Obstetric medicine is a time sensitive, unpredictable challenge for patients and practitioners. Skillsets unique to obstetric practice focus on the timely management of common emergency scenarios that are relatively unique to this patient population. In line with international practices, obstetric medicine is highly centralised in Dublin.1,2 However, patients present as unscheduled emergencies to settings that do not routinely provide obstetric care. In our hospital, these emergency presentations highlighted patient safety issues,which we addressed in this Quality Improvement (QI) project
In Tallaght University Hospital (TUH), several presentations of obstetric patients in extremis highlighted a critical medication safety issue. Consider the scenario presented on the right.
Following a post-partum haemorrhage (PPH) presenting to TUH, where several necessary uterotonics were not immediately available for use, a working group was established to evaluate the hospitals preparedness for obstetric patient’semergency presentations.
Examining this, we felt PPH and Pre-Eclampsia(PET) were 2 obstetric emergencies, whcih require specific pharmacotherapies and thus attention. Additionally, whilstthese emergencies are unique to the obstetric population, they often present in the
post-partum period, and thus to non-obstetric settings like ours.
Developing local policies and even low-tech innovations like ours, (a drug pack), requires a significant QI framework to ensure ideas and initiatives lead to actual implementation. Our path
to implementation is highlighted below for readers.
We developed local guidelines and information sheets to guide practioners, often unfamiliar with pregnant patients, on the management of PET and PPH. These guidelines, located within the drug packs, include local contact numbers, bleeps, door codes, additional pack locations as well as clinical advice on drug dosing information and administration. We choose to highlight how practitioners seek specialist advice, escalate management to theatre and activate the massive transfusion protocol to prompt practitioners to recognise the need for early escalation of care. These guidelines now accompany emergency drug packs made available in our emergency department (ED and theatre.
Additionally, we conducted a theatre simulation to educate nursing and anaesthesia staff on the availability of these packs and highlight specific management priorities. The inclusion of information about these packs in the induction booklet ensures new trainees are aware of their availability from day 1. Finally, we believe all Model 4 non-obstetric hospitals, and Model 4 sites with obstetrics but where obstetrics is not managed in the general theatre complex, should consider the introduction of these pack to their emergency department and theatre. Delays to management, especially delays in improving uterine tone in the case of PPH, can be devastating.
This project had a large working group, with direction from Dr Ciara-Jean Murphy, Consultant Anaesthesiologist, and significant input from Mary Coyle, Critical Care & Anaesthesiologist Lead Pharmacist, amongst others.
References available on request.
Written by Dr Tom Wall, Specialist Anaesthesiology Trainee
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