Reducing length of stay for women who present as outpatients to delivery suite: A clinical practice improvement project
Article Outline
- Summary
- Background to the problem
- Background literature
- Site and participants
- Methods
- Project and diagnostic phases
- Initial findings
- The intervention phase
- Clinical midwifery pathways and standing orders
- Selection and development of the advanced practice midwives
- Redesign of outpatient clinical process
- Design of the evaluation
- Impact and evaluation phase
- Length of stay
- Clinicians’ time savings and estimated cost savings
- Women's satisfaction
- Staff satisfaction
- Sustaining improvements phase
- Conclusion
- Acknowledgments
- References
- Copyright
Summary
Problem
Access block is an increasing problem in delivery suites due to the rising birth rates. As well as more labouring women, more women are presenting to delivery suite with pregnancy concerns (at 18 weeks gestation and over). Waiting times for women with pregnancy concerns were prolonged because, prior to the implementation of the present project, these women were required to be assessed by a midwife and then a medical officer.
Aim
The aim of this project was to safely and effectively reduce the length of stay of pregnant women presenting with pregnancy concerns who were managed as outpatients in the delivery suite.
Project setting
The project was undertaken in the Delivery Suite of a major tertiary referral hospital, NSW, Australia.
Methods
The project team used clinical practice improvement methodology (clinical audit, outpatient flow mapping, flowcharting, cause and effect diagrams, brainstorming, multi-voting and Pareto charting) to investigate and propose recommendations to improve the clinical process for this group of women.
Subjects
Five hundred thirty two pregnant women who were not in labour.
Intervention
The interventions involved developing the new clinical midwifery pathways and standing orders for the categories of cases where the midwives were able to assess, order tests and make independent clinical decisions; selecting, training and accrediting the advanced practice midwives; implementing the new clinical pathways; and evaluating the effectiveness, cost and stakeholder satisfaction levels with the changes.
Findings
The average length of stay was reduced from 178.4 to 91.5
min (49%) p<0.001. Approximately 8h a week of midwifery specialist time (AU$33.75 per hour) was estimated to have been saved each week during the project at a cost saving of about AU$270.00 per week. The yearly projected saving would be AU$14,040.00 per annum.
Conclusion
The use of advanced practice midwives reduced the overall length of stay for women with pregnancy concerns. There were no adverse events or complaints. Women, midwives and doctors all evaluated the change positively. These findings provide evidence to support this advanced practice midwifery model in other similar maternity services.
Keywords: Advanced practice, Midwives, Delivery suite, Pregnancy, Outpatients, Clinical practice improvement
Background to the problem
This paper focuses on women who present to delivery suite with pregnancy concerns (at 18 weeks gestation and over). The rising birth rate in Australia1 has meant that delivery suites have become busier. In addition to admitting higher numbers of women in labour, more women, who have pregnancy concerns are presenting to delivery suite. This clinical practice improvement process was begun because we thought the system for managing these women was inefficient. Before implementing the new process all women who presented were first assessed by a midwife, and then by a doctor. The doctor then ordered any required investigations, and/or treatment. The woman then waited for the results of investigations before a definite management plan was made. During this time they were cared for by a midwife.
There was much anecdotal evidence of dissatisfaction among all stakeholders. Women and their families were frustrated with unreasonable waiting at times for routine care that was within the scope of advanced midwifery practice. Midwives and medical officers were equally unhappy with the status quo because of the duplication of assessments and the extra workload created for both groups. In the delivery suite there were a number of midwives who had the advanced knowledge and skills to be able to safely and efficiently manage most of the women, who presented with pregnancy concerns. These midwives in particular felt undervalued and underutilised. All delivery suite midwives agreed that women waited longer than necessary for their health care, as a result of over dependence on doctors and the under utilisation of midwives. Finally, the women presenting with pregnancy concerns took up beds and thus reduced the availability of beds which often led to access block within the unit.
