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PLAN OF ACTION TO IMPROVE O&G SERVICES AT DISTRICT HOSPITAL            LEVEL:               TO         ACHIEVE MDG 5      ...
Statistics for Sarawak:The state MMR for 2011 is 19.9/100,000 Live Births
National MMRNational MMR in 2009 – 30/100,000 LB
Sarawak State MMR• National MMR have reached a plateau between 28-  30/100,000 LB for the last 10 years• MDG 5 target for ...
Achieving MDG 5: Can we do it?• Ensure every component of the  healthcare services in the state plays  it’s role, implemen...
SARAWAK DATA:•   Approx. 40,000+ deliveries per year•   60% delivered in specialist hospitals•   25% delivered in non spec...
No. of Maternal death per classification                 2009        2010   2011Direct              8         5      5Indi...
No. of direct & indirect deaths by                  venue:Places of death                  2009        2010Gov. Specialist...
TOP 4 CAUSES OF MATERNAL DEATH•   PPH•   HEART DISEASE IN PREGNANCY•   ECLAMPSIA/HELLP SYNDROME•   OBSTETRIC EMBOLISM
State CEMD 2009 -2011• 30-40% of cases were preventable• Failure to appreciate severity• Inappropriate, inadequate and del...
DEFICIENCIES NOTED FROM STATE CEMD• Directives & guidelines not followed• Lack of blood & blood products in DH• Substandar...
Lessons from National CEMD• More than 60% of maternal deaths  occurred during the postnatal period• The risk of maternal d...
POA: Manpower & Equipment Needs• Hospital Directors should address hospital  needs in terms of manpower and O&G  medical e...
POA: Ensure all O&G directives are implemented• All previous and future directives from JKNS  and O&G guidelines MUST be i...
POA: Improve A&E/OPD services• All antenatal and postnatal mothers should be  considered as HIGH RISK when attending  A&E/...
POA: Ensuring Optimal Blood & FFP Level• By Whom: Hospital Director• Activities:    1.   Assign a lab assistant to be resp...
POA: Improving PPH Management in DH•    By Whom: Hospital Director/LW Nursing Sister•    Activities:    1. Compulsory regu...
POA: Reduce Delays in Transfer of ill Patients• By Whom: Hospital Director• Activities:    1.   Refer to specialist early!...
POA: Improve O&G Clinical Services in Hospitals•   By Whom: Hospital Directors/O&G specialists•   Activities & Targets:   ...
POA: Improve Postnatal Care•   By Whom: Hospital Directors/Maternity NS•   Activities:    1. E-notifications should be imp...
POA: Reduce Risk of Obstetric Embolism• By Whom: Hospital Directors• Activities:  1. All caesarean sections require thromb...
POA: Improving FP Services in DH• By Whom: Hospital Director/obstetric counselor• Activities:    1.   Obstetric counselors...
POA: Promoting Pre-Pregnancy Clinic• By Whom: Hospital Director/Obstetric Counselor• Activities:    1. Identify women in t...
Monitoring & Feedback• JKNS needs to obtain feedback from all  hospitals for the various targets set• All the components o...
sgh-og.tumblr.com• Website by the O&G Department, SGH• Bookmark website in maternity & LW  desktops• Videos (O&G procedure...
POA for Hospital to achieve MDG 5
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POA for Hospital to achieve MDG 5

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Plan of Action to Improve O&G Services at District Hospital Level to Achieve Millennium Development Goal 5.

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POA for Hospital to achieve MDG 5

  1. 1. PLAN OF ACTION TO IMPROVE O&G SERVICES AT DISTRICT HOSPITAL LEVEL: TO ACHIEVE MDG 5 By Dr. Harris N. Suharjono 20.02.2012
  2. 2. Statistics for Sarawak:The state MMR for 2011 is 19.9/100,000 Live Births
  3. 3. National MMRNational MMR in 2009 – 30/100,000 LB
  4. 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. 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. 6. SARAWAK DATA:• Approx. 40,000+ 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. 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. 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. 9. TOP 4 CAUSES OF MATERNAL DEATH• PPH• HEART DISEASE IN PREGNANCY• ECLAMPSIA/HELLP SYNDROME• OBSTETRIC EMBOLISM
  10. 10. State CEMD 2009 -2011• 30-40% of cases were preventable• Failure to appreciate severity• Inappropriate, inadequate and delayed therapy• Delay in transfer!
  11. 11. DEFICIENCIES NOTED FROM STATE CEMD• Directives & guidelines not followed• Lack of blood & blood products in DH• Substandard management of PPH at DH• Delays in transferring ill patients to specialist hospitals• Obstetric patients only seen by MA in A&E or OPD• Unsafe clinical practices in LW• Inadequate post natal care• Failure to offer TOP in early pregnancy by physicians and cardiologists• More specialists & specialist hospitals!
  12. 12. 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
  13. 13. 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 by End of March 2012• JKNS to compile and forward at the appropriate time• Buddy specialist could assist if required• Kindly cc a copy to me at harris@suharjono.com
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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!)
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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)
  23. 23. 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 would benefit or require pre-pregnancy assessment before embarking on another pregnancy to the nearest ‘Pre-Pregnancy Clinic’• Aim of FP and Pre-pregnancy clinic is to reduce unplanned pregnancies, grand multi parity and optimization before pregnancy to reduce maternal morbidity & mortality• Time Frame: Immediate
  24. 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. 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

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