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POA to Achieve MDG5
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  • 1. 2012 Plan of Action for Hospitals in Sarawak:“Working Together Towards Achieveing MDG 5” By Dr. Harris N. Suharjono 20.02.2012
  • 2. Statistics for Sarawak:The state MMR for 2011 is 19.9/100,000 Live Births
  • 3. National MMRNational MMR in 2009 – 30/100,000 LB
  • 4. Sarawak State MMR• National MMR have reached a plateau between 28- 30/100,000 LB for the last 10 years• MDG 5 target for state by 2015 – 11.08/100,000 LB• State MMR showing a decreasing trend the last 4 years but…..• MMR for 2010 (21.3) & 2011 (19.9) – are we reaching a plateau?
  • 5. Achieving MDG 5: Can we do it?• Ensure every component of the healthcare services in the state plays it’s role, implement and monitor policies and strive to improve• Leadership at every level is of critical importance!• DHOs & Hospital Directors plays a very important role
  • 6. SARAWAK DATA:• Approx. 45,000+ deliveries per year• 60% delivered in specialist hospitals• 25% delivered in non specialist hospitals• 5% delivered in health clinics• 1.5% home deliveries• 8.5% delivered in private health centers
  • 7. No. of Maternal death per classification 2009 2010 2011Direct 8 5 5Indirect 4 4 4Fortuitous 15 15 11Unknown 2 4 4The estimated live births:2010 = 42,2922011 = 45,118
  • 8. No. of direct & indirect deaths by venue:Places of death 2009 2010Gov. Specialist Hosp. 6 7District Hospital 5 0Private Health Center 0 1Health clinic 0 0Homes 1 0BID 0 1 Total: 12 9
  • 9. TOP 4 CAUSES OF MATERNAL DEATH• PPH• HEART DISEASE IN PREGNANCY• ECLAMPSIA/HELLP SYNDROME• OBSTETRIC EMBOLISM
  • 10. State CEMD 2009 -2011• 30-40% of cases were preventable• Failure to appreciate severity• Inappropriate, inadequate and delayed therapy• Delay in transfer!
  • 11. Lessons from National CEMD• More than 60% of maternal deaths occurred during the postnatal period• The risk of maternal deaths higher in women over 40 yrs and in mothers who already had 6 or more children• Deaths due to obstetric embolism is rising• Non booked cases have higher risk of mortality• Home deliveries is unsafe
  • 12. POA: Manpower & Equipment Needs• Hospital Directors should address hospital needs in terms of manpower and O&G medical equipment including ambulance services• To list out needs and forward to JKNS• JKNS to compile and forward at the appropriate time• Buddy specialist could assist if required
  • 13. POA: Ensure all O&G directives are implemented• All previous and future directives from JKNS and O&G guidelines MUST be implemented and practiced• By Whom: Hospital Director / LW nursing sister• Activities: 1. MO, A&E and LW Staff should be briefed 2. All directives should be displayed on notice board (Target – 100%) 3. Directives and guidelines should easily accessible in a file in LW- (Target 100%)• Time Frame: Immediate
  • 14. POA: Improve A&E/OPD services• All antenatal and postnatal mothers should be considered as HIGH RISK when attending A&E/OPD• By Whom: Hospital Director• Activities: Brief all MO and A&E/OPD staff• Target: 1. Antenatal & postnatal cases must be reviewed by MO (95%) 2. Repeat A&E visits for the same complaints should be admitted for further monitoring and management (95%) 3. Low tolerance for admission• Time Frame: Immediate
  • 15. POA: Ensuring Optimal Blood & FFP Level• By Whom: Hospital Director• Activities: 1. Assign a lab assistant to be responsible (Target) 2. Daily stock level check• Targets: 1. Ensure optimal level achieved at most times 2. Yellow alert should be at 70% optimum stock 3. Red alert should be at 50% optimum stock, response time to replenish stock within 24 hours 4. Increase FFP stock by 20% if possible• Time Frame: Immediate
  • 16. POA: Improving PPH Management in DH• By Whom: Hospital Director/LW Nursing Sister• Activities: 1. Compulsory regular obstetric drills (Target 3x/year) 2. ‘Red Alert’ system to be implemented (TARGET) 3. PPH box to be made available and regularly checked 4. Carboprost at least 4 ampoules must be made available in LW at all times 5. BAKRI balloons once used have to be indented 6. ‘PPH management flowchart’ have to be on the notice board in LW 7. Ambulance driver should be called once Red Alert is activated• Time Frame: Immediate
  • 17. POA: Reduce Delays in Transfer of ill Patients• By Whom: Hospital Director• Activities: 1. Refer to specialist early! 2. All hospital directors/MO must be well versed with SOP on using medevac services 3. Brainstorm and decide best way to reduce transit time 4. Reduce time taken to prepare patient for transfer 5. Ensure ambulance services is adequate to meet demands and have contingency plans!• Target: 1. Audit time taken to transfer ill obstetric cases to specialist hospital from decision to arrival. 2. Then try to reduce transfer time from decision to arrival at specialist hospital by 20% (without driving faster!)
