Achieving best practice in maternity care ... of services is based on the best clinical evidence, where .... The computer screening programme uses branching.
British Journal of Obstetrics and Gynaecology August 1997, Vol. 104, pp. 873-875
COMMENTARIES
Achieving best practice in maternity care The very mention of audit switches most clinicians off. Why should this be? Much effort has been expended on the introduction of clinical audit in the National Health Service. Obstetrics has long been acknowledged as having led the way in systematic, critical analysis of the quality of medical care. However, most papers on obstetric audit have provided little evidence of improved care resulting from such analysis’. They tend to be simple descriptions of performance which may or may not identify remediable deficiencies. Despite the fact that clinical mistakes and misjudgments are common, clinical audit is rarely used to identify these errors and generate corrective actions. We all tend to learn from our own mistakes but, clearly, it would be beneficial if we could also learn from the mistakes of others. Reluctance to expose errors or to have work evaluated by others is at the heart of the ineffectiveness of audit. The basis of this reluctance is understandable-the possibility of subsequent litigation, our diminution as authority figures and perhaps, perceived erosion of clinical autonomy. Within the field of maternity care, mistakes are made by all those who care for women, but most of the important mistakes are attributable to the actions of obstetricians,because of their central role in the clinical process. The first national audit in obstetrics, the Confidential Enquiries Into Maternal Deaths, has been concerned with fatal outcome. While being an important measure in the 1950s and 1960s and still important in the developing world, improved standards of care have resulted in far fewer maternal deaths and have led to calls for wider measures of adverse outcome. The recent Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993 demonstrated substandard care in nearly half of the reported cases2. One can only speculate to what extent such deficiencies are responsible for maternal morbidity. Furthermore such reports fail to include ‘near misses’: those cases with a satisfactory outcome but where care is inadequate. In addition, inadequate care can be detrimental to the fetus and neonate as reported in the recent Confidential Enquiry into Stillbirths and Deaths in Infancy3. Forty percent of deaths in normally formed babies during birth were linked to suboptimal care by obstetricians, midwives and general practitioners, all of whom were criticised for ignoring well established guidelines. 0 RCOG 1997 British Journal of Obstetrics and Gynaecologv
Inadequacies of audit in obstetric care may, in part, be explained by the over emphasis on ‘outcome’ as opposed to ‘process’. Outcome audit measures the effect of clinical activities on patients’ health and on patient satisfaction. Very often however, the outcome of an individual case is more a function of the severity of the underlying disease than the efficacy of clinical care-a poor outcome may occur despite impeccable care and a good outcome may be achieved despite poor care. Process audit serves a very different function: it is an audit of the appropriateness of clinical activities. Many actions or omissions can have serious consequences which may not be apparent in outcome audit. The evolution of evidence-based medicine and risk management emphasises the inadequacies of clinical audit. Evidence-based medicine, the emerging practice paradigm, is rapidly replacing the traditional practice paradigm ‘medicine by authority’. The practice of evidence-based medicine has been defined as “the integration of individual clinical expertise with the best available external clinical evidence from systematic resear~h”~. Resistance to change in personal practice is a significant obstacle to evidence-based change. Increased public awareness of the limitations of clinical medicine has emphasised the importance of clinical audit and the improvement of health care through the application of risk management. This signifies a new spirit in which clinicians and managers unite to “close the gap between the sciences of discovery and implementati~n”~. At a regional level, collaboration between purchasers and providers gives added impetus to this process. As far as maternity care is concerned, this collaboration involves contracts where the specification of services is based on the best clinical evidence, where there may also be a requirement for routinely collected data on performance and the formulation of clinical guidelines, all evidence-based6. Maternity care was fortunate to be the first speciality to have a systematic review of all clinical trials undertaken in the field. For over twenty years, Iain Chalmers and his colleagues at the National Perinatal Epidemiology Unit in Oxford have developed a register of controlled trials of maternity care. From this review of over 7000 trials came the major publication Effective Cure in Pregnancy and Childbirth, which is now available as The Cochrane Pregnancy and Childbirth Database7-”. In this, elements of care are classified as effective, 873
