key: cord-0736282-7f6o5ise
authors: Roberts, F.E.; Yeeles, H.; Marks, K.; Douglass, J.
title: P.97 Enhancing multidisciplinary communication in emergency obstetric surgery during the COVID 19 pandemic
date: 2021-06-09
journal: Int J Obstet Anesth
DOI: 10.1016/j.ijoa.2021.103095
sha: 7a2ce1bf8ea926c936f5cd298382429459730066
doc_id: 736282
cord_uid: 7f6o5ise

nan

Introduction: Risk factor identification and preoperative optimisation can reduce morbidity and mortality and is the accepted standard of care. The COVID-19 pandemic presented issues in providing quality and preoperative assessment (PA) for elective caesarean section (CS). We needed to balance best medical practice with ensuring safety of patients and staff. Although mobile technologies have facilitated remote provision of medical services, its applicability to PA remains unclear. 1 We hypothesised that virtual anaesthetic assessment could offer a high quality, safe alternative to in-person PA.

Methods: Following ethics approval we established evidence-based definitions for virtual assessment, and developed a virtual pathway to run with the in-person system. The team followed the 3-step Institute of Healthcare Improvement model. 2 We aimed for 100% of women scheduled for elective CS to be placed on the correct pathway by February 2021. We measured outcomes (number of patients correctly identified and referred to the anaesthetic clinic [AC]), and process measures (number of patients not referred, did not attend [DNA] rate, unanticipated surgery delays/cancellations). Measures including patient/ provider satisfaction and cost were assessed. We implemented plan-dostudy-act (PDSA) cycles (referral form for virtual and in-person assessment, equipment and video platform provision [WebEX], GDPR compliance, ethics, consent, documentation). The team executed the project in three phases, with Jan-Feb 2021 being our target for mainstream rollout of video PA. Patients who did not meet the criteria for virtual PA were assessed in person.

Results: Between July and December 2020, 1031 women were referred to the AC. 41% (419) were assessed virtually and 612 (59%) in person. Over 97% elective CS patients were referred. DNA rate was 9% for in-person assessment and 3% for virtual. There were no day of surgery cancellations or delays. Despite an initial cost in the set up of hardware there was a reduction in footfall by 41% and more effective utilization of resources. Patient and staff feedback surveys are ongoing however anecdotal feedback is positive in terms of ease of use and satisfaction with the assessment. Discussion: We have described the development and implementation of virtual PA for elective CS. Strengths of our project include excellent compliance by referring obstetricians, low DNA rate, and no cancellations/delays. We acknowledge limitations: lack of physical examination and pre-operative tests, questionable airway exam, possibility of confidentiality breach. Our project demonstrates the development of a safe, effective video anaesthetic consultation pathway. More research is needed to address some of the challenges presented by the virtual assessment of obstetric patients. Introduction: The COVID 19 pandemic has presented significant challenges to the delivery of safe, efficient care for emergency obstetric surgery. In particular donning airborne personal protective equipment (PPE) in a timely fashion and the associated barriers to communication in the operating theatre. Improvements to multi-disciplinary communication (MDT) has been identified in MBRRACE reports 1 as an area that is crucial in reducing maternal and fetal morbidity and mortality. We introduced a new "Emergency Pre-Brief" communication process for all obstetric surgical cases prior to transfer to theatre in May 2020 and evaluated feedback from an MDT staff survey about the impact of this change in practice on communication and patient care.

Methods: An "Emergency Pre-Brief" communication document was designed and introduced with MDT input through the labour ward forum. It included essential patient information: category of urgency, procedure type, indication for delivery/procedure, obstetric and medical complications, fetal concerns, allergies, abnormal blood results, G&S status, blood or cell salvage required, COVID swab result, type of anaesthetic, risk of GA conversion and PPE to be used. The brief takes place on labour ward, led by the theatre coordinator with members of the MDT before transfer to theatre. The coordinator returns to theatre to communicate the details to the team to ensure they are prepared for the correct anaesthesia and surgery, in the correct PPE and are aware of the concerns relating the case. In June 2020 a snap shot audit was completed to look at decision to delivery times for Category 1 CS to ensure standards are being upheld. We conducted an MDT staff survey in January 2021 to assess the impact of this change in practice.