We responded to this perceived problem by designing a clinical practice improvement project to investigate and redesign the clinical process for outpatient maternity services. Clinical practice improvement “profiles the care process by analysing the content and timing of individual steps of a medical care process”2, p. 16. The goal is to determine how to achieve superior health outcomes for the minimal required necessary cost. The ultimate aim is improved care processes where women get better care faster. The clinical practice improvement process also results in the creation of extensive data which is then available to answer new questions for further clinical practice improvement.2
The clinical practice improvement process involves five recognised steps:
Background literature
A literature search was undertaken in an attempt to find previous clinical practice improvement research aimed at reducing the length of stay of pregnant women who present to delivery suite as outpatients. The search terms were: ‘advanced practice’ ‘nursing or midwifery’ (or the truncation of these words) ‘extended skills’, ‘delivery suites or birthing units’, ‘triage’, ‘outpatients’, and ‘organisation of maternity care’. We searched the following databases: Cinahl, Medline, Science Direct, Cochrane, and Maternity & Infant Care.
We also searched for ‘advanced practice’ because there was a perceived need to describe and define the role of the midwives who would, relieve the medical officers in caring for all women who present as outpatients so as to improve the efficiency of the service to women. The midwifery literature is silent on the concept of advanced practice midwives. The concept of ‘Advanced practice’ is well developed in the nursing literature4, 5 and not in midwifery but that does not mean that it is not relevant to midwifery; indeed, in our view, the concept of advanced practice is relevant to all practice disciplines. In the discipline of nursing advanced practice means “direct comprehensive care, optimizing patients’ use of, and progression through, a health service; education of patients, communities, clinicians and students; engaging in research to create and support a culture of enquiry and professional leadership”4, p. 388. We defined advanced practice midwives in the tertiary referral hospital where this project was undertaken as, midwives with enhanced skills, knowledge and practice being utilised to assess women antenatally when they present to hospital with a pregnancy concern.
We decided to refer to the midwives, who implemented the new clinical process, as being advanced practice midwives for two main reasons. The midwives would be required, by their employing hospital, to independently assess, diagnose and manage women with conditions such as non-labour abdominal pain, urinary tract infection (UTI), vomiting, diarrhea and dehydration and fever of unknown origin; all of which are category B (consultation required) in the Australian College of Midwives Guidelines for Consultation and Referral.6 We recognise that our decision to use the concept, ‘advanced practice’ for the midwives involved in this project, is controversial in midwifery because midwifery has not yet developed a position on advanced practice. Advanced practice midwifery does not mean the same as a Midwife Practitioner which is a protected title in New South Wales and denotes “an expert practitioner within a defined scope of practice”.7 Nonetheless we believe that the debate needs to occur and that a scholarly journal is an appropriate venue for the debate. In deciding to apply the term ‘advanced practice’ to midwives who were relieving for doctors in caring for women who may have high risk pregnancies we do not want to imply that this is the only form of practice that is ‘advanced’. Equally we see that midwives who are credentialed to provide independent midwifery care in birth centres and homebirths may also be practising at an advanced level.
The second reason for the ‘advanced practice’ description being used was because of the extra level of experience, knowledge and skill that is required for a midwife to be able to independently assess, diagnose and manage women who present to delivery suite with pregnancy concerns. Accredited competence in following skills is not currently a routine part of pre-registration midwifery programs:
The literature search found two midwifery practice improvement projects. The first clinical redesign was reported in the United Kingdom.8 This project led to replacing medical assessment with midwifery assessment for women presenting as outpatients to delivery suite. “The main finding of the project was that 43% of delivery suite activity was inappropriate and could be diverted elsewhere; freeing up resources and improving the care for birthing women”8, p. 551. In this project the new clinical practice process; midwives assess women, offering appropriate treatment and advice before they return home or transfer to the relevant clinical area. The aim, to reduce pressure on delivery suite was achieved. There was a flow on benefit to the maternity wards which also experienced a reduction in admissions. A full evaluation is yet to be published but there is anecdotal evidence to suggest a reduction in admission rates and improved clinical outcomes.8
The second paper reports on the establishment of a Delivery Suite Assessment Unit in a large teaching hospital in the United Kingdom.9 The Assessment Unit was established adjacent to the standard delivery suite. The aim of the new unit was to “reduce antenatal admissions to delivery suite and provide a more appropriate environment for women attending for antenatal or labour assessment”9, p. 506. The results of the first 12 months’ audit indicated that the establishment of the new unit has been successful in reducing antenatal admissions to delivery suite and the wards. These positive results suggest that some midwives have the necessary skills to be able to independently triage, assess and care for the majority of women who present antenatally with pregnancy-related concerns.9
Site and participants
This project was conducted at a tertiary referral maternity unit which is a combined 15-bed delivery suite and birth centre. In 2008, 3807 babies were born in this hospital. The hospital also managed 3267 women who presented with a pregnancy concern that was treated as an outpatient presentation. The delivery suite employs 61.4 full time equivalent midwives.