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promising, not proven or harmful. The scientific evidence is therefore available to support clinical practice. However, the evidence evolves so rapidly that it is difficult for clinicians always to be aware of the latest developments, and even when they are aware, there are substantial variations in clinical practice. It has become apparent that clear evidence of the benefit of an intervention is only the first step to achieving effective care, The discrepancy between knowledge and practice, although disturbing, should not be surprising. Clinical practice is determined by a large number of competing and interacting factors, of which knowledge of best practice is only one, for nonmedical factors may be important in motivating clinical actions. Even when clinicians wish to practice evidence-based care, they may not find this possible, for National Health Service constraints, limited facilities and pressure of time may all conspire in the prevention of the most effective treatments. Women themselves may be unwilling to accept interventions, even when these are well validated-like clinicians, their choices are not made on the basis of evidence alone. Medical science tries to improve the quality of medical care by seeking a better understanding of disease processes and developing new diagnostic techniques and treatments. The processes by which this understanding and these new treatments are incorporated into a system of health care has received less attention.Audit has not bridged the gap between research and practiceI2, and to achieve this, significant changes in the way undergraduates are taught, postgraduates are trained and doctors practice are required. Such changes would amount to a revolution in medicine, anathema to doctors, and so evolution is what we must hope for. Identifying and disseminating evidence is not enough. Research into methods of implementation is needed. We suggest three broad strategies: learning how to practice evidence-based medicine ourselves; considering evidence-based medicine summaries produced by others; and adopting evidence-based practice protocols developed by respected colleague^'^. Obstetric audit can lead the way. One way to promote effective health care (and discourage ineffective care) is to develop and implement clinical practice guidelines, which are systematically developed statements relating to specific clinical circumstances, to assist decisions about appropriate treatments. They are an attempt to distil a large body of evidence from randomised trials together with clinical experience into a convenient, readable form. Guidelines that are based upon solid scientific evidence and a reliable process for judging its value, could help clinicians cope with the excessive information they face. Clinical practice guidelines are intended to be used as an aid to making decisions, not a substitute.
Clinical practice guidelines can also provide a mechanism for evaluating the quality of care. In Leicester, a process clinical audit tool has been developed to help introduce best practice in maternity care. This audit tool is a qualitative clinical audit system originating From the United States. It has two purposes: to measure the quality of health care and the outcome for the woman; and to develop objective standards to measure performance and improvement. Using retrospective data abstracted from medical records, the audit tool identifies problems of clinical practice which are then subjected to peer review. Explicit screening criteria have been developed by a Medical Advisory Panel of eminent obstetricians. The criteria, based on medical science and accepted clinical practice, aim to define substandard care. The criteria encompass process and outcome simultaneously, taking into account prognostic factors such as severity of illness. An illustration of a typical application of this audit tool might be a review of a woman delivered by caesarean section. The process tool will generate specific interrogation ‘screens’ based on branch logic which will determine if the management process was flawed. When a flaw is identified, the notes will be flagged up for peer review with the stated reasons, under specific subsections, such as treatment selection: ‘Indication for caesarean section not substantiated’; outcomes to be reviewed: ‘Length of stay greater than 7 days after caesarean section’; documentation: anaesthesia ‘ASA risk level not recorded’; diagnostic workup: ‘Incomplete laboratory workup for severe pre-eclampsia’; treatment implementation: ‘Fetus not delivered within 24 hours of admission’. The medical record can be screened at several levels, starting at the general speciality level followed by screening for selected diagnoses and procedures that are medically important. Users may define additional hospital-specific screens of particular relevance to them. The computer screening programme uses branching logic, asking questions relevant to the case being assessed; for example, the number of questions in the caesarean section screen exceeds 2000, yet typically the computer asks around 30 during abstraction. This audit tool links the data with the criteria in order to screen cases for substandard care. The system defers to the obstetrician’s complex judgments regarding the quality of care. The system is periodically reviewed to ensure the criteria of substandard care are clinically current and reflect acceptable medical practice. The role of computers in audit had not been considered in any depth until recent times. The role of computers in the audit cycle offers an efficient way of measuring performance through data collection. While other computer systems provide conventional generic screens, this system has the potential to offer greater specificity for the case being analysed. 0 RCOG 1997 Br J Obstet Gynaecol 104, 873-875
COMMENTARIES
We believe that the potential for guidelines of clinical practice to influence the quality of patient care is considerable, particularly when associated with the process of audit, in the setting of evidence-based purchaserprovider contracts. Developing the capacity to apply evidence-based practice through clinical audit takes time, commitment and preparedness to learn. Nurturing these qualities within the NHS is a process and not an event. It requires collaboration among clinicians, purchasers and managers. Excellent medical practice should combine care and science-both are essential. The clinician who practices scientific medicine without compassion becomes a machine; the clinician who practices compassionate medicine without science becomes dangeroust4.The mechanisms whereby compassionate, scientific medicine is incorporated into maternity care in an effective way, to the satisfaction of mothers and their families, require investigation. More time and resources should be invested in undergraduate medical education and postgraduate training in order to teach these concepts.
