Research-Based Articles

Summary: Methodology study developing key performance indicators (KPI) for massive transfusion.

Abstract: Background and objectives: To develop key performance indicators (KPI) for use in quality assessment of our institutional goal-directed massive transfusion (GDMT).

Materials and methods: A team comprising our transfusion and emergency medicine departments carried out a cross-sectional data analysis of GDMT in adult patients from January 2021 to December 2022. The study was rooted in the Define, Measure, Analyse, Improve, Control (DMAIC) approach. Features of KPIs were (a) importance, (b) scientific soundness and (c) feasibility. Study parameters were defined and analysed using measures of central tendencies and benchmark comparison.

Results: Ninety-two massive transfusion events occurred and 1405 blood components were used. Trauma was the leading cause, followed by postpartum haemorrhage and upper gastrointestinal bleeding. Appropriate GDMT activation was observed only in 43.47% of events. The turnaround time (TAT) was within the benchmark in 85.8% of events with an average of 16 ± 10 min. The average utilization of blood components was 20.5 (interquartile range [IQR] = 11.3) in the appropriate group and 5.5 (IQR = 4.25) in the inappropriate group with a wastage rate of 3.5%. Duration of activation was 6.19 ± 4.59 h, and the adherence to thromboelastography was 66.3%. Overall mortality was 45.65%, and the average duration of hospital stay was 6.1 ± 5.9 days.

Conclusion: The KPIs developed were easy to capture, and the analysis provided a comprehensive approach to the quality improvement of the GDMT protocol.

Keywords: Massive transfusion, quality improvement, key performance indicators

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement

Summary: Observational audit quantifying existing compliance rates of protocols with national guidelines.

Abstract: Objectives: The principal objective of this work was to assess how well the written protocols of maternity units used for the prevention and management of postpartum hemorrhage (PPH) corresponded to the 2004 French guidelines on this topic. The second objective was to assess whether or not this correspondence with the national guidelines varied according to hospital level (basic, specialized, and subspecialized) and status (teaching, public, and private).

Methods: This observational multicenter cross-sectional study took place in September 2010 and included French perinatal networks that volunteered to participate. We asked 300 French maternity units belonging to these networks to participate by emailing a copy of their department's protocol for PPH to the study team. This team designed and performed a clinical audit of these protocols, defining 16 criteria that incorporated the 2004 French guidelines for prevention and management of PPH. The main outcome measure was the percentage of units reporting protocols meeting these criteria.

Results: Of the 244 maternity units responding, 97.1 % had a written protocol but only 67.0 % had a local protocol. Protocol correspondence with the 2004 French guidelines was good for the criteria involving quantitative assessment of the quantity of blood loss (83.5 %) and secondary management of PPH (>80 %). Correspondence with the guidelines was poor in terms of defining PPH in the protocol (25.3 %) and of requiring the recording of the time of PPH diagnosis (53.2 %) and of the volume of blood loss (55.7 %). These results differed only slightly according to maternity unit status or level.

Conclusion: In all, 67.0 % (159/237) of maternity units had a local protocol for PPH. The contents of these protocols should be improved to be closer to the national guidelines.

Keywords: Postpartum hemorrhage, protocols, maternity units, audit, France

Topic(s):

• Clinical consensus, guidelines, protocols
• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement

Summary: Quality improvement initiative description using a toolkit, but lacking specific quantified adherence rates (pre/post).

Abstract: Objective: To expand a hospital system's maternal mental health program to standardize screening for perinatal mood and anxiety disorders.

Design: Quality improvement initiative using a continuous Plan-Do-Study-Act (PDSA) cycle.

Setting/local problem: In a hospital system consisting of 66 maternity care centers across the United States, there was significant variation in maternal mental health screening, referral, and education practices. The COVID-19 pandemic and increasing rates of severe maternal morbidity further elevated system-level concern about the quality of maternal mental health care being provided.

Participants: Perinatal nurses.

Methods: An "all-or-none" bundle methodology was used to measure adherence to a system standard for maternal mental health screening, referral, and education.

Interventions: A toolkit was designed internally to support streamlined implementation and ensure standardization for screening, referral, and education. This comprehensive toolkit includes screening forms, a referral algorithm, staff education, patient education literature, and a community resource list template. Training on how to use the toolkit was provided to nurses, chaplains, and social workers.

Results: The initial system bundle adherence rate was 76% (2017) in the first year of the program. The following year, the bundle adherence rate increased to 97% (2018). Despite the disruption caused by the COVID-19 pandemic, this mental health initiative has maintained an overall adherence rate of 92% (2020-2022).

Conclusion: This nurse-led quality improvement initiative has been successfully implemented across a geographically and demographically diverse hospital system. The initial and sustained high rates of adherence with the system standard for screening, referral, and education illustrate perinatal nurses' commitment to the delivery of high-quality maternal mental health care in the acute care setting.

Keywords: Maternal mental health; postpartum; education; screening

Topic(s):

• Quality, performance, and outcome indicators
• Universal screening tools and billing codes
• Workforce training and development

Intervention Type: Screening Education and Promotion

Summary: Observational audit quantifying guideline adherence rates (6.0% discrepancy observed).

Abstract: Introduction: Transfusion of blood products occurs frequently as part of the treatment of post-partum haemorrhage, but since it is both expensive and has potentially severe complications, prescription of blood products should be restricted. The aim of this study was to examine if restrictive red blood cell transfusion (RBC-T) practice for obstetric patients was in line with national Danish guidelines.

Methods: A retrospective quality assurance study was conducted at Rigshospitalet, Denmark. The study counted the participation of the Department of Anaesthesiology and Surgery, the Juliane Marie Centre, the Danish Blood Bank and the Department of Obstetrics. Patients were identified via the patient database of the Danish Blood Bank in 2015-2017, and patient files were read.

Results: Out of 16,698 delivering women, 196 (1.2%) received one or more RBC-T from 2015 to 2017. A total of 133 women (67.9%) received more than one RBC-T and the median was two. The most common reason for RBC-T was a "low haemoglobin level (Hb) + anaemic symptoms" (37.0%). A total of 20.3% of all RBC-Ts were prescribed based simply on a low Hb. The most common symptom of anaemia was dizziness.

Conclusions: The majority of RBC-Ts for obstetric patients were conducted in line with the guidelines. However, 6.0% of RBC-Ts were registered to be in discrepancy with the guidelines and 20.3% of RBC-Ts were prescribed on the "low Hb" criterium solely. It is possible, though, that the 20.3% is overestimated due to insufficient descriptions of indications for RBC-T in patient files.

Keywords: Red blood cell transfusion; postpartum hemorrhage; guidelines; adherence

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Quality improvement project that notes an increase in education, but lacks specific, quantified pre/post data on education or referral rates.

Abstract: Symptoms of urgent maternal warning signs (UMWS) may occur during pregnancy or after delivery and may have lasting effects or indicate a life-threatening situation if left untreated. The state department of health sponsored a quality improvement project (QIP) to broaden the reach of UMWS education beyond traditional clinical settings, to public health settings where prenatal and postpartum women are seen. Specifically, the QIP implemented process changes to provide education (written and verbal) and resources to individuals receiving services from Women, Infants, and Children clinics during pregnancy and up to 12 weeks postpartum. Clinics submitted participant-level data although the Research Electronic Data Capture secure data portal. The key results indicated an increase in both written and verbal education. In addition, the project monitored referrals made specific to conditions identified through project-specific data collection and the provision of UMWS education.

Keywords: Maternal health; warning signs; quality improvement; implementation

Topic(s):

• Community outreach and engagement
• Resources for consumers/new mothers

Intervention Type: Education and Promotion Outreach

Summary: Quality improvement study comparing different blood loss measurement methods.

Abstract: Background: Accurate measurement of blood loss during delivery is important for early hemorrhage detection.

Methods: We compared quantitative blood loss and estimated blood loss to calculated blood loss. We reviewed cesarean deliveries for estimated blood loss and quantitative blood loss, December 1, 2018, to December 1, 2019. A standard formula was used for calculated blood loss.

