantitative variables, respectively. Simple and adjusted generalized linear models were used to evaluate the association between pregestational obesity and caesarean delivery. Finally, population attributable risk was calculated. Data analysis was performed using STATA.v.14.0.Participants2309 pregnant women with a singleton pregnancy who gave birth at a public hospital in the Metropolitan Region of Santiago, Chile in 2015.ResultsThe prevalence of pregestational obesity was 21.4%, and the incidence of caesarean deliveries was 34.8% (33% of which corresponded to elective, 46% to emergency, and 21% to non-emergency/medically necessary caesarean deliveries). Pregestational obesity increased the risk of caesarean delivery (aRR = 1.46; 95%CI. [1.19–1.79] as well as the risk of elective (aRR = 1.74; 95%CI. [1.23–2.45]) and emergency caesarean delivery (aRR = 1.44; 95%CI. [1.03–2.00]). The population attributable risk of pregestational obesity for caesarean section was 32%.ConclusionGiven the significant association between pregestational obesity and caesarean delivery, it is necessary to develop strategies to decrease obesity among women of childbearing age in order to decrease obstetric intervention.