A project team took overall responsibility for the design, implementation, evaluation and conduct of the project. The team comprised five clinical midwifery specialists, two clinical midwifery consultants, two midwifery managers, a clinical midwifery educator, an administrative officer and the director of obstetrics who is a consultant obstetrician. Other participants who made contributions to the project included the 18 midwives with advanced practice skills, 3 clinical midwifery managers, medical residents, registrars and consultant obstetricians. There were 252 women in the pre-intervention phase and 280 women in the post-intervention phase.
Methods
Data collection methods included: clinical audit, flowcharting, cause and effect diagrams, brainstorming, multi-voting and Pareto charting. We also conducted individual in-depth interviews, and focused on group discussions with women and health professionals. This is consistent with the clinical practice improvement methodology and the sequential “plan, do, study, act” cycle.10
Project and diagnostic phases
The team began by setting goals and time frames. The time frames were:
| Project and diagnostic phase | April–December 2007 |
| Intervention phase | January–June 2008 |
| Impact and evaluation phase | July–August 2008 |
| Sustaining improvements | Ongoing |
Then we investigated the extent of the problem. Unlike emergency departments, delivery suite has no database that captures data around emergency and outpatient presentations. Therefore, there was no documented evidence that antenatal outpatient presentations were problematic for maternity services. The diagnostic phase involved collecting baseline data from the birthing services activity database11 and reviewing the clinical flow of outpatient presentations to delivery suite. The pre-intervention flow chart was developed to show this (Fig. 1). The flow chart demonstrates the complex clinical pathway and the double handling of women who present with pregnancy-related concerns. The project team recommended to the hospital's senior management that we undertake a formal clinical practice improvement project. The project was conducted in line with the NHMRC guidelines for the ethical conduct of quality assurance research12 and was approved by senior management before the next stage was commenced.
Figure 1.
Pre-intervention outpatient flow chart.
Initial findings
The summary of the findings from the initial audit was as follows:min (Fig. 3).
The team considered possible ways to address these identified problems. Certain options were ruled out earlier because of lack of resources. For example, we were unable to increase the midwifery or medical staff establishment. Secondly, there was no space available to create a speciality maternity outpatients unit either within or outside the delivery suite. Given these limitations, the project team then considered the feasibility of midwives, with advanced knowledge and skills, providing autonomous care and decided it was possible with careful planning and education. Streamlining the clinical process of outpatients in this manner was thought to be the most effective and efficient way of caring for maternity outpatients. This model was attractive because it was likely to be effective and would not increase costs; there was even the potential to reduce costs.
The intervention phase
The four recommended interventions were addressed and the delivery suite was prepared for a pilot project and evaluation of outcomes.
Clinical midwifery pathways and standing orders
There were 12 common outpatient categories of pregnancy concerns (Box 1) that the project team agreed could be assessed and managed by advanced practice midwives. All 12 categories had a clinical midwifery pathway developed. When the clinical midwifery pathway required particular pathology tests, investigations or administration of medication, the standing orders were approved by senior managers including the Director of Obstetrics, the Manager of the Pathology Services and the Quality Use of Medicines Committee. Together these defined the scope of practice for the advanced practice midwife. The pathways gained final approval from the Division of Obstetrics and Gynaecology Executive Committee and Policy and Procedures Committee prior to the project commencing.
Categories excluded for this project:
Selection and development of the advanced practice midwives
Interested midwives were invited to submit an expression of interest. They were then selected against essential criteria (see the selection criteria in Box 2). Prior to the implementation phase of the project, all advanced practice midwives and clinical midwifery managers involved had to gain hospital accreditation for pathology collection in order to sign pathology requests and interpret results. The educational program to teach the midwives was designed in consultation with the hospital's pathology service and supported by the Obstetrics & Gynaecology executive. The program for maternity outpatient presentations required project midwives’ compulsory attendance at lectures on biochemistry, haematology and microbiology and achievement of an 80% pass mark in the pathology department approved examination. A pathology workbook was developed which contained a matrix (of specific tests) that were identified in the clinical pathways as being needed for our common maternity outpatient presentations.
