Evaluation of a quality improvement cycle intervention in the provision of PMTCT at a regional hospital

Van Niekerk, Elizabeth C (2013-12)

Thesis (MMed)-- Stellenbosch University, 2013.

Thesis

ENGLISH ABSTRACT: The vast majority of new Human Immunodeficiency Virus (HIV) infections in infants and young children occur through mother-to-child-transmission (MTCT), either during pregnancy, labour or delivery or by breastfeeding. Without access to perinatal MTCT (PMTCT) programmes approximately 30% of all babies born annually will be infected with HIV. OBJECTIVES The aim was to implement and audit a quality improvement cycle at the Worcester Obstetric Unit, which comprises of Worcester Hospital, a regional hospital in the Western Cape Province and its level one midwife obstetric Unit (MOU), in order to improve the quality of the PMTCT programme. The intervention included the implementation of easy changes and tools in the Antenatal Clinic, Infectious Diseases Clinic and Labour ward. METHODS The files and antenatal records of all HIV positive patients and patients with an unknown HIV status, who delivered at the Worcester Obstetric Unit during January, February and March of 2010 and 2011, were reviewed. All HIV negative patients and patients that had stillbirths and miscarriages were excluded. The pre-interventional findings of 2010 were compared with the post-interventional findings of 2011. RESULTS At the Worcester Obstetric Unit, for the study time period, there were 907 deliveries in 2010, of which 102 (11.2%) patients were HIV positive and 4 (0.4%) had an unknown HIV status compared to 2011, with 865 deliveries of which 108(12.5%) patients were HIV positive and no patients had an unknown HIV status. Significantly more patients were diagnosed with HIV before they fell pregnant than during pregnancy in the 2011 group, when compared with the 2010 group. A CD4 count was done on 94% of patients who were newly diagnosed with HIV and those with an unknown CD4 count result in the 2010 group, compared to 92% in 2011. There was a significant improvement after the intervention in the time it took from when blood was drawn for a CD4 count until the result was followed up, the median time decreased from 34 to 8 days (p=0.000001). Significantly more patients qualified for highly active antiretroviral therapy (HAART) after the guidelines were changed and the CD4 cut off was increased to 350 cells/l (p=0.001). Prior the intervention 18 patients did not receive the correct management before delivery due to preventable reasons, compared to one at the MOU. After the intervention this decreased significantly to only one patient at Worcester Hospital and none at the MOU (p=0.000001). Before the intervention adherence to the PMTCT protocol at the MOU was significantly better than at the hospital (p=0.0005) and after the intervention there was no significant difference (p=1.0). CONCLUSION Although the audit and quality improvement cycle was performed at a single hospital, with specific changes geared towards their needs, the basic principles can be applied to any Unit in the country providing a PMTCT service. Educating staff, creating awareness and reminding staff of the basic principles of PMTCT, implementing small changes and streamlining processes and setting specific goals or timelines, can lead to significant improvements in care, which ultimately will lead to a decrease in PMTCT of HIV and HIV related maternal and infant morbidity and mortality.

AFRIKAANSE OPSOMMING: Die oorgrote meerderheid (>90%) van nuwe Menslike Immuniteitsgebreksvirus (MIV) infeksies in babas en jong kinders vind plaas deur middel van moeder-na-kind-oordrag, hetsy gedurende swangerskap, die kraamproses of borsvoeding. Sonder toegang tot perinatale voorkomingsprogramme (PMTCT) sal ongeveer 30% van alle babas jaarliks met MIV geïnfekteer word. DOELWITTE Die doel van die studie was om ‘n gehalteverbeteringsiklus by die Worcester Verloskunde Eenheid, wat bestaan uit Worcester Hospitaal, 'n streekshospitaal in die Wes-Kaapprovinsie en sy vlak een vroedvrou verlossingseenheid (VVE), te implementer en daarna te oudit, om sodoende die gehalte van die PMTCT-program te verbeter. Die intervensie het bestaan uit die implementering van eenvoudige veranderinge en prosesse in die voorgeboortekliniek, infeksiesiekte-kliniek en kraamsaal. METODES Die lêers en voorgeboorte rekords van alle MIV-positiewe pasiënte en pasiënte met 'n onbekende MIV-status, wat gedurende Januarie, Februarie en Maart van 2010 en 2011 verlos het by die Worcester Verloskunde Eenheid, is nagegaan. Alle MIV-negatiewe pasiënte en pasiënte met doodgebore babas en miskrame is uitgesluit. Die pre-intervensie bevindings van 2010 is vergelyk met die post-intervensie bevindings van 2011. RESULTATE By die Worcester Verloskunde Eenheid was daar 907 geboortes gedurende die studietydperk in 2010, waarvan 102 (11,2%) pasiënte MIV-positief was en 4 (0,4%) met ‘n onbekende MIV-status. In 2011 was daar 865 geboortes waarvan 108 (12,5%) pasiënte MIV-positief was en geen met 'n onbekende MIV-status. In die 2011-groep is beduidend meer pasiënte gediagnoseer met MIV voor as tydens swangerskap. In die 2010-groep is daar 'n CD4-telling gedoen vir 94% van nuut gediagnoseerde pasiënte en diegene met 'n onbekende CD4-telling, in vergelyking met 92% in 2011. Daar was 'n beduidende verbetering na die intervensie in die tyd wat dit geneem het vandat bloed getrek is vir 'n CD4-telling totdat die resultaat opgevolg is. Die mediane tyd het verminder vanaf 34 na 8 dae (p = 0.000001). Nadat die riglyne vir kwalifisering vir hoogs aktiewe antiretrovirale terapie (HAART) verander is na ‘n CD4 telling 350 selle/l het daar beduidend meer pasiënte gekwalifiseer vir HAART. By Worcester Hospitaal het 18 pasiënte voor die intervensie nie die korrekte behandeling intrapartum ontvang nie weens voorkombare redes, in vergelyking met slegs een pasiënt by die VVE. Na die intervensie was daar ‘n beduidende afname na slegs een pasiënt by Worcester Hospitaal en geen by die MOU (p = 0.000001). Voor die intervensie was die korrekte uitvoering van die PMTCT-protokol by die MOU beduidend beter as by die hospitaal (p = 0,0005) en na die intervensie was daar geen beduidende verskil (p = 1.0). GEVOLGTREKKING Alhoewel die oudit en gehalteverbeteringsiklus uitgevoer is by 'n enkele hospitaal, met spesifieke veranderinge gerig tot hul behoeftes, kan die basiese beginsels toegepas word in enige eenheid in die land wat ‘n PMTCT diens verskaf. Opvoeding van personeel en bewusmaking rakende die basiese beginsels van PMTCT, klein veranderinge en die vaartbelyning van prosesse by die voorgeboorte klinieke en die stel van spesifieke doelwitte of tydlyne, kan lei tot aansienlike verbeteringe in pasiënte sorg. Dit sal uiteindelik lei tot 'n afname in die MIV oordrag van moeder na kind, asook MIV-verwante morbiditeit en mortaliteit in moeders en kinders.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/85669
This item appears in the following collections: