Advanced audit: A criteria based audit of the management of severe hypertension

Setting

Delivery suite of Mulago Hospital, a large government tertiary referral hospital in Kampala, Uganda.

Standard setting and data collection

A local expert panel developed standards for the management of severe pre-eclampsia. Management practices were evaluated against standards, and recommendations developed and implemented. A repeat audit was conducted 6 months later.

Standards

• Patients with severe pre-eclampsia should be seen by a doctor within 1 hour of arrival and by a specialist within 2 hours.

• Antihypertensive treatment should be started within 20 minutes of diagnosis.

• Urine analysis should be done within 2 hours of arrival.

• Blood pressure should be monitored every 30-60 minutes when the diastolic blood pressure is ³ 110 mm Hg.

• The fetal heart rate should be monitored every 30 minutes when the diastolic blood pressure is ³ 110 mm Hg.

• When eclampsia occurs magnesium sulphate should be administered.

• Full blood count with renal and liver function tests should be done in the first 24 hours if delivery is not immediately planned.

• Corticosteroid therapy should be given in all pregnancies between 28 and 34 weeks gestation.

• Hypertensive triage should be introduced at the labour ward reception desk.

• Two more blood pressure machines should be acquired, and one fixed to the wall in the admission room.

• Urine dipsticks should be purchased and split in half before release (to increase number of tests).

• A protocol for corticosteroid use should be displayed and the appropriate drugs bought.

• Charts for recording blood pressure and fetal heart rate should be drawn by hand onto file paper at the time of admission. New forms should be produced when financial resources allow.

• Management guidelines for severe pre-eclampsia should be displayed on labour ward.

• The "gap in care" that occurred during the morning handover meeting should be covered by the intern on duty.

• A director of labour ward was appointed. The director subsequently reorganised the staffing on labour ward, giving each member a specific role in the management of emergencies.

• A fundraising committee was established to raise funds for the drugs and equipment in the recommendations above.

• The hospital director was lobbied to increase staffing on the labour suite.

The initial audit showed that most standards were rarely achieved. A number of changes were made: additional supplies were purchased after a fundraising effort, guidelines were produced, labour ward procedures were streamlined, and two extra midwives were deployed.

In the re-audit there were improvements in all areas: initiation of antihypertensive treatment within 20 minutes improved from 30% to 58% (odds ratio 3.21 (95% confidence interval 1.26 to 8.16), P=0.024); the number of women in whom urine analysis was done within the first 2 hours increased from 33% to 63% (odds ratio 3.45 (1.40 to 8.52), P=0.012); specialist review of patients within 2 hours improved from 20% to 45% (odds ratio 3.75 (1.41 to 10.01), P=0.013); monitoring of the fetal heart improved from 0% to 26% (P<0.0021); the proportion of women with adequate blood pressure monitoring improved from 7% to 45% (11.01 (2.94 to 41.28), P=0.0002); and the prescription and administration of corticosteroids in preterm pregnancies increased from 9% to 100% (P=0.03).

Simplified audit: An audit of intraoperative monitoring

Setting

Gombe Hospital, a small district general hospital in rural Uganda with four doctors. Operations were conducted with ketamine and local anaesthetic administered by the surgeon.

Standard setting and data collection

The absence of any intraoperative monitoring had been suggested as a problem in discussions after some recent intraoperative deaths. No data were formally collected.

Root cause analysis

• There was no qualified anaesthetist in the hospital because, although one had been recruited, he had refused to come to such a rural area, and because no further attempts had been made to recruit one.
• There was no sphygmomanometer or stethoscope available in theatre because there had been no requests for one by theatre staff because they were not aware that it was needed.
• There were inadequate numbers of staff to conduct the monitoring because there was a shortage of nursing staff in the hospital because not enough had been recruited regionally.
• There was no basic knowledge of what should be done because the person in charge of theatre had not received formal training in theatre work, and because there were no guidelines available.

• A letter should be written to the doctor in charge of the hospital requesting a stethoscope and sphygmomanometer.
• A letter should be written to the director of the district health services requesting the deployment of an anaesthetist to the facility.
• One of the doctors would consult a book on basic anaesthesia and give a teaching session on intraoperative monitoring.
• A set of guidelines for intraoperative monitoring would be drawn up and displayed in theatre.
• Doctors would request one of the theatre staff to take the blood pressure and pulse of the patient during surgery.

After the letter to the director of the district health services, it was decided to train two local nurses as nurse anaesthetists. A stethoscope and sphygmomanometer were found locked in a cupboard in theatres, and these were released for use. No anaesthetic textbook was available locally, but one was bought and used to prepare guidelines and a short training course.

A re-audit will be conducted once the local nurse anaesthetists have arrived.