Essential
Extended clinical skills
A midwife with extensive clinical skills and experience that has been accredited by HNE Health/JHH or Documentation of the following skills:
Desirable
The midwifery managers responsible for rostering were committed to the success of the project. Careful planning was required to have 24h, 7-day week coverage by the 18 participating midwives. One quadrant of the delivery suite, containing four rooms, was allocated as the area for outpatients’ presentations. With competing demands in the unit, it was not always possible to maintain the rostered advanced practice midwife. Nor was it possible to always have an empty room within the delivery suite quadrant for potential outpatients. During these times, the care of women presenting with pregnancy concerns reverted to previous practice (Fig. 1). Only one midwife working in a continuity of care model had the relevant knowledge and skills and agreed to participate in this project.
Redesign of outpatient clinical process
Prior to the implementation phase other members of the delivery suite team were educated about the project. Providing education to all maternity staff resulted in acknowledgement of the extent of the problems. Talking about the project with all staff garnered support for the new referral pathways. The midwives in the project were acknowledged by other staff as having advanced practice skills and all staff understood how the new clinical pathways were supposed to work.
Women who were cared for by the advanced practice midwives as part of the project were entered into the database. A hospital label was entered into the project diary for each woman. The diary supported coordination of care through careful communication between midwives and the women; for example, for review of pathology results, planned interventions, and changes to follow-up plans. On presentation to delivery suite the midwives conducted antenatal assessment using the standard delivery suite antenatal assessment forms. Special red project stamps were provided for the pathology requests to make it easy to identify which women were being assessed by the advanced practice midwives. Stamps were also available for documentation of pathology tests, investigations or interventions performed in the woman's progress notes.
The redesigned clinical flow of an outpatient through the delivery suite and the pathway for medical referral and consultation was developed. The new process is presented in Fig. 2. In the new process the woman was triaged to an advanced practice midwife. The midwife conducted an overall assessment, ordered and interpreted pathology and other investigations and instigated interventions. The outcome of the midwifery assessment and intervention resulted in one of three pathways:
Figure 2.
Post-intervention outpatient flow chart.
Design of the evaluation
The fourth aspect of the project to be implemented was the development of a database. An initial database was designed to measure quantitative data to determine the current average length of stay for our 12 outpatient categories. Following advice from a statistician, we further developed the database to enable it to reflect the change in the clinical process. Data was collected at the time of the woman's arrival and at the time of commencing the midwifery assessment. The time spent in each step along the journey and the time of discharge were also recorded. A maternal satisfaction questionnaire was designed as well as in-depth interviewing of staff and focus group discussions to add qualitative data to the evaluation of our service.
Impact and evaluation phase
On completion of the 6-month project, the data was analysed using analysis of variance, Student's t-tests for independent samples and chi-squared analysis. The statistical analysis was performed using Systat 11 statistical software.
Length of stay
The pre-intervention and post-intervention comparative lengths of stay in each of the 12 outpatient categories and overall are identified in Fig. 3. The average length of stay was reduced from 178.4 to 91.5min (49%) p<0.001. The overall reduction in the average length of stay per presentation was 86.9min.
Figure 3.
Pre- and post-intervention average length of stay (minutes).
The statistical data analysis demonstrated that the use of advanced practice midwives in outpatient presentations can significantly reduce the length of stay in hospitals (Fig. 3), this result was statistically significant (p<0.001). The following categories of presentation had statistically significant reductions in post-intervention lengths of stay: abdominal pain; CTG and/or decreased baby movements; early labour management; actual or possible ruptured membranes; and threatened premature labour. None of the categories showed a statistically significant increase in length of stay. The amount of time saved increased as the project progressed, as the midwives became more familiar and proficient with the assessment and management pathways. The advanced practice midwives have been the key contributors to the reductions in length of stay and improvements in women's satisfaction (discussed below). The success of this midwifery model of advanced practice is related to in part to the earlier initiation of investigations and treatments. In addition, advanced practice midwives were able to triage women and initiate timely and appropriate referral to medical officers. This allowed women to be either discharged to home or moved to appropriate ward areas more quickly. This improved efficiency eases both access blocks and women's waiting times.
