Improving the Patient Journey for Mothers having an Elective Caesarean

Improving the Patient Journey for Mothers having an Elective Caesarean

Nepean Hospital established an Obstetric Pre-anaesthetic Assessment Clinic (OPAC) for high-risk obstetric patients and those undergoing an elective caesarean section. Anaesthetists at the clinic assess the patient and explain anaesthetic procedures in a way that allows patients to give informed consent.

Aim

• To ensure 80 per cent of all elective caesarean patients are assessed in an OPAC by an anaesthetist within three months, and 95 per cent within six months.
• To ensure all pregnant mothers are provided with information about regional analgesia and anaesthesia through written and audio-visual patient education, within 12 months of opening the pre-operative clinic.

Benefits

• Allows clinicians to assess patients in a calm and supportive environment.
• Provides information to patients in a clinic environment rather than in the operating theatre before surgery.
• Reduces the time taken to assess patients.
• Maximises the use of operating theatre and anaesthetist time.
• Improves patient safety by reducing the risk of missing information.
• Educates patients about their anaesthetic options, so they can provide informed consent.
• Allows patients to view patient education videos in the comfort of their home.

Background

Prior to the project, there was no OPAC available for patients undergoing elective caesarean section at Nepean Hospital. Patients were seen by the obstetric team and then booked directly into the operating theatre for surgery. This included those with pregnancy-induced hypertension, gestational diabetes and other medical and psychological issues. Only very high-risk obstetric patients, such as those with cardiac disease or a body mass index over 40, were assessed by an anaesthetist before the day of surgery.

On the day of surgery, the anaesthetist would assess the patient and explain the procedure, including the risks and benefits of invasive spinal and epidural anaesthesia. This process took a significant amount of time and was conducted immediately prior to the anaesthetic, which meant the patient was often too anxious to absorb the information provided. Many patients also became frightened after hearing the risks.  This made it difficult to provide information and obtain informed consent from the patient, which is a legal requirement.¹

A survey conducted prior to the project also found that Antenatal Clinic midwives found it difficult to obtain anaesthetic advice for patients who had conditions such as pregnancy-induced hypertension, gestational diabetes, obesity and back problems, but were not considered in the very high-risk category. It was determined that an OPAC would improve patient safety and satisfaction, as well as provide care to Australian and international standards.

Implementation

• A satisfaction survey was conducted with obstetric patients, anaesthetists and obstetric midwives at Nepean Hospital. It showed that many first-time caesarean section patients and those who had problems with previous deliveries preferred a consultation with an anaesthetist prior to admission for surgery. Staff suggested it may increase theatre efficiency and would provide more robust anaesthetic assessment and planning.
• The Nepean Hospital OPAC was established on 4 August 2017. Initially, six sessions were held over a four-week period. The clinic is now held each Friday. It is run by anaesthetists and consists of consultations for all elective caesarean patients, to assess their suitability for anaesthesia and provide information on anaesthetic options, to gain informed consent in a relaxed and supportive environment.
• A patient information brochure was published in September 2017, to inform patients about their anaesthetic options, as well as the risks and benefits of each. The brochure was included in the pack provided to all elective caesarean patients and those who booked into the Obstetric Antenatal Clinic. It was developed in consultation with the Department of Anaesthetics, the Obstetric Special Interest Group of Anaesthetists, obstetricians, midwives and patients.
• Multiple in-service education sessions were held for midwives and administration staff, to help them understand the OPAC and associated paperwork.
• A patient referral process was developed, including an ‘Anaesthetist Seen’ stamp for patient cards, to help birthing suite midwives identify which patients had been to the OPAC , so they can transfer the paperwork from their notes to the folder taken to theatre.
• A patient education video is currently in development by the Nepean Hospital Multimedia Unit. This will be displayed in the waiting area of the Antenatal Clinic and shown in antenatal classes. A web link will also allow patients to view this video at home. Funding is being sourced for TV screens, a dedicated clinic computer for education and labour costs to set up the network in the Antenatal Clinic area.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

• May 2017: Project start
• May-July 2017: Initial surveys
• August 2017: Clinic established
• September 2017: Patient information brochures published
• October 2017: Follow-up survey
• February 2018: Video production started
• March-May 2018: Follow-up survey
• June 2018: Additional clinic sessions included in proposed budget

Implementation site

Antenatal Clinic, Nepean Hospital, NBMLHD

Partnerships

Clinical Excellence Commission. Clinical Leadership Program

Results

• 50 per cent of elective caesarean patients were assessed in the OPAC prior to surgery within three months of implementation. This was lower than the target of 80 per cent, due to a number of issues with patient referrals. These were identified in an audit completed at three months and rectified.
• 90 per cent of elective caesarean patients were assessed in the OPAC prior to surgery within six months, achieving the aim of the project. The next audit will review the capacity of the clinic, as it is now over-booked.
• Obstetric operating theatres are running more efficiently, booking more caesarean sections per session (based on availability).
• All pregnant mothers were provided with information about regional analgesia and anaesthesia, via the clinic and patient education brochure. The audio-visual education (video) is expected to be completed by the end of 2018.
• Patient follow-up surveys showed that satisfaction is high and patients are happy with the information provided in the clinic. The majority of patients have read the brochure by the day of surgery.

Lessons learnt

• A positive attitude is helpful when dealing with challenges such as funding, clinic space and negative staff.
• It is important to follow up on progress of delegated tasks, to ensure they are completed to a high standard.
• In-service education for midwives and administration staff is vital, to ensure they understand how to file charts, where to find them and how to transfer them to the folder used on the day of surgery.
• It is best to only book patients at 36-37 weeks gestation (unless an early delivery is required), so there is availability in the clinic for those who need a caesarean within two to three weeks.
• It is difficult to make time for drafting, editing, designing and approving patient information brochures, particularly when there is no time allocated to non-clinical work. Although it takes time, it is important not to give up.
• Good communication skills, tolerance and a good attitude towards all stakeholders is vital to the success of the project.
• Creating an education video is difficult but enriching. It is important to think carefully about getting the right people and settings in the video, with consent and approvals along the way.

References

NSW Ministry of Health. Consent to Medical Treatment – Patient Information. Policy Directive PD2005_406. North Sydney NSW: NSW Health; 2020.

Further reading

• Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines on Pre-Anaesthesia Consultation and Patient Preparation. Melbourne, VIC: ANZCA; 2017.
• Clinical Guidelines, UK Obstetric Anaesthetists Association
• Obstetric Anaesthetists’ Association. OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2013. London, England: The Association of Anaesthetists of Great Britain and Ireland; 2013.
• The American Society of Anaesthesiologists (ASA). Practice Guidelines for Obstetric Anaesthesia. USA: ASA; 2016.

Contact

Dr Manoj Mallikahewa
Senior Consultant Anaesthetist
Nepean Hospital
Nepean Blue Mountains Local Health District
Phone: 0408 769 590
manoj_mallikahewa@hotmail.com