Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap

Abstract

BackgroundCriteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.ObjectiveThe prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004–2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.MethodsA CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit.ResultsThere was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).ConclusionCBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.

Monitoring maternal and newborn health outcomes in Bauchi State, Nigeria: an evaluation of a standards-based quality improvement intervention

“…A similar inverse relationship between AMTSL practice and PPH incidence was also observed after the quality improvement interventions in Niger and Mali [25]. Similar results were also observed in studies of hospitals in Tanzania [23] following quality improvement interventions [26]. …”

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania

“…The principally agreed-upon criterion for diagnosis is a prolonged active labour, implying a failure of labour to progress due to cephalopelvic disproportion [15] that requires surgical or assisted vaginal delivery [5]. Maaloe et al [12] and Kidanto et al [37] reported on failure to interpret signs of prolonged labour as obstructed labour in both rural and urban health facilities. Unlike the Malawi audit [9], the agreed-upon diagnosis in our study included additional minor criteria that improved the standards of diagnosis.…”

“…As others have confirmed, a mandatory patient review by a senior obstetrician and a more efficient timeline for intervention, either singly or in combination resulted in improved care [37,39,40]. However, awareness of care providers that an evaluation was being conducted might also have positively or negatively influenced the changes in practice that were recorded [41].…”

“…Kongnyuy et al [9] and Wagaarachchi et al [46] suggested quality improvement that included primary health care facilities where patients with complications are quickly diagnosed and sent to the top of the health facility ladder, thus lowering the risk of complications associated with delays in receiving needed speciality care. Similarly, Kidanto et al [37] recommended a decision-to-delivery interval of two hours for eclampsia patients who required resuscitation to prevent surgical complications, including control of seizures and blood pressure levels before CS. Since the majority of women delivered at MNH are either public or referred patients [47], some presented with complications of obstructed labour on admission, including foetal distress, impending or ruptured uterus, and chrorioamnionitis (MNH Obstetric database 2014, unpublished report).…”

Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit

“…These CBAs have shown positive improvement in the quality of care in some low income counties [7]. This study had an aim of assessing the quality of care given to inpatients with PPH and severe pre-eclampsia in St. Francis Hospital Nsambya as a way of reducing maternal mortality.…”