2019 Salus Global Patient Safety Award Winner

Hospital: St. Mary’s Hospital
City: Montreal, Quebec, Canada
Initiative: Prevention, Diagnosis, and Treatment of Infectious Complications During Labour and Delivery

Background and Overview

Our objective was to improve the clinical management of patient’s identified with Chorioamnionitis.

Our core moreOB team is composed of Family Physicians, Obstetricians, Nurse Managers, Clinical Nurses, & an Advanced-Practice Nurse Consultant as well as a member of the quality improvement department. It was identified that there existed variability on our unit regarding what healthcare professionals were using as criteria to diagnose and treat chorio, as well as which antibiotics were being used and for how long.

The key strategies we used to audit our practice were a literature review to agree on a definition and diagnositic criteria for clinical chorioamnionitis. The TRIPLE I definition of chorio was decided upon and the criteria used to perform our chart audits. In order to perform the audit, patients were grouped into one of 4 determined sub-groups by the core-team:

1. Met TRIPLE I criteria and was treated appropriately.

2. Met TRIPLS I criteria and was not treated.

3. Did not meet TRIPLE I criteria but was treated.

4. Did not meet TRIPLE I criteria and was not treated.

Upon completion of a first audit, it was determined that there were several practice changes that needed to be addressed that were leading to unjustified diagnosis of chorio. These issues were investigated further using a second audit of 20 charts that a diagnosis of chorio was determined, however did not meet diagnositic criteria. In order to address these practice changes, a clinical management algorithm was developed by the advanced-practice nurse consultant in collaboration with the obstetricians and family physicians and implemented on the unit at the end of our moreOB Workshops in June 2018.

Our success was measured using a retrospective chart review (Pre- moreOB June2015-June 2017), as well as a 1-year post implementation chart review (June 2018-June 2019).

Body of Submission

The initial data collection was conducted by the clinical nurse from the unit and analysed with assistance from the quality department. Results of the first audit were shared at core-team meetings. These results helped us identify immediately problem areas that we could target as inappropriate diagnostic criteria (malodorous fluid and maternal tachycardia). This issue was addressed in to the moreOB workshops.

St Mary 1

Results were shared with the core-team upon which it was decided that a more in-depth audit was needed to determine why 52% of patients were being treated despite not having any criteria for clinical chorio. The results of the second audit helped us determine that a large majority of our patients were treated with presence of fetal tachycardia, regardless of maternal temp.

St Mary 2

Upon sharing results the nurse clinician divulged a query she had when conducting the data collection. A large majority of patients were determined to have had a maternal fever without necessarily meeting the definition for intrapartum fever outlined in TRIPLE I. A second query she brought up was that very often the elevations in temperature were directly following epidurals or medications leading us to the conclusion that external factors affecting temperature were not being taken into consideration during nursing evaluations.

The core-teams conclusions of these results were shared within the workshops:

St Mary 3

In-depth discussion of the audit results upon core-team meetings helped us determine two areas of practice improvement that needed to be addressed in the workshop in order to decrease our unjustified clinical chorio diagnoses:

1. Distinguishing between isolated events of elevated maternal temperature & intrapartum fever

a. Dehydration

b. Epidural

c. Medications

2. Chain of communication

a. Pertinent information (emphasis on SBAR reporting)

b. Appropriate use of terminology

The enclosed clinical management algorithm was developed to address interprofessional issues determined to have an impact on the diagnosis of chorioamnionitis on our unit. The top portion targeting nursing practice and proper screening of patients at risk for chorioamnionitis. The bottom portion targeting physician practice with a focus on proper antibiotics use as well as management guidelines for patients with confirmed intrapartum fever but not necessarily diagnostic criteria for TRIPLE I.

1-year post algorithm and moreOB workshops audit was performed by the Advanced-Practice Nurse Consultant using the same initial criteria for TRIPLE I as well as the same sub-groups outlined in the first audit.

St Mary 4

Summary

The moreOB Module 7 year helped us clearly identify underlying interprofessional issues in our unit practice leading to unsafe patient outcomes. We identified that many of our patients were being treated unnecessarily ultimately having an impact on length of stay, unnecessary separation of the mother-baby dyade and an impact on both maternal and newborn microbiome.

Using the audit principles outlined in moreOB, our unit was able to prevent many near-misses and neonatal morbidity with the complete elimination of the most concerning sub-group: Patients meeting criteria for clinical chorioamnionitis but not receiving treatment.

We were able to outline with the quality department a plan for continuous monitoring of outcomes and continue to work on other issues identified in the module as having a potential implication of diagnosis of chorio. The algorithm continues to be used on the unit and is being shared with medical residents upon rotation.

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More than OB

We can apply a similar approach to communication and teamwork that we bring to OB to adjacent maternal/infant care departments and even other hospital units such as emergency, ICU, cardiology, and other risk management areas.