Results: Overall (n = 483), median values (m; interquartile range [IQR]) for estimated blood loss (600.0 mL; IQR 500.0-800.0) and quantitative blood loss (557.0 mL; IQR 350.0 - 824.0) were significantly lower (both P values < 0.001) than calculated blood loss (929.4 mL; IQR 551.5 - 1351.5). Compared to calculated blood loss, both estimated blood loss and quantitative blood loss had low sensitivity, high specificity, and low negative predictive values. Only 10 additional patients were identified as having a postpartum hemorrhage through quantitative blood loss.

Discussion: Quantitative blood loss and estimated blood loss are immediately available in clinical practice, while calculated blood loss is not and requires additional time to obtain. All methods currently available have shortcomings. Continued efforts to create a reliable tool for identifying blood loss are needed.

Keywords: Blood loss, cesarean birth, measurement, quality improvement

Topic(s):

• Quality, performance, and outcome indicators
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Epidemiology and Surveillance

Summary: Observational comparison/Methodology assessment of review processes.

Abstract: Objective: To compare results from facility-level and state-level severe maternal morbidity (SMM) reviews in Illinois. Design: We report descriptive characteristics about SMM cases and compare the results of both review processes, including the primary cause, assessment of preventability, and factors that contributed to the severity of the SMM cases. Setting: All birthing hospitals in Illinois. Participants: A total of 81 SMM cases were reviewed by a facility-level committee and the state-level review committee. SMM was defined as any intensive care or critical care unit admission and/or transfusion of 4 or more units of packed red blood cells from conception to 42 days postpartum. Results: Among the cases reviewed by both committees, hemorrhage was the primary cause of morbidity, with 26 (32.1%) and 38 (46.9%) hemorrhage cases identified by the facility-level and state-level committees, respectively. Both committees identified infection/sepsis (n = 12) and preeclampsia/eclampsia (n = 12) as the next most common causes of SMM. State-level review found more cases potentially preventable (n = 29, 35.8% vs n = 18, 22.2%) and more cases not preventable but improvement in care needed (n = 31, 38.3% vs n = 27, 33.3%). State-level review found more provider and system opportunities to alter the SMM outcome and fewer patient opportunities than facility-level review. Conclusion: State-level review found more SMM cases potentially preventable and identified more opportunities to improve care than facility-level review. State-level review has the potential to strengthen facility-level reviews by identifying opportunities to improve the review process and develop recommendations and tools to aid facility-level reviews.

Keywords: Morbidity ; Maternal Health Services ; Quality Assessment ; Human ; Female ; Adolescence ; Adult ; Illinois ; Birth Setting ; Record Review ; Case Studies ; Audit ; Adolescent: 13-18 years ; Adult: 19-44 years ; Female

Topic(s):

• Quality, performance, and outcome indicators
• Data collection, measurement, analysis

Intervention Type: Policy Development and Enforcement Epidemiology and Surveillance

Summary: Observational study quantifying association between collaboration and participant retention (OR:1.177).

Abstract: The study aimed to examine the association between cross-sector collaboration in Nurse-Family Partnership (NFP), a model home visiting program, and participant retention. We used the 2018 NFP Collaboration Survey that measured agency-level collaboration, operationalized as relational coordination and structural integration, among nine community provider types (including obstetrics care, substance use treatment, child welfare). This dataset was linked to 2014-2018 NFP program implementation data (n = 36,900). We used random-intercept models with nurse-level random effects to examine the associations between provider-specific collaborations and participant retention adjusting for client, nurse, and agency characteristics. The adjusted models suggest that stronger relational coordination between nurses and substance use treatment providers (OR:1.177, 95% CI: 1.09-1.26) and greater structural integration with child welfare (OR: 1.062, CI: 1.04-1.09) were positively associated with participant retention at birth. Stronger structural integration between other home visiting programs and supplemental nutrition for women, infants, and children was negatively associated with participant retention at birth (OR: 0.985, CI: 0.97-0.99). Structural integration with child welfare remained significantly associated with participant retention at 12-month postpartum (OR: 1.032, CI: 1.01-1.05). In terms of client-level characteristics, clients who were unmarried, African-American, or visited by nurses who ceased NFP employment prior to their infant's birth were more likely to drop out of the NFP program. Older clients and high school graduates were more likely to remain in NFP. Visits by a nurse with a master's degree, agency rurality, and healthcare systems that implement the program were associated with participant retention. Cross-sector collaboration in a home visiting setting that bridges healthcare and addresses social determinants of health has potential to improve participant retention. This study sets the groundwork for future research to explore the implications of collaborative activities between preventive services and community providers.

Keywords: Home visiting; cross-sector collaboration; retention; public health

Topic(s):

• Community outreach and engagement
• Behavioral/mental health services and substance use

Intervention Type: Collaboration Case Management

Summary: Methodological study (Delphi process) developing a consensus-based model for integrated care (reached $\ge 75%$ agreement on nine domains).

Abstract: Perinatal mental illness is an important public health issue, with one in five birthing persons experiencing clinically significant symptoms of anxiety and/or depression during pregnancy or the postpartum period. The purpose of this study was to develop a consensus-based model of integrated perinatal mental health care to enhance service delivery and improve parent and family outcomes. We conducted a three-round Delphi study using online surveys to reach consensus (≥75% agreement) on key domains and indicators of integrated perinatal mental health care. We invited modifications to indicators and domains during each round and shared a summary of results with participants following rounds one and two. Descriptive statistics were generated for quantitative data and a thematic analysis of qualitative data was undertaken. Study participants included professional experts in perinatal mental health (e.g., clinicians, researchers) (n = 36) and people with lived experience of perinatal mental illness within the past 5 years from across Canada (e.g., patients, family members) (n = 11). Consensus was reached and all nine domains of the proposed model for integrated perinatal mental health care were retained. Qualitative results informed the modification of indicators and development of an additional domain and indicators capturing the need for antiracist, culturally safe care. The development of an integrated model of perinatal mental health benefitted from diverse expertise to guide the focus of included domains and indicators. Engaging in a consensus-building process helps to create the conditions for change within health services.

Keywords: perinatal mental health, integrated care, consensus, Delphi

Topic(s):

• Clinical consensus, guidelines, protocols
• Behavioral/mental health services and substance use

Intervention Type: Collaboration

Summary: Quality improvement project describing program development, lacking specific quantifiable pre/post data.

Abstract: Postpartum depression (PPD) is higher among NICU mothers compared to mothers without infants in the NICU. Routine screening improves early PPD identification and treatment for mothers. Key national women and infant organizations endorse facility-based policies that address PPD screening. In addition to PPD screening, the key national organizations recommend facilities providing care to women and infants develop a method of referral for maternal PPD evaluation, treatment, and follow-up. Due to the timing, onset, and maternal predisposition to PPD, the NICU is a prime setting for PPD screening. Despite recommendations, PPD screening is not routine in the NICU. This article describes the development and assessment of a PPD screening program implemented in the NICU. Data analysis of 30 NICU mothers evaluated the risk of PPD based on screening tool scores, maternal diagnostic evaluation compliance, and documentation of maternal follow-up with designated NICU staff.

Keywords: Edinburgh Postnatal Depression Scale; NICU; follow-up; postpartum depression; referral.

Keywords: Postpartum depression, Screening program, NICU, Development, Implementation

Topic(s):

• Universal screening tools and billing codes
• Promising models of care and best practices

Intervention Type: Screening Referral and Follow-Up

Summary: Methodology/Model development for SMM prediction.

Abstract: Background: Improvement in the prediction and prevention of severe maternal morbidity (SMM) - a range of life-threatening conditions during pregnancy, at delivery or within 42 days postpartum - is a public health priority. Reduction of SMM at a population level would be facilitated by early identification and prediction. We sought to develop and internally validate a model to predict maternal end-organ injury or death using variables routinely collected during pre-pregnancy and the early pregnancy period.