  • 18. POA: Improve O&G Clinical Services in Hospitals• By Whom: Hospital Directors/O&G specialists• Activities & Targets: 1. Identify weaknesses by doing regular clinical audit of near misses and bad outcome (6 in 6 months) 2. Improve clinical work processes to reduce errors 3. Improve skills & knowledge of MO and LW staff through CME / workshops ( Organize 6 in 6 months) 4. ‘Buddy Specialist’ to do supervisory visits in DH (2x/year) 5. Short attachments for medical officers• Time Frame: To start immediately
  • 19. POA: Improve Postnatal Care• By Whom: Hospital Directors/Maternity NS• Activities: 1. E-notifications should be implemented by all 2. Write postnatal management plan in high risk patients on e-notification so that clinic staff can prioritize home visits 3. Unwell postnatal patients attending A&E/OPD should be managed as high risk and are at risk of DVT/PE – admit and manage accordingly• Target: 1. e-notifications for all deliveries (100%) 2. All unwell postnatal mothers (within 42 days) attending A&E/OPD should be admitted• Time Frame: Immediate
  • 20. POA: Reduce Risk of Obstetric Embolism• By Whom: Hospital Directors• Activities: 1. All caesarean sections require thromboprophylaxis (LMWH or SC heparin) follow guidelines 2. High risk patients require 7 days of thromboprophylaxis (continue after discharge) 3. All postnatal mothers should be advised to drink adequate water and to mobilize 4. All postnatal mothers must be counseled to go to the nearest clinic if they are feeling unwell• Time Frame: Practice immediately
  • 21. POA: Improving FP Services in DH• By Whom: Hospital Director/obstetric counselor• Activities: 1. Obstetric counselors to organize activities & set targets 2. All antenatal & postnatal mothers should be counseled 3. Make IUCD, Depo-provera and OCP available 4. Send obstetric counselor for training to insert IUCD 5. Advocate postnatal BTL for high risk patients in remote areas 6. Promote family planning in hospital (leaflets, videos)• Target: 1. All antenatal & postnatal mothers must be given family planning counseling – April 2012 onwards 2. Obstetric counselor to be sent for training for IUCD insertion by July 2012 (credentialing & privileging)
  • 22. POA: Promoting Pre-Pregnancy Clinic• By Whom: Hospital Director/Obstetric Counselor• Activities: 1. Identify women in the reproductive age group with medical diseases or high risk postnatal patients who require pre-pregnancy assessment to the nearest ‘Pre-Pregnancy Clinic’ (PPC)• Aim is to optimize or to counsel to reduce maternal morbidity & mortality• District hospital can refer patients direct to Specialist PPC in nearest hospital• Target: To be decided soon!
  • 23. POA: Pre-Pregnancy Clinic in Specialist Hospitals• SGH, Miri, Bintulu & Sibu compulsory to run regular PPC• Being audited by MOH!• By Whom: Hospital Director & O&G dept. HOD• Activities: 1. Inform other clinical departments about PPC 2. Actively source for patients from within the hospital 3. PPC from health side needs to improve numbers and refer cases 4. All cases with medical or obstetric issues to be seen in the PPC 5. Need to find solutions to low numbers both health/hospital at JKNS level• Target: 100% increase in PPC attendance by June 2012
  • 24. Monitoring & Feedback• JKNS needs to obtain feedback from all hospitals for the various targets set• All the components of the ‘Plan of Action’ and the targets set for 2012 are achievable
  • 25. sgh-og.tumblr.com• Website by the O&G Department, SGH• Bookmark website in maternity & LW desktops• Videos (O&G procedures)• Guidelines• Lectures• Downloads – forms, patient information leaflets, LW manual etc