Results: The Emergency Pre-Brief has been fully implemented in our clinical practice since May 2020. The decision-to-delivery snap shot audit for Category 1 CS ranged from 9-33 min. The MDT staff survey reported 87% of respondents agreed the pre brief had improved MDT communication, 80% reported a positive change to efficiency of theatre preparations and safe delivery of care, 74% reported improved postpartum surgical theatre efficiency. 84% reported improved mutual understanding of multi-speciality concerns.

Discussion: The COVID-19 pandemic has presented many challenges for obstetric services. We have shown the Emergency Pre-Brief process has improved communication and ensured timely preparations for surgery. It is an example of effective MDT working and is something that can be used by other obstetric units, particularly in light of essential actions in the Ockenden report 2 of staff working together in partnership. Introduction: The Mercy Hospital for Women has recently introduced enhanced recovery after surgery (ERAS) for caesarean section. In auditing our practice before and after introduction of this program and discovered a key area for quality improvement in our practice around stewardship of our post-discharge analgesia, particularly around simple analgesia. We wished to devise a novel method of tackling this issue.

Methods: We consulted all stakeholders involved in patient analgesia management; the acute pain service, anaesthetists, pharmacy and the domiciliary services in the development of a pain medication tracker for patients to use on discharge. This was designed, approved, and trialled on a number of test-case patients.

Results: The pain medication tracker has been deemed to be useful in both the education of patients by the post-operative pain service in The Mercy Hospital for Women and by the patients in the at-home setting. It has been introduced by the Acute Pain Service as routine documentation to good effect. We plan to formally audit the results of the pain medication tracker.

Discussion: While most research in the area of discharge medication non-compliance is in geriatric populations and chronic diseases requiring medications. 1,2 we know that it is a universal problem. In this instance it was felt that the issue was multifactoral in nature. Issues included poor patient education, inconsistent availability and attendance at antenatal classes, time constraints around individual education of patients by the post-operative acute pain team and domiciliary midwifery team. Neuraxial opioids as well as regular simple analgesics are the mainstay of post-operative analgesic management and the best way to reduce systemic opioid intake. 3 We wished to improve patients' understanding and compliance with taking analgesia after discharge. We know that simple interventions such as visual aids can improve patient understanding and medication compliance. 2 Feedback from staff and patients following the introduction of this aid was very positive and led to the introduction of this pain medication tracker being used universally for all caesarean section patients on discharge. Introduction: Arterial pulse waveform analysis provides beat-tobeat monitoring of maternal cardiac output and is increasingly utilised in the management of obstetric patients. Common indications include preeclampsia, haemorrhage, obesity or cardiac disease. Such patients would ordinarily be managed in a high dependence or critical care area and 18% of women cared for in our obstetric high dependency unit required invasive arterial monitoring. We observed varying degrees of comfort amongst midwifery staff on managing arterial lines and sought to formally assess this.

Methods: An anonymous survey was sent to 67 midwives in our maternity unit across a two-week period in November 2020. We asked five questions regarding confidence in handling of arterial lines (Likert-type scale) and two in response to a series of proposed interventions. After identifying a service need, we designed a poster and distributed this both in visible locations on labour ward and online. We followed this with an educational package and drop-in sessions and repeated the survey in January 2021.

Results: 46% (31) of midwives completed our initial survey. Following a poster campaign and drop-in sessions, 36% (24) of midwives completed a follow-up survey. 92% (22) had reviewed our poster and all found it useful. 18 midwives attended a drop-in session, all of whom found it useful. All assessed areas of arterial line care improved.

Midwife self-reported comfort with arterial-lines Discussion: Arterial lines are integral in management of critically-ill obstetric patients and demand high acuity nursing care. The Enhanced Maternal Care Guidelines include comprehensive statements regarding arterial line care. 1 With the low frequency of individual midwives encountering an arterial line, attrition of skills is likely. Our goal is to empower midwives with educational resources to build on and maintain their skills and confidence. Our poster has been well-received and circulated to all midwives, placed in high visibility areas in labour ward and in the midwifery reference handbook in the high dependency unit. Educational sessions were challenging to coordinate during the COVID-19 pandemic so we are now moving to a virtual platform. We hope to capitalise on this significant improvement in midwifery confidence levels in arterial line management, but also to continue to foster

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