Methods: We performed a population-based cohort study using linked administrative health data in Ontario, Canada, from April 1, 2006 to March 31, 2014. We included women aged 18-60 years with a livebirth or stillbirth, of which one birth was randomly selected per woman. We constructed a clinical prediction model for the primary composite outcome of any maternal end-organ injury or death, arising between 20 weeks' gestation and 42 days after the birth hospital discharge date. Our model included variables collected from 12 months before estimated conception until 19 weeks' gestation. We developed a separate model for parous women to allow for the inclusion of factors from previous pregnancy(ies).

Results: Of 634,290 women, 1969 experienced the primary composite outcome (3.1 per 1000). Predictive factors in the main model included maternal world region of origin, chronic medical conditions, parity, and obstetrical/perinatal issues - with moderate model discrimination (C-statistic 0.68, 95% CI 0.66-0.69). Among 333,435 parous women, the C-statistic was 0.71 (0.69-0.73) in the model using variables from the current (index) pregnancy as well as pre-pregnancy predictors and variables from any previous pregnancy.

Conclusions: A combination of factors ascertained early in pregnancy through a basic medical history help to identify women at risk for severe morbidity, who may benefit from targeted preventive and surveillance strategies including appropriate specialty-based antenatal care pathways. Further refinement and external validation of this model are warranted and can support evidence-based improvements in clinical practice.

Keywords: severe maternal morbidity, prediction, model, pre-conception, early pregnancy, Ontario

Topic(s):

• Data collection, measurement, analysis
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Epidemiology and Surveillance

Summary: Quality improvement initiative aiming to increase BP checks from 40% to 70%, but the abstract does not provide the final achieved outcome rate.

Abstract: Objective: To improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).

Methods: A quality improvement initiative was implemented at a large academic medical centre in the USA for postpartum individuals with HDP. The primary aim was to increase completed BP checks within 7 days of hospital discharge from 40% to 70% in people with HDP in 6 months. Secondary aims included improving rates of scheduled visits, completed visits within 3 days for severe HDP and unattended visits. The balancing measure was readmission rate. Statistical process control charts were used, and data were stratified by race and ethnicity. Direct feedback from birthing individuals was obtained through phone interviews with a focus on black birthing people after a racial disparity was noted in unattended visits.

Results: Statistically significant improvements were noted across all measures. Completed and scheduled visits within 7 days of discharge improved from 40% to 76% and 61% to 90%, respectively. Completed visits within 3 days for individuals with severe HDP improved from 9% to 49%. The unattended visit rate was 26% at baseline with non-Hispanic black individuals 2.3 times more likely to experience an unattended visit than non-Hispanic white counterparts. The unattended visit rate decreased to 15% overall with an elimination of disparity. A need for BP devices at discharge and enhanced education for black individuals was identified through patient feedback.

Conclusion: Timely follow-up of postpartum individuals with HDP is challenging and requires modification to our care delivery. A hospital-level quality improvement initiative using birthing individual and frontline feedback is illustrated to improve equitable, person-centred care.

Keywords: hypertensive disorders of pregnancy; quality improvement; discharge; postpartum care; health equity

Topic(s):

• Quality, performance, and outcome indicators
• Health equity and access to care

Intervention Type: Referral and Follow-Up

Summary: Observational study developing and applying a measurement tool to quantify quality across existing units.

Abstract: To develop a new tool to assess the global quality of care for post-partum hemorrhage (PPH)-the leading preventable cause of maternal mortality worldwide-and to identify characteristics of maternity units associated with inadequate PPH management. This is a secondary analysis of the EPIMOMS population-based study conducted in 2012-2013 in 119 french maternity units (182,309 women who gave birth). We included women with severe PPH. We first developed a score to quantify the quality of care for PPH. Then, we identified characteristics of the maternity units associated with "inadequate care" defined by a score below the 25th percentile, with multi-level logistic regression adjusted for individual characteristics. The score combined 8 key components of care and took into account delivery mode and PPH cause. For PPH after vaginal delivery, the risk of inadequate care was increased in low versus high-volume maternity units (< 1000 deliveries/year: aOR-2.20 [1.12-4.32], [1000-2000 [deliveries/year: aOR-1.90 [1.02-3.56] compared to ≥ 3500 deliveries/year), in private versus public units (aOR-1.72 [1.00-2.97]), and in low versus high-level of care units (aOR-2.04 [1.24-3.35]). For PPH after cesarean, the only characteristic associated with an increased risk of inadequate care was the absence of 24/24-onsite anesthesiologist (aOR-4.34 [1.41-13.31]). These results indicate where opportunities for improvement are the greatest.

Keywords: Postpartum hemorrhage, quality of care, quantitative tool, population-based study

Topic(s):

• Quality, performance, and outcome indicators
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Policy Development and Enforcement Screening

Summary: Review and advocacy for QI initiatives, citing external examples.

Abstract: The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.

Keywords: Perinatal opioid use; mother-infant dyad; quality improvement

Topic(s):

• Quality, performance, and outcome indicators
• Dyadic, culturally congruent, family-centered care

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Methodology study proposing and illustrating a framework for consensus-building.

Abstract: Background: Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements - the changes that need to be made in a healthcare process - remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study.

Methods: Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus.

Results: We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video.

Conclusions: The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.

Keywords: healthcare process improvement, consensus, remote, obstetric emergency

Topic(s):

• Quality, performance, and outcome indicators
• Workforce training and development

Intervention Type: Collaboration Referral and Follow-Up

Summary: Methodology study using modified Delphi to identify process indicators.

Abstract: Objective: Identify process indicators to measure public health nursing practice during first postnatal visits in Ireland.

Design: Using a RAND/UCLA appropriateness- "modified Delphi" method, a two-round rating and ranking process was completed in 2016. Fifty-nine statements were reviewed for consensus and priority ranking.

Sample: The sample comprised a panel of 21 national and international experts.

Results: Fifty-nine indicators were identified and subsequently reduced across two rounds of consensus testing. Fifty-six indicators achieved consensus and priority ranking identified 13 indicators to measure care for mothers and 15 indicators to measure care for newborns resulting in 28 process indicators to enable Public Health Nurses (PHNs) to measure care during the first postnatal visit.

Conclusions: Measurement of care using quality indicators plays an integral role in quality improvement. Developing quality indicators is important in improving care outcomes. This two round "modified Delphi" study combined with literature and previous qualitative findings identified process indicators to measure public health nursing practice at first postnatal visits and enables benchmarking. Developing quality indicators for public health nursing practice using a "modified Delphi" technique has enabled a platform to provide consensus amongst a panel of experts and identified key processes of care by PHNs and mothers.

Keywords: Public health nursing, quality indicators, Delphi method, consensus, practice standards

Topic(s):

• Quality, performance, and outcome indicators
• Workforce training and development

Intervention Type: Consultation Consultation

Summary: Quality improvement project describing program development, lacking specific quantifiable pre/post data.

Abstract: The aim of this paper is to describe the development of a standardized screening program for parents of infants in the Neonatal Intensive Care Unit (NICU) and to assess its implementation. The standardized screening protocol assessed parental mental health symptoms including depression, anxiety and trauma. Screening began at 14 days post NICU admission and was implemented as part of routine medical care for all caregivers with infants admitted to the NICU at two weeks of age. Screenings were facilitated by pediatric social workers and psychology postdoctoral fellows and included review of critical self-harm items. A total of 158 parents ages 18-42 years (mean = 31.04) were eligible for screening, with 150 completed screenings. Positive screens on any of the three measures resulted in a mental health referral. Approximately 27% of parents had a positive screen that resulted in a mental health referral. The standardized screening protocol was found to be feasible, widely accepted, and effective in establishing referrals for in house mental health services. This model can be used as an example to help other NICUs implement their own universal screening protocols.

Keywords: Anxiety; NICU; PTSD; Postpartum depression; Standardized screening.

Keywords: Standardized screening protocol, Parental depression, Anxiety, PTSD symptoms, Neonatal Intensive Care Unit (NICU)

Topic(s):

• Universal screening tools and billing codes
• Behavioral/mental health services and substance use

Intervention Type: Screening Consultation

Summary: Review and analysis of QI initiatives.

