The Obstetric Anal Sphincter Injury (OASI) Care Bundle
The Obstetric Anal Sphincter Injury (OASI) Care Bundle A quality improvement programme to reduce the incidence of third- and fourth-degree perineal tears Current issues in OASI prevention in the UK Inconsistencies in approaches to preventing OASIs Inconsistencies in training and skills Lack of awareness of risk factors and long-term impact of OASIs Variation in practice between midwives and doctors Our Care Bundle aims to address these issues Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOP). Int Urogynecol J 2011;22:127985 2 Ismail KM, Paschetta E, Papoutsis D, Freeman RM. Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey. Acta Obstet Gynecol
Scand.2015 Feb;94(2):165-74. 3 Andrews V, Sultan AH, Thakar R, Jones PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth. 2006 Jun;33(2):117-22. 4 Naidu M, Kapoor DS, Evans S, Vinayakarao L, Thakar R, Sultan AH. Cutting an episiotomy at 60 degrees: how good are we? Int Urogynecol J. 2015 Jun;26(6):813-6. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol. 2002 Feb 10;101(1):19-21. 1 What is a Care Bundle? A care bundle is a small set of evidence-based interventions for a defined patient segment or population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually. Institute for Healthcare Improvement There are three major components to the intervention which will be implemented together: Such as posters, pens, balloons,
memory aids Campaign materials Champions will attend a Skills Development Day Training in interventions Guidance and support in rolling out in their units Training materials provided: E.g. videos, visual aids and a quiz Multidisciplinary skills development module 4 evidence-based interventions that, when implemented together, will
result in significantly better outcomes than when implemented individually. A Care Bundle Guide will be provided The OASI Care Bundle 1 2 Inform the woman about OASI and what steps can be taken to minimize her risk. (an information leaflet will be provided) Use of manual perineal protection Spontaneous births if position allows it (women excluded) All assisted births (forceps and ventouse) who give birth in water are 3 Medio-lateral episiotomy (60 degree angle) at crowning to be used when indicated.
4 Perineum must be examined after delivery and any tears graded according to the RCOG guidelines. Examination should include a per rectum check, even when the perineum appears intact. The intervention will be facilitated by: 1. Local clinical champions (one midwife and one obstetrician from each unit). They will champion the project including: ensuring that staff have completed the multi-disciplinary skills development module, monitoring local compliance with the care bundle, reporting on unit-level OASI rates, and participating in shared learning days with the other units in their block. 2. Leadership and support from professional organisations will be provided by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) who will actively promote the project and will provide a joint statement endorsing the use of care bundle. In addition, the professional and educational networks of the Colleges will be actively used to support the skills development module. 3. Continuous monitoring and feedback will allow participant units to measure their progress, by reporting their OASI rates, compliance with the care bundle, and uptake of the skills development module. Units will participate in shared learning days with other units to provide a forum to discuss the project as it progresses. Evaluation of implementation outcomes
Acceptability Satisfaction with intervention Feasibility Survey of champions on Skills Development Day (A, F) Improved knowledge, awareness & skills Routine monitoring of basic data (F, C) Extent to which intervention can be applied Focus groups with clinicians during site visits (A, F, S) Standardised delivery of the evidence based intervention Coverage
Extent to which population receive the intervention Focus groups with champions at Shared Learning Day (A, F, S) Sustainability Extent to which intervention is maintained Follow-up interviews with champions (S) Continued uptake & sustainability of the intervention Number of eligible women in each time period 32,800 women are potentially eligible to receive the care bundle over a 12 month period.
Overall programme plan Project set-up Block 1 Roll-out Implementation Block 2 Block 3 Block 4 Where we are now Evaluation Practice outcomes Stages in each block Dissemination Planning
Skills development day Roll-out Implementation Shared learning day Clinical outcomes Our project team Ranee Thakar Vivienne Novis LouiseDougall Silverton Anita Croydon Health Services NHS Trust RCOG; Frimley Health NHS Foundation Trust
Alexandra Hellyer Posy Bidwell Louise Thomas Anita Dougall RCM RCOG RCOG; London School of Hygiene and Tropical Medicine Kings College London RCOG; London School of Hygiene and Tropical Medicine RCOG RCOG RCOG RCOG Alison Elderfield RCOG Jan van der Meulen Nick Sevdalis Ipek Gurol-Urganci
Clinical lead Midwifery lead Director for Midwifery Director, Clinical Quality Senior Methodology Advisor Quality Improvement Lead Evaluation lead Project manager Research Fellow Head of Quality Improvement Senior Director, Clinical Quality Head of the Lindsay Stewart Centre Any questions?
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