Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana.

BACKGROUND: Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra. METHODS: This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT). RESULTS: Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility. CONCLUSIONS: This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.

Evaluation of two newborn resuscitation training strategies in regional hospitals in Ghana.

AIM: In Ghana, institutional delivery has been emphasized to improve maternal and newborn outcomes. The Making Every Baby Count Initiative, a large coordinated training effort, aimed to improve newborn outcomes through government engagement and provider training across four regions of Ghana. Two newborn resuscitation training and evaluation approaches are described for front line newborn care providers at five regional hospitals. METHODS: A modified newborn resuscitation program was taught at the Greater Accra Regional Hospital (GARH) and evaluated with real-time resuscitation observations. A programmatic shift, led to a different approach being utilized in Sunyani, Koforidua, Ho and Kumasi South Regional Hospitals. This included Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) training followed by objective structured clinical examinations (OSCE) with manikins at fixed intervals. Data was collected on training outcomes, fresh stillbirth and institutional newborn mortality rates. RESULTS: Training was conducted for 412 newborn care providers. For 120 staff trained at GARH, resuscitation observations and chart review found improvements in conducting positive pressure ventilation. For 292 providers that received HBB and ECEB training, OSCE pass rates exceeded 90%, but follow-up decreased from 98% to 84% over time. A decrease in fresh stillbirth and institutional newborn mortality occurred at GARH (p â€‹< â€‹0.05), but not in the other four regional hospitals. CONCLUSION: Newborn resuscitation training is warranted in low-resource settings; however, the optimal training, monitoring and evaluation approach remains unclear, particularly in referral hospitals. Although, mortality reductions were observed at GARH, this cannot be solely attributed to newborn resuscitation training.

Addressing the third delay: implementing a novel obstetric triage system in Ghana.

Institutional delivery has been proposed as a method for reducing maternal morbidity and mortality, but little is known about how referral hospitals in low-resource settings can best manage the expected influx of patients. In this study, we assess the impact of an obstetric triage improvement programme on reducing hospital-based delay in a referral hospital in Accra, Ghana. An Active Implementation Framework is used to describe a 5-year intervention to introduce and monitor obstetric triage capabilities. Baseline data, collected from September to November 2012, revealed significant delays in patient assessment on arrival. A triage training course and monitoring of quality improvement tools occurred in 2013 and 2014. Implementation barriers led to the construction of a free-standing obstetric triage pavilion, opened January 2015, with dedicated midwives. Data were collected at three time intervals following the triage pavilion opening and compared with baseline including: referral indications, patient and labour characteristics, waiting time from arrival to assessment and the documentation of a care plan. An obstetric triage improvement programme reduced the median (IQR) patient waiting time from facility arrival to first assessment by a midwife from 40 min (15-100) to 5 min (2-6) (p<0.001) over the 5-year intervention. The triage pavilion enhanced performance resulting in the elimination of previous delays associated with the time of admission and disease acuity. Care plan documentation increased from 51% to 96%. Obstetric triage, when properly implemented, reduced delay in a busy, low-resource hospital. The implementation process was sustained under local leadership during transition to a new hospital.

The introduction of a midwife-led obstetric triage system into a regional referral hospital in Ghana.

OBJECTIVE: to introduce and embed a midwife-led obstetric triage system in a busy labour ward in Accra, Ghana to improve the quality of care and to reduce delay. DESIGN: the study utilized a participatory action research design. Local staff participated in baseline data collection, the triage training course design and delivery, and post-training monitoring and evaluation. SETTING: a regional referral hospital in Accra, Ghana undertaking 11,032 deliveries in 2012. PARTICIPANTS: all midwives and medical staff. MEASUREMENTS: measurements included maternal health outcomes, observations of labour ward activity, structured assessments of midwife actions during admission, waiting times, focus group discussions, and learning needs assessments which informed the course content. During training, two quality improvement tools were developed; coloured risk acuity wristbands and a one page triage assessment form. Participants measured compliance and accuracy in the use of these tools following course completion. FINDINGS: initially, no formal triage system was in place. The environment was chaotic with poor compliance to existing protocols. Sixty-two midwives received triage training between 2013 and 2014. Two Triage Champions became responsible for triage implementation, monitoring and further training. Following training, the 'in-charge' midwives recorded a cumulative average of 83.4% of women wearing coloured wristbands. A separate audit by the Triage Champions found that 495/535 (93%) of the wristbands were correctly applied based on the diagnosis. Quarterly monitoring of the triage assessment forms by Kybele trainers, showed that 92% recorded the risk acuity colour, 85% a 'working diagnosis' and 82% a 'plan.' Median (interquartile range) waiting times were reduced from 40 (15-100) to 29 (11-60) minutes (p = 007). Twenty of 25 of the staff reported that the wristbands were helpful. CONCLUSIONS: an interactive triage training course led to the development of a triage assessment form and the use of coloured patient wristbands which resulted in delay reduction and improved quality of maternity care.