Abstract: Parental mental health is an essential sixth vital sign that, when taken into consideration, allows clinicians to improve clinical outcomes for both parents and infants. Although standards exist for screening, referral, and treatment for perinatal mood and anxiety disorders (PMADs), they are not reliably done in practice, and even when addressed, interventions are often minimal in scope. Quality improvement methodology can accelerate the implementation of interventions to address PMADs, but hurdles exist, and systems are not well designed, particularly in pediatric inpatient facilities. In this article, we review the effect of PMADs on parents and their infants and identify quality improvement interventions that can increase screening and referral to treatment of parents experiencing PMADs.

Keywords: Parental mental health; perinatal period; quality improvement

Topic(s):

• Quality, performance, and outcome indicators
• Behavioral/mental health services and substance use

Intervention Type: Screening Referral and Follow-Up

Summary: Observational audit quantifying existing safety gaps and incidence of near-miss events (0.6% ICU transfers).

Abstract: Background: The rarity of maternal deaths in developed countries has increased interest in auditing cases of severe maternal morbidity or maternal 'near miss'. The assessment and preventability of cases of maternal 'near misses' are important in improving the provision of maternity care.

Aims: To describe the epidemiology and determine aspects of preventability in care among women admitted to an obstetric intensive care unit (ICU) in Far North Queensland.

Materials and methods: A retrospective observational study of pregnant and postpartum patients admitted to the Cairns Hospital ICU between 1 January 2013 and 31 December 2017 was undertaken. Cases of severe maternal morbidity were identified using the World Health Organization (WHO) 'near miss' criteria and reviewed to determine reasons for admission to ICU and ascertain aspects of preventability in the care provided.

Results: Sixty-nine out of 12 081 (0.6%) women admitted for obstetric care were transferred to the ICU with 31 cases fulfilling WHO 'near miss' criteria. The most common direct obstetric-related diagnosis for ICU admission was hypertensive disease of pregnancy and obstetric haemorrhage. Indirect obstetric causes contributed to approximately 40% of ICU admissions. Among the 31 cases of WHO 'near miss', ten cases were deemed preventable with the most common reason for preventability related to lack of recognition of high-risk clinical status.

Conclusion: Maternal 'near miss' and rates of obstetric admission to the ICU at Cairns Hospital are reassuringly low. Nevertheless, one-third of women with 'near miss' required improvements in the provision of care, emphasising the need for continued audit and improvement of clinical practice.

Keywords: maternal mortality; surveillance; safety net; non-obstetric providers; maternal health

Topic(s):

• Quality, performance, and outcome indicators
• Workforce training and development

Intervention Type: Disease and Health Event Investigation Policy Development and Enforcement

Summary: Study protocol for action research.

Abstract: This study aims to evaluate the care quality for “close to death” mothers in hospitals through action research. The maternal near miss approach has been developed by the World Health Organization for assessing and improving the quality of care. The study will use action research to examine the incidence, characteristics, and features of the care provided for maternal near-miss cases in hospitals. The WHO near miss criteria will be applied to gather and analyze the data, and indicators related to maternal near miss, access to and quality of maternal care. The findings are expected to help identify issues that may lead to life-threatening conditions and can be used to monitor and improve the quality of care in maternity settings.

Keywords: Pregnancy complication; Quality improvement; Quality of health care; WHO near miss approach.

Topic(s):

• Behavioral/mental health services and substance use

Intervention Type: Disease and Health Event Investigation Policy Development and Enforcement

Summary: Prospective audit quantifying secondary failure incidence (41.8% confirmed by EAUS).

Abstract: Aim: The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events.

Method: Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed.

Results: Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157).

Conclusion: Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

Keywords: obstetric sphincter injury, repair, secondary failure, risk factors

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Data collection, measurement, analysis

Intervention Type: Screening

Summary: Quality improvement project; abstract lacks specific quantifiable pre/post data for screening rates or confidence scores.

Abstract: Background: Unidentified and untreated postpartum depression (PPD) can have a negative impact on children. This Quality Improvement (QI) project aimed to increase PPD screening through provider education and enhancing pediatric primary care provider (PCP) confidence in using the Edinburg Postnatal Depression Screening (EPDS) tool, discussing PPD with mothers, and providing resources.

Design and methods: PCPs and staff were educated on the project. Providers were surveyed prior to and after implementation to assess confidence with screening for and addressing PPD. Mothers of infants 0-6 months were screened using the EPDS at well-care visits. Discussion of PPD and resource support was provided if needed.

Results: A total of 273 mothers met criteria for screening, and of those 65% (n = 178) had a documented score. 12.4% of mothers had a score of 10 or greater, indicating high risk for PPD. Results from PCPs were compared both pre- and post-project. Screening for PPD increased from 3 to 4.5, using the EPDS tool from 2.25 to 4.75, discussing PPD with mothers from 2.75 to 4.25, and providing resources from 2.25 to 4.25.

Conclusions: PPD screening increased, and provider confidence with using the EPDS, discussing PPD with mothers, and providing resources in pediatric primary care increased.

Keywords: Postpartum depression; screening; pediatric care; quality improvement

Topic(s):

• Universal screening tools and billing codes
• Quality, performance, and outcome indicators

Intervention Type: Screening Referral and Follow-Up

Summary: Observational study quantifying current timely treatment rates (94.6%).

Abstract: Background: Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality. National guidelines recommend treatment within 30 to 60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. The objectives of this study were to quantify the number of patients who did not receive timely treatment of severe hypertension, identify barriers to timely treatment, and evaluate if race/ethnicity was associated with timeliness of treatment.

Methods: The researchers created an automated report to identify women who experienced severe hypertension during the delivery admission. The record for each case was reviewed to determine if treatment was timely (within 30 minutes). The study team compared rates of severe peripartum hypertension and rates of timely vs. not timely treatment by race/ethnicity.

Results: There were 12,069 deliveries from April 1, 2019, to March 31, 2021-with 684 (5.7%) women with at least one episode of severe hypertension, of whom 241 (35.2%) did not require treatment, leaving 443 (64.8%) women requiring treatment. A total of 441 women received treatment, with 417 (94.6%) treated in a timely manner. Black, Asian, and Hispanic women were all more likely to experience severe hypertension requiring treatment than white women (10.0%, 8.8%, 7.3% vs. 4.0%, respectively, p < 0.001). However, there was no difference in the in the rates of timely treatment between groups (92.6%, 93.0%, 93.9% vs. 96.3%, respectively, p = 0.59).

Conclusion: Among patients with severe hypertension, 94.6% were treated in a timely manner, and race/ethnicity was not associated with timeliness of treatment. Provider education at all levels at our institution seems to be effective for timely treatment of severe hypertension and suggests that this process could be beneficial at other institutions.

Keywords: Peripartum hypertension; treatment; race; ethnicity

Topic(s):

• Health equity and access to care
• Chronic health conditions/mortality and morbidity drivers

Intervention Type: Epidemiology and Surveillance Consultation

Summary: National clinical audit quantifying incidence and management.

Abstract: Objective: To assess major obstetric haemorrhage incidence, management and quality of care in Irish maternity units.

Design: In collaboration with Irish maternity units the National Perinatal Epidemiology Centre (Leitao et al., 2020) carried out a national clinical audit and surveillance of major obstetric haemorrhage (MOH).

Methods: MOH was defined as blood loss of at least 2500 ml, transfusion of five or more units of blood or documented treatment for coagulopathy. Co-ordinators in maternity units completed detailed case assessment forms. The denominator data obtained from the individual units was restricted to live births and stillbirths of babies weighing at least 500 g. International Classification of Diseases diagnostic codes from hospital discharge records were used to identify cases of postpartum haemorrhage (PPH) and blood transfusion.

Results: During the time period, 2011-2018, there was a 54 % increase in MOH, a 60 % increase in PPH and a 54 % increase in blood transfusion. For 497 reported cases of MOH in 2011-2013, the median estimated blood loss was 3000 ml (range: 600-13,000 ml) and uterine atony was the most common cause. At least one uterotonic agent was used to arrest the bleeding in 94 % of the 477 MOH cases associated with a vaginal or caesarean delivery. A blood transfusion was received in 93 % of cases. Regarding quality of care, the vast majority of reported cases were described as receiving appropriate care and were well managed.