Aidan W. F. Halligan, Consultant/ Senior Lecturer (Obstetrics and Gynaecology) David J. Taylor, Professor/ Clinical Director (Obstetrics and Gynaecology) Leicester Royal Infirmary NHS Trust and University of Leicestec Leicester
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Nicholas J. Naftalin, Medical Director Peter M. Homa, Chief Executive Leicester Royal Infirmary NHS Trust Bernard J. Crump Director of Public Health Leicestershire Health Authority References 1 McIntyre N. Evaluation in clinical practice: problems, precedents and principles. JEval CIin Practice 1995; 1: 5-13.
2 Report on Confidential Enquiries into Maternal Deaths in the UK 1991-1993. HMSO, 1996. 3 Confidential Enquiry into Stillbirths and Deaths in Infancy. Report for Trent Region 1993. NHS Executive, 1995. 4 Sackett DL, Rosenberg MC. On the need for evidence based medicine. JPublicHealth Med 1995; 17: 330-334. 5 Jones R. Why do qualitative research? EMJ 1995; 311: 2 . 6 Royce R. Observations on the NHS internal market: will the dodo get thelastlaugh?EMJ1995;311:431433. 7 Chalmers I. Improving the quality and dissemination of reviews of clinical research. In: Lock S, editor. The Future of Medical Journals. London: BMJ Publications, 1991: 127-146. 8 Chalmers I. Underuse of antenatal corticosteroids and future litigation. Lancet 1993; 341: 699. 9 Chalmers I, Dickersin K, Chalmers TC. Getting to grips with Archie Cochrane's agenda. BMJ 1991; 305: 786-787. 10 Chalmers 1, Enkin M, Keirse M. Effective Care in Pregnancy and Childbirth. Oxford Oxford University Press, 1986. 1 1 Chalmers I, Hetherington J, Newdick M et al. The Oxford Database of Perinatal Trials: developing a register of published reports of controlled trials. Control Clin Trials 1986; 7: 306-324. 12 Smith R. Filling the lacuna between research and practice: An interview with Michael Peckham. BMJ 1993; 307: 1403-1407. 13 Sackett DL, Haynes RB.On the need for evidence based medicine. Evidence BasedMed 1996; 1: 5-6. 14 Grimes DA. Introducing evidence based medicine into a department of obstetrics and gynaecology. Obstet Gynecoll995; 86: 45 1-457.
British Journal of Obstetrics and Gynaecology August 1997, Vol. 104, pp. 875-876
Perinatal audit in Europe Sir William Osler used to confess to his students that half of what he taught them was wrong, adding that his problem, and theirs, was that he did not know which half. How much has changed 80 years on? While parturition is certainly much safer for mother and baby than it was, the cost in often unnecessary intervention and morbidity is, one suspects, far higher than it need be. It is an indictment of our profession that there is still no consensus on basic questions such as optimal maternal posture during childbirth, when the umbilical cord should be divided, or how best to deliver the premature breech baby. These and many other questions can only be answered by scientific comparison of the outcome of different management options. If use is to be made of multicentre studies, or if the reports from different centres are to be comparable and trusted, then first there must be common agreed definitions, nomenclature, and 0 RCOG 1997 Br J Obstet Gynaecol 104, 875-876
methodology for collecting, analysing and reporting data. In Europe, and indeed across the world, progress in perinatal audit has been hamstrung by the myriad differences and inconsistencies that exist in this area, often dictated by national legal and administrative rules. The World Health Organi~ation'-~ (WHO) and the International Federation of Gynecology and obstetric^^,^ (FIGO) have tried to achieve a degree of standardisation, but their recommendations have not always been followed, even on fundamental matters such as the definition of life or death at birth. Recognising this problem the General Assembly of the European Association of Perinatal Medicine set up a Working Party on Perinatal Audit and Evaluation. The Working Party which was composed of 15 obstetricians, paediatricians, statisticians and epidemiologists from across Europe, met in