Transforming Maternal and Neonatal Outcomes in Tertiary Hospitals in Ghana: An Integrated Approach for Systems Change.

OBJECTIVE: In Ghana, regional referral facilities by design receive a disproportionate number of high-risk obstetric and neonatal cases and therefore have mortality rates higher than the national average. High volumes and case complexity result in these facilities experiencing unique clinical, operational, and leadership challenges. In order to improve outcomes in these settings, an integrated approach to strengthen the overall system is needed. METHODS: Clinical skills strengthening, quality improvement training, and leadership skill building have all been used to improve maternal and neonatal outcomes with some degree of success. We present here a customized model tailored to the particular context of tertiary referral hospitals that develops these three skills simultaneously, so that the complex interaction between clinical conditions, resource constraints, and organizational issues that affect the lives of mothers and babies can be considered together. This model uses local data to identify the drivers of poor maternal and neonatal outcomes and creates an integrated training package to focus on approaches to addressing these drivers. Based on this training, quality improvement projects are introduced to change the appropriate clinical or operational processes, or to strengthen organizational leadership. RESULTS: In testing in one of the largest referral hospitals in Ghana, the model has been well received and has improved performance in several cross-cutting areas affecting the quality of maternal and neonatal care, such as triage, patient flow, and NICU hand hygiene. CONCLUSION: An integrated approach to systems strengthening in referral hospitals holds much promise for improving outcomes for mothers with high-risk pregnancies and babies in Ghana and in other low-resource settings.

Objectif : Au Ghana, les établissements de recours régionaux reçoivent, de par leur nature, un nombre disproportionné de cas obstétricaux et néonataux exposés à des risques élevés; par conséquent, ces établissements comptent des taux de mortalité plus élevés que la moyenne nationale. Les volumes élevés et la complexité des cas font en sorte que ces établissements ont à faire face à des défis cliniques, opérationnels et de direction particuliers. Dans de telles situations, l'amélioration des issues nécessite la mise en œuvre d'une approche intégrée visant à renforcer le système dans sa globalité. Méthodes : Le renforcement des compétences cliniques, la formation en amélioration de la qualité et la consolidation des compétences propres au leadership sont des outils qui ont tous été utilisés, avec un certain succès, pour améliorer les issues maternelles et néonatales. Nous présentons ici un modèle, ayant été adapté au contexte particulier des hôpitaux de recours tertiaires, qui favorise la mise en œuvre simultanée de ces trois outils, de façon à ce que l'interaction complexe entre les conditions cliniques, les contraintes en matière de ressources et les facteurs organisationnels qui affectent la vie des mères et des enfants puisse être envisagée dans son ensemble. Ce modèle utilise des données locales pour identifier les éléments associés à l'obtention de piètres issues maternelles et néonatales, pour ensuite créer un programme intégré de formation axé sur des approches permettant d'aborder ces éléments. En fonction de ce programme de formation, des projets d'amélioration de la qualité sont mis en œuvre pour modifier les processus cliniques ou opérationnels appropriés, ou pour renforcer le leadership organisationnel. Résultats : Dans le cadre de sa mise à l'essai au sein de l'un des plus importants hôpitaux de recours du Ghana, ce modèle a été bien reçu et a permis une amélioration du rendement dans plusieurs domaines transsectoriels affectant la qualité des soins maternels et néonataux, comme le triage, le roulement des patientes et l'hygiène des mains en UNSI. Conclusion : La mise en œuvre d'une approche intégrée envers le renforcement des systèmes au sein des hôpitaux de recours s'avère fort prometteuse pour l'amélioration des issues chez les mères connaissant des grossesses exposées à des risques élevés et les nouveau-nés du Ghana et d'autres milieux ne disposant que de faibles ressources.