Conclusion: Internationally, obstetric haemorrhage and especially PPH and its increasing trend remains a major challenge for service providers and clinical staff. A standardisation of definitions of PPH/severe PPH/MOH and agreed approaches to quantitation of blood loss would be valuable developments to allow better investigation and shared learning. Reducing the burden of this morbidity through improvements in care should be a real focus of maternity services.

Keywords: Obstetric haemorrhage, incidence, management, quality of care, Ireland

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Quality, performance, and outcome indicators

Intervention Type: Epidemiology and Surveillance Direct Care

Summary: Observational study reporting initial implementation outcomes and alert rates of a new PROMs/PREMs tool, representing baseline data for future QI.

Abstract: Background: The International Consortium for Health Outcomes Measurement has published a set of patient-centered outcome measures for pregnancy and childbirth (PCB set), including patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs). To establish value-based pregnancy and childbirth care, the PCB set was implemented in the Netherlands, using the outcomes on the patient level for shared decision-making and on an aggregated level for quality improvement.

Objective: This study aims to report first outcomes, experiences, and practice insights of implementing the PCB set in clinical practice.

Methods: In total, 7 obstetric care networks across the Netherlands, each consisting of 1 or 2 hospitals and multiple community midwifery practices (ranging in number from 2 to 18), implemented the PROM and PREM domains of the PCB set as part of clinical routine. This observational study included all women participating in the clinical project. PROMs and PREMs were assessed with questionnaires at 5 time points: 2 during pregnancy and 3 post partum. Clinical threshold values (alerts) supported care professionals interpreting the answers, indicating possibly alarming outcomes per domain. Data collection took place from February 2020 to September 2021. Data analysis included missing (pattern) analysis, sum scores, alert rates, and sensitivity analysis.

Results: In total, 1923 questionnaires were collected across the 5 time points: 816 (42.43%) at T1 (first trimester), 793 (41.23%) at T2 (early third trimester), 125 (6.5%) at T3 (maternity week), 170 (8.84%) at T4 (6 weeks post partum), and 19 (1%) at T5 (6 months post partum). Of these, 84% (1615/1923) were filled out completely. Missing items per domain ranged from 0% to 13%, with the highest missing rates for depression, pain with intercourse, and experience with pain relief at birth. No notable missing patterns were found. For the PROM domains, relatively high alert rates were found both in pregnancy and post partum for incontinence (469/1798, 26.08%), pain with intercourse (229/1005, 22.79%), breastfeeding self-efficacy (175/765, 22.88%), and mother-child bonding (122/288, 42.36%). Regarding the PREM domains, the highest alert rates were found for birth experience (37/170, 21.76%), shared decision-making (101/982, 10.29%), and discussing pain relief ante partum (310/793, 39.09%). Some domains showed very little clinical variation; for example, role of the mother and satisfaction with care.

Conclusions: The PCB set is a useful tool to assess patient-reported outcomes and experiences that need to be addressed over the whole course of pregnancy and childbirth. Our results provide opportunities to improve and personalize perinatal care. Furthermore, we could propose several recommendations regarding methods and timeline of measurements based on our findings. This study supports the implementation of the PCB set in clinical practice, thereby advancing the transformation toward patient-centered, value-based health care for pregnancy and childbirth.

Keywords: Perinatal care, patient-reported outcomes, experience measures, clinical practice

Topic(s):

• Data collection, measurement, analysis
• Quality, performance, and outcome indicators

Intervention Type: Screening Direct Care

Summary: Validation study of a psychometric screening tool (PSAS-FR).

Abstract: Purpose: This study aims to validate the Postpartum‐Specific‐Anxiety‐Scale (PSAS) as a French‐language instrument, which assesses maternal and infant‐related anxieties during the postpartum period. Design and Methods: The methodology included six stages: preliminary French translation; selection of most articulate items and back‐translation; rectification of discrepancies; pilot study (n = 257); reliability and validity studies (n = 258; n = 874); and test–retest reliability study (n = 231). Findings: The PSAS‐FR demonstrated good acceptability, high internal consistency of the global scale (Cronbach's α = 0.93), and each of the factors; along with good validity, and test–retest reliability. The receiver operating characteristic analysis suggested a satisfactory screening tool. Practice Implications: The PSAS‐FR appears to be a valid and reliable tool to screen for postpartum anxieties in the French‐speaking population.

Keywords: Postnatal Period ; Anxiety ; Population France ; Instrument Validation ; Human ; Female ; Adolescence ; Adult ; Middle Age ; France ; Scales ; Pilot Studies ; Reliability and Validity ; Test-Retest Reliability ; Internal Consistency ; Coefficient alpha ; ROC Curve ; Criterion-Related Validity ; Sensitivity and Specificity ; Descriptive Statistics ; State-Trait Anxiety Inventory ; Psychological Tests ; Summated Rating Scaling ; Inferential Statistics ; Data Analysis Software ; Spearman's Rank Correlation Coefficient ; Edinburgh Postnatal Depression Scale ; Adolescent: 13-18 years ; Adult: 19-44 years ; Middle Aged: 45-64 years ; Female

Topic(s):

• Universal screening tools and billing codes
• Behavioral/mental health services and substance use

Intervention Type: Screening Consultation

Summary: Action research study to improve an instrument measuring satisfaction.

Abstract: Objectives: to improve an instrument that measures postpartum women's satisfaction with obstetric care.

Methods: action research, developed from a preliminary version of an instrument prepared by nurse-midwives working in public services in the Federal District. The analysis of the results of application of instrument carried out in a pilot test, analysis of evidence of instrument validity, literature review, focus group with the instrument's developers and interview with the target audience were carried out.

Results: factorial analysis showed three existing factors in the construct. Seven nurses participated, discussing the instrument reformulation, and 20 mothers reported their perceptions about the care received during childbirth, generating five thematic units.

Final considerations: instrument improvement occurred through item and response scale reconstruction and reorganization, in addition to application of a pre-test with the target population, resulting in an instrument composed of 13 items.

Keywords: satisfaction, obstetric services, assessment, puerperal women

Topic(s):

• Data collection, measurement, analysis
• Quality, performance, and outcome indicators

Intervention Type: Consultation Collaboration

Summary: Descriptive piece defining QA, QI, bundles, and metrics.

Abstract: Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.

Keywords: Quality assurance, quality improvement, labor and delivery, obstetric care, patient safety

Topic(s):

• Quality, performance, and outcome indicators

Intervention Type: Policy Development and Enforcement Screening

Summary: Quality improvement project; abstract notes outcomes support continuing the practice but lacks specific quantifiable pre/post data for the attendance rate change.

Abstract: Objective: To increase the percentage of women who attend postpartum visits and decrease the number of days to the first postpartum visit by implementing a scheduling change.

Design: Quality improvement project.

Setting/local problem: A small nurse practitioner maternity care clinic in an academic health center at which only 74% of the women who attended two or more prenatal visits attended postpartum clinic visits.

Participants: A diverse sample of 25 publicly insured women who gave birth during the 5-month implementation period.

Intervention/measurements: We added a 2- to 3-week postpartum appointment to our standard 6-week postpartum appointment. The measurable outcomes were the percentage of women who attended postpartum clinic visits and the number of days to the first postpartum visit.

Results: During the first 4 months of the 5-month project implementation phase, 14 of the 20 (70%) women who gave birth attended postpartum visits. The attendance at postpartum visits in the last month of the project was 100% (all five women). Days to first postpartum visit decreased from a mean of 40.7 in the baseline year to a mean of 21.8 by the last month of project implementation.

Conclusion: Despite the small scope of this project, our outcomes support continuing the practice of scheduling an earlier postpartum clinic appointment. The timing for when to preschedule postpartum appointments and contextual factors, such as the availability and use of telehealth technology and COVID-19 pandemic challenges, should be considered when implementing similar projects in other settings.

Keywords: postpartum clinic visits; quality improvement; publicly insured women; maternal health; access to care

Topic(s):

• Quality, performance, and outcome indicators
• Health equity and access to care

Intervention Type: Referral and Follow-Up Consultation

Summary: Observational study quantifying patient dissatisfaction with analgesic care (40% considered it insufficient).

Abstract: Objective: Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation.

Methods: This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project.

Results: A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor.

Conclusion: This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Keywords: Analgesic care, labor, quality, benchmarking, cross-sectional

Topic(s):

• Data collection, measurement, analysis
• Quality, performance, and outcome indicators

Intervention Type: Epidemiology and Surveillance Direct Care

Summary: Retrospective chart review quantifying the documentation rate of SMBP readings during telehealth visits (43.4% had SMBP documented).

Abstract: Introduction: Preeclampsia is a significant cause of morbidity and mortality. The United States Preventative Services Task Force released 2023 recommendations encouraging more research on telehealth's role in facilitating blood pressure monitoring for patients with hypertensive disorders of pregnancy, including preeclampsia. This study evaluates the integration of self-measured blood pressure (SMBP) into telehealth obstetric visits during the COVID-19 pandemic for pregnant patients at risk of preeclampsia. Methods: A retrospective chart review was conducted of patients with one or more preeclampsia risk factors who delivered at a tertiary hospital from January to March 2021. Information pertaining to patients' number of antepartum, postpartum, and telehealth visits, blood pressure cuff access, and documentation of SMBP readings was recorded. Analyses were conducted in RStudio version 2022.12.0 + 353 (R Foundation for Statistical Computing). Results: Of 721 eligible patients, 244 (33.8%) had 2 or more ante- or postpartum telehealth visits. Of these 244 patients, 142 (58.2%) had chart documentation of owning a home blood pressure cuff. Only 106 (43.4%) had 1 or more SMBP documented in their telehealth visit notes, and they were more likely to have received care at federally qualified health centers than maternal fetal medicine clinics (p = 0.018) or private clinics (p < 0.001). Charts revealed no explanation for lack of blood pressure documentation during telehealth visits for most cases (n = 129, 93.5%). Conclusions: Opportunities exist to standardize blood pressure recording and documentation during telehealth visits, especially for patients with risk factors for preeclampsia, and to advocate for greater access to home blood pressure cuffs for all pregnant patients.

Keywords: Blood pressure, telehealth, preeclampsia, monitoring, pregnancy

Topic(s):

• Quality, performance, and outcome indicators
• Infrastructure development, financing, and expansion of services

Intervention Type: Screening Screening

Summary: Retrospective audit quantifying compliance with screening and treatment guidelines.

Abstract: Background: Anaemia during pregnancy is common worldwide. In Australia, approximately 17% of non-pregnant women of reproductive age have anaemia, increasing to a rate of 25% in pregnant women. This study sought to determine the rate of screening for anaemia in pregnancy in regional New South Wales, and to determine whether screening and treatment protocols followed the recommended guidelines.

Methods: This retrospective study reviewed antenatal and postnatal (48 h) data of women (n = 150) who had a live birth at Bathurst Hospital between 01/01/2020 and 30/04/2020. Demographic data, risk factors for anaemia in pregnancy, antenatal bloods, treatments provided in trimesters one (T1), two (T2) and three (T3), and postpartum complications were recorded. These were compared to the Australian Red Cross Guidelines (ARCG) using descriptive statistics.

Results: Of the women with screening data available (n = 103), they were mostly aged 20-35yrs (79.6%), 23.3% were obese, 97.1% were iron deficient, 17% were anaemic and only a few (5.3%) completed the full pregnancy screening as recommended by the ARCG while a majority completed only partial screenings specifically Hb levels in T1 (56.7%), T2 (44.7%) and T3 (36.6%). Compliance to oral iron was largely undocumented, but constipation was a common side effect among the women. IV iron was administered in 14.0% of women, approximately 1.75x higher than the recommended rate.

Conclusions: This study provided useful information about compliance to screening and treatment guidelines for anaemia in pregnancy. We identified the need for improved documentation and communication between various health providers to ensure adequate antenatal care to prevent maternal complications during pregnancy. This will improve patient care and encourage further developments in maternal care, bridging the rural health gap.

Keywords: Anaemia; Guidelines; Iron supplements; Pregnancy; Rural.

Keywords: Pregnancy-related anaemia; screening; treatment; guidelines; audit

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Consultation

Summary: Study protocol focused on determining the optimal organizational entity for implementing PRMs.

Abstract: Background: The integration of patient-centered care (PCC) and value-based healthcare (VBHC) principles, emphasizing personalized, responsive care and cost efficiency, is crucial in modern healthcare. Despite advocation from the International Consortium for Health Outcomes Measurement (ICHOM) for the global adoption of these principles through patient-reported measures (PRMs), their implementation, especially the pregnancy and childbirth (PCB) set, remains limited in maternity care. This study focuses on understanding the optimal organizational entity for integrating standard ICHOM-PCB-PRMs into routine maternity care in Finland. It aims to clarify the distribution of tasks among stakeholders and gather Finnish maternity healthcare professionals' perspectives on organizational responsibility in PRM collection. The emphasis was on identifying the optimal organizational framework for managing PRMs in maternity care.

Results: A total of 66 maternity healthcare professionals participated in the study, reaching a consensus that public maternity care centers in Finland should be the primary entity responsible for managing PRMs in the maternity sector. Key aspects such as confidence with the role as a mother, maternal confidence with breastfeeding, and satisfaction with the result of care were identified as crucial and should be inquired about in both public maternity care centers and hospital maternity wards. The findings highlight the importance of comprehensive and consistent attention to these PRMs across public maternity care centers and hospital maternity settings to ensure holistic and effective maternal care.

Conclusions: The study highlights the central role of public maternity care centers in the collection and management of PRMs within Finnish maternity care, as agreed upon by the professional consensus. It underscores the importance of a consistent and holistic approach to PRM inquiry across different care settings to enhance the quality and effectiveness of maternity care. This finding is crucial for policymakers and healthcare practitioners, suggesting that reinforcing the collaborative efforts between public maternity care centers and hospital maternity wards is vital for a patient-centric, efficient healthcare system. Aligning with PCC and VBHC principles, this approach aims to improve healthcare outcomes for pregnant and postpartum women in Finland, emphasizing the need for a unified strategy in managing maternity care.

Keywords: patient-reported measures; maternity care; Finland; implementation; organizations

Topic(s):

• Quality, performance, and outcome indicators
• Infrastructure development, financing, and expansion of services

Intervention Type: Consultation Policy Development and Enforcement

Summary: Validation study quantifying the accuracy of a screening tool (OEWS) in a specific population (Sensitivity 42%, Specificity 83%).

Abstract: Objective: Several authorities have recommended the use of an obstetric early warning system (OEWS) to prevent severe morbidity and mortality. Data on the accuracy of OEWS in different clinical settings and maternal populations are still scarce. Our aim was to validate OEWS to detect maternal morbidity among high-risk women in the postnatal ward.

Methods: An OEWS was assigned to women with a body mass index >35 kg/m2, postpartum hemorrhage (PPH) >1500 mL, preeclampsia, concern over the maternal condition, chorioamnionitis, or type 1 diabetes. Morbidity was defined as worsening preeclampsia, action on hemorrhage, thromboembolia, diabetic ketoacidosis, puerperal infections, transfer to the intensive care unit, cardiopulmonary dysfunction, or death during the stay in the postnatal ward. The use of OEWS was implemented on November 1, 2016, and the study period ended on April 30, 2018.

Results: The study group included 827 women. The incidence of maternal morbidity was 29%. Women with PPH (odds ratio [OR], 6.4 [95% confidence interval, 3.5-11.6]) and preeclampsia (OR, 5.7 [3.5-9.6]) had the highest risk for morbidity. The sensitivity of OEWS for any morbidity was 42% (35%-48%), the specificity was 83% (80%-86%), the positive predictive value was 50% (44%-56%), and the negative predictive value was 78% (76%-80%). Systolic (OR, 6.8 [4.0-11.5]) and diastolic (OR, 3.3 [1.8-6.0]) blood pressure as well as pulse (OR, 2.1 [1.1-4.2]) predicted morbidity the most.

Conclusions: In high-risk women, OEWS revealed one-half of the morbidity. Women with PPH and preeclampsia benefited most from it. Abnormal blood pressure and pulse had the strongest associations with morbidity.

Keywords: Obstetric early warning, maternal morbidity, postnatal, high-risk

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Quality, performance, and outcome indicators

Intervention Type: Screening Counseling

Summary: Quality improvement project describing program development and referral algorithm implementation, lacking specific quantifiable pre/post data.

Abstract: Background: Postpartum depression (PPD) is a common mental health condition that affects approximately 13% of postpartum women in the United States. However, the prevalence in the neonatal intensive care unit (NICU) has been shown to be higher. Routine screening for maternal PPD is recommended at infant primary care well-child visits up to 6 months of age. The absence of a routine PPD screening program in a level IV NICU created a large gap in screening in an at-risk population.

Purpose: To develop and implement a screening program in the NICU to increase the identification of maternal PPD symptoms and to develop both a referral algorithm for NICU staff to follow and a referral resource packet to be given to mothers with positive PPD screenings.

Methods: Mothers with infants in the NICU were screened for PPD using the Edinburgh Postnatal Depression Scale (EPDS). Bedside nurses administered the screening tool and used a referral algorithm to determine appropriate follow-up. EPDS scores of 10 or more were considered positive and indicated a need for referral.

Results: The overall EPDS screening compliance was 66% with a positive rate of 26%. Nurses followed the referral algorithm appropriately 100% of the time. It was confirmed that 93% of the mothers with positive EPDS screenings sought help from a mental health provider.

Implications for practice and research: Routine maternal PPD screening should be implemented in all NICU settings. Postpartum mental health issues should not be the sole responsibility of obstetricians, mental health providers, or maternal primary care providers.

Keywords: Postpartum depression, Screening, Neonatal Intensive Care Unit (NICU)

Topic(s):

• Universal screening tools and billing codes
• Behavioral/mental health services and substance use

Intervention Type: Screening Disease and Health Event Investigation

Summary: Descriptive piece proposing a new SMM definition and SMM subtypes for surveillance.

Abstract: Background: There is no international consensus on the definition and components of severe maternal morbidity (SMM).

Objectives: To propose a comprehensive definition of SMM, to create an empirically justified list of SMM types and subtypes, and to use this to examine SMM in Canada.

Methods: Severe maternal morbidity was defined as a set of heterogeneous maternal conditions known to be associated with severe illness and with prolonged hospitalisation or high case fatality. Candidate SMM types/subtypes were evaluated using information on all hospital deliveries in Canada (excluding Quebec), 2006-2015. SMM rates for 2012-2016 were quantified as a composite and as SMM types/subtypes. Rate ratios and population attributable fractions (PAF) associated with overall and specific SMM types/subtypes were estimated in relation to length of hospital stay (LOS > 7 days) and case fatality.

Results: There were 22 799 cases of SMM subtypes (among 1 418 545 deliveries) that were associated with a prolonged LOS or high case fatality. Between 2012 and 2016, the composite SMM rate was 16.1 (95% confidence interval [CI] 15.9, 16.3) per 1000 deliveries. Severe pre-eclampsia and HELLP syndrome (514.6 per 100 000 deliveries), and severe postpartum haemorrhage (433.2 per 100 000 deliveries) were the most common SMM types, while case fatality rates among SMM subtypes were highest among women who had cardiac arrest and resuscitation (241.1 per 1000), hepatic failure (147.1 per 1000), dialysis (67.6 per 1000), and cerebrovascular accident/stroke (51.0 per 1000). The PAF for prolonged hospital stay related to SMM was 17.8% (95% CI 17.3, 18.3), while the PAF for maternal death associated with SMM was 88.0% (95% CI 74.6, 94.4).

Conclusions: The proposed definition of SMM and associated list of SMM subtypes could be used for standardised SMM surveillance, with rate ratios and PAFs associated with specific SMM types/subtypes serving to inform clinical practice and public health policy.

Keywords: Severe maternal morbidity, surveillance, pregnancy, hospitalization, mortality

Topic(s):

• Chronic health conditions/mortality and morbidity drivers
• Data collection, measurement, analysis

Intervention Type: Epidemiology and Surveillance Counseling

Summary: Special Statement/Critique of quality metrics.

Abstract: Hospital readmission is considered a core measure of quality in healthcare. Readmission soon after hospital discharge can result from suboptimal care during the index hospitalization or from inadequate systems for postdischarge care. For many conditions, readmission is associated with a high rate of serious morbidity and potentially avoidable costs. In obstetrics, for postpartum care specifically, hospitals and payers can easily track the rate of maternal readmission after childbirth and may seek to incentivize obstetricians, maternal-fetal medicine specialists, or provider groups to reduce the rate of readmission. However, this practice has not been shown to improve outcomes or reduce harm. There are major concerns with incentivizing providers to reduce postpartum readmissions, including the lack of a standardized metric, a baseline rate of 1% to 2% that is too low to accurately discriminate between random variation and controllable factors, the need for risk adjustment that greatly complicates rate calculations, the potential for bias depending on the duration of the follow-up interval, the potential for the "gaming" of the metric, the lack of evidence that obstetrical providers can influence the rate, and the potential for unintended harm in the vulnerable postpartum population. Until these problems are adequately addressed, maternal readmission rate after a childbirth hospitalization currently has limited utility as a metric for quality or performance improvement or as a factor to adjust provider reimbursement.

Keywords: postpartum readmission; quality metric; maternal-fetal medicine; quality of care; SMFM

Topic(s):

• Quality, performance, and outcome indicators
• Clinical consensus, guidelines, protocols

Intervention Type: Policy Development and Enforcement Consultation

Summary: Study examining the validity of an assessment tool.

Abstract: Background: Australian clinical practice guidelines support comprehensive psychosocial assessment as a routine component of maternity care.

Aim: To examine the concurrent and predictive validity of the Antenatal Risk Questionnaire-Revised (ANRQ-R) when used across the perinatal period.

Methods: Women completed the ANRQ-R and a diagnostic reference standard (SAGE-SR) in the second and third trimesters and at 3-months postpartum. ANRQ-R test performance for cut-off scores at each time-point was assessed using Receiver Operator Characteristic (ROC) analysis.

Findings: Overall sample sizes were N=1166 (second trimester), N=957 (third trimester) and N=796 (3-month postpartum). 6.5%, 5.6% and 6.2% of women met SAGE-SR criteria for any depressive or anxiety disorder at these time-points ('cases'), respectively. ROC analysis yielded acceptable areas under the curve (AUC) when the ANRQ-R was used to detect current (AUC=0.789-0.798) or predict future (AUC=0.705-0.789) depression or anxiety. Using an example cut-off score of 18 or more, the ANRQ-R correctly classified 72-76% of concurrent 'cases' and 'non-cases' (sensitivity=0.70-0.74, specificity=0.72-0.76) and correctly predicted 74-78% of postnatal 'cases' and 'non-cases' (sensitivity=0.52-0.72, specificity=0.75-0.79). Completion of the ANRQ-R earlier in pregnancy yielded greater positive likelihood ratios for predicting depression or anxiety at 3-months postpartum (cut-off ≥18: second trimester=3.8; third trimester=2.2).

Conclusion: The ANRQ-R is a structured psychosocial assessment questionnaire that can be scored to provide an overall measure of psychosocial risk. Cut-off scores need not be uniform across settings. Such decisions should be guided by factors including diagnostic prevalence rates, local needs and resource availability.

Keywords: Psychosocial assessment, perinatal, antenatal risk, questionnaire, validity

Topic(s):

• Universal screening tools and billing codes
• Data collection, measurement, analysis

Intervention Type: Screening Epidemiology and Surveillance

Summary: Quality improvement project; abstract states increase in completed screenings and consultations but lacks specific pre/post figures.

Abstract: Introduction: Perinatal mood and anxiety disorders are the most common complication during pregnancy and postpartum. Screening, diagnosis, and treatment for these disorders are inhibited by limited mental health resources for patients and health care providers, lack of provider training, and time constraints. Systematic screening combined with onsite mental health consultation is an evidence-based method to increase timely diagnosis and treatment. The purpose of this quality improvement project was to promote and improve onsite mental health consultations through the implementation of a systematic screening guideline.

Process: The systematic screening guidelines included administration of the Patient Health Questionnaire-9 at the perinatal intake visit, the Edinburgh Perinatal Depression Scale between 28 and 32 weeks' gestation and again between 2 and 8 weeks postpartum. The guidelines included onsite mental health consultations for eligible women. Screening rates, attended onsite mental health consultations, and health care provider satisfaction and feedback surveys were collected over a 3-month period, before and after guideline implementation.

Outcomes: Perinatal mood and anxiety disorder screening rates were significantly increased from 24.9% to 64.2% (P < .001) at the perinatal intake visit and in the third trimester from 0.3% to 32.8% (P < .001) with the implementation of a systematic screening guideline. Onsite mental health consultations significantly increased from 7.2% to 15.2% (P < .001). Perinatal care providers (n = 9, 100%) were satisfied with the screening guideline and reported that it added 5 minutes or less to their office visits.

Discussion: The implementation of a systematic perinatal mood and anxiety disorder screening guideline increased completed screenings in the perinatal period and increased the number of attended onsite mental health consultations. Systematic screening combined with onsite mental health consultation is a successful way to identify at-risk women and offer critical and convenient maternal mental health care without increasing the burden on perinatal care providers.

Keywords: Perinatal mood disorders, anxiety, screening, mental health, quality improvement

Topic(s):

• Universal screening tools and billing codes
• Promising models of care and best practices

Intervention Type: Screening Education and Promotion

Summary: Evaluation of institutional bundle implementation; lacks specific quantified change rates for hemorrhage/transfusion in the abstract.

Abstract: Objective: In 2015, a multidisciplinary consensus bundle of recommendations for the anticipation and management of postpartum hemorrhage was published. Our goal was to evaluate the successes and failures of our institutional bundle implementation process.

Study design: An interdisciplinary committee was created to facilitate bundle implementation. All components of the bundle were addressed with cross-disciplinary teaching between stakeholders on the obstetrics units. Tools were built in the electronic medical record to facilitate bundle components of risk stratification, quantitative blood loss calculation, and stage-based hemorrhage management. Bundle components were individually evaluated for acceptability and sustainability. Overall rates of hemorrhage and transfusion from the periods 1 year before and after bundle implementation were also evaluated.

Results: Readiness bundle components were successfully implemented, although simulation drills demonstrated limited sustainability. Recognition components were mixed: risk stratification was successfully and sustainably implemented while quantitative blood loss met resistance and was ultimately discontinued as it did not clinically perform superiorly to estimated blood loss. Among response and reporting elements, patient level support and team debriefing were noted as particular deficiencies in our program.

Conclusion: The postpartum hemorrhage patient safety bundle provided concrete individual elements, which overall improved the success of a stratified program implementation. Multiple deficiencies in acceptability and sustainability were uncovered during our process, particularly concerns about quantitative blood loss implementation and team communication skills.

Key points: · Supply readiness and protocol development were "quick wins.". · Culture change elements included recognition, response, and communication.. · Dedicated champions and electronic medical record tools improved sustainability.. · Poor acceptability and lack of improved outcomes led to element failure..

Keywords: Postpartum hemorrhage, patient safety, bundle, implementation, lessons learned

Topic(s):

• Quality, performance, and outcome indicators
• Promising models of care and best practices

Intervention Type: Policy Development and Enforcement Direct Care

Summary: Methodology/Validation study for a new quality assessment tool.

Abstract: Background: Quality maternity care is known to improve a range of maternal and neonatal outcomes. The Lancet Series on Midwifery's Quality Maternal and Newborn Care (QMNC) Framework is a high‐level synthesis of the global evidence on quality maternity care. Initial qualitative work demonstrated the Framework's adaptability in evaluating service user and provider perceptions of the quality of maternity care. However, evaluating services at scale requires a survey instrument. This paper reports the validation of the QMNC Framework index (QMNCFi), a five‐part survey for the evaluation of maternity care across diverse settings. Methods: International online English language survey of women who had given birth in the previous year in Australia, Ghana, India and the United Kingdom (UK). It was distributed through service user networks (UK and Australia) and at postnatal clinics (Ghana and India). All forms were completed online. Test–retest was conducted to assess reliability. Results: Five hundred and forty mothers completed the survey (Australia 136; Ghana 131; India 153; UK 120). Construct validity: Cronbach's α in 12 of the survey's 13 sections ranged from 0.795 to 0.986; for the remaining section the alpha was 0.594. Reliability: 55 participants completed the QMNCFi a second time. Intraclass correlation coefficient results ranged from 0.657 to 0.939 across the 13 sections. Field researchers in Ghana and India reported that the survey was easily understood and completed. Conclusion: This survey has shown that, across diverse contexts, the QMNCFi is a valid, reliable, and comprehensive tool for measuring service user perceptions of the quality of care over time.

Keywords: Scales Evaluation ; Maternal Health Services ; Quality of Health Care Evaluation ; Instrument Validation ; Human ; Surveys ; Validation Studies ; Descriptive Statistics ; Data Analysis Software ; Midwifery ; Male ; Female ; Adult ; Adult: 19-44 years ; Male ; Female

Topic(s):

• Quality, performance, and outcome indicators
• Data collection, measurement, analysis

Intervention Type: Screening Case Management

Summary: Retrospective cohort study analyzing variation in prescribing rates and size across providers/hospitals (observational).

Abstract: Introduction: Our aim was to evaluate variation in opioid prescribing rates and prescription size following childbirth across providers and hospitals.

Methods: This retrospective cohort study analyzed claims data from a single-payer Preferred Provider Organization from June 2014 to May 2019 in 84 hospitals in a statewide quality collaborative. All patients aged 12-55 years, undergoing childbirth, with continuous enrollment in pregnancy were included. The primary outcome was the predicted rate of postpartum opioid fills from 7 days before birth to 3 days after discharge. Secondary outcomes included postpartum opioid prescription size in oral morphine equivalents, a standardized measure that includes the number of pills prescribed times the strength of the medication. Multilevel regression models accounted for clustering. We calculated attributable variation in opioid fills using the intraclass correlation coefficient.

Results: Of 41,427 births, 15,459 patients (37.2%) filled a postpartum opioid prescription (vaginal, 4,624/27,536 [16.8%]; cesarean, 10,835/13,891 [78.0%]). The median postpartum prescription size was 150 oral morphine equivalents (interquartile range [IQR], 30) (vaginal, 135; [IQR, 45]; cesarean, 150 [IQR, 75]). In adjusted models, the rates of opioid prescribing after vaginal birth differed from cesarean birth (vaginal median, 12.1% [range, 1.1%-60.0%]; cesarean median, 80.4% [range, 43.6%-90.2%]). More variation in postpartum opioid fills was attributable to providers and hospitals for vaginal (provider, 29%; hospital, 24%) than cesarean birth (provider, 8%; hospital, 6%). Variation in prescription size was driven by providers for vaginal birth (provider, 27%; hospital, 6%) and providers and hospitals for cesarean birth (provider, 29%; hospital, 21%).

Conclusions: Across a statewide quality collaborative, variation in postpartum opioid prescribing is attributable to providers and hospitals. Future efforts at the provider and hospital levels are needed to implement best practices for postpartum opioid prescribing.

Keywords: Opioid prescribing, vaginal birth, cesarean, variation, analysis

Topic(s):

• Behavioral/mental health services and substance use
• Quality, performance, and outcome indicators

Intervention Type: Epidemiology and Surveillance