Clinicians’ time savings and estimated cost savings
The total time saving in waiting hours over the 6 months during which the project was running was calculated to be 371h 36min (see Box 3). On the assumption that the staffing ratio in delivery suite is a maximum of one midwife to two women, we adjusted the calculation to reflect the staff allocation. This equates to 186h of midwifery time that was saved or expressed in another way, a cost saving of one shift per week at clinical midwifery specialist rate AU$33.75. In reality during the project, the substantial amount of midwifery hours saved allowed midwives to provide better care and support for other women in the delivery suite. Data was not collected on the average times for medical assessment, as that was not part of the project design. We estimate that the medical assessment time averages about 20min for each woman and on that basis over 90h of medical time was saved during the project.
The estimated cost saving in paid midwifery time alone, (based on a clinical midwife specialist hourly rate of $33.75) equates to a saving of AU$7020.00 over the 6 months of the project. The cost saving is projected to be AU$14,040.00 per annum now that the program is ongoing.
Women's satisfaction
A survey was administered to two convenient samples of women: 50 prior to the implementation of the project and 61 during the project. The questionnaire used scales as well as asking open-ended questions. The scales within the survey focused on rating women's satisfaction with the service including: site of care provision, ease of access, waiting times, quality and appropriateness of the care provided, own understanding of treatment and advice, and quality and appropriateness of follow-up management plans. The individual scales rated satisfaction as either; ‘dissatisfied’, ‘somewhat satisfied’, and ‘completely satisfied’. The overall satisfaction was a five-point scale from ‘poor’ through to ‘excellent’. The survey was explained by an advanced practice midwife and verbal agreement to complete the questionnaire was obtained. The women completed the questionnaire, in private, and handed the folded questionnaire to the midwifery manager on duty, who immediately placed it in the envelope designed for receiving the completed questionnaires.
Satisfaction with the service was rated as very good or excellent by 88% of the women who experienced the pre-intervention care as compared to 98% of women who experienced the new intervention of advanced practice midwifery lead care. There was marked improvement in the satisfaction of women in relation to ‘advice’ and ‘follow up care plan’. With pre-intervention 75% of women reported satisfaction whereas with the new midwifery-led intervention, 92% of women were satisfied. The women who expressed dissatisfaction identified waiting time to see the doctor and waiting time for results of tests as the main aspects of concern expressed in the qualitative comments. The majority of women in the post-intervention phase did not complete the qualitative comments section of the survey; we assumed that this was because that they had expressed their satisfaction through questionnaire scales.
Staff satisfaction
Eight in-depth interviews were conducted with midwives and doctors. Additionally, a focus group of eight advanced practice midwives met to discuss satisfaction with the new clinical process. Theme analysis identified the following themes.
The benefits of having an advanced practice midwife on duty were obvious in any shift and resulted in prompt care and mitigated against access block. As the project progressed, other midwives began to express a desire to become an advanced practice midwife. The individual midwife's reasons for choosing to develop into the advance role varied; for some it was the collaborative support for this study and the evidence of a safe and efficient model. Others wanted to develop the skills so that they could personally provide this care to any woman who presented, and not have to hand care over to a designated midwife or medical officer. For some midwives, a level of enhanced professional kudos associated with the advanced practice role was a significant motivator.
Sustaining improvements phase
Key factors to sustaining the new clinical process have been the recognition and support of senior clinicians and administrators in both midwifery and medicine. The new clinical process is viewed by the area health service as safe, efficient, and cost effective midwifery model of care. Given the current high bed occupancy rate in delivery suite, it would be ideal to create a dedicated maternity outpatient assessment unit outside, but adjacent to, the delivery suite.
We need an efficient and effective way of collecting and analysing data. There are plans to integrate maternity outpatient data on presentations, waiting times and length of stay into a dedicated maternity services database. Meanwhile, there will be an annual audit attended over a month long period to monitor the length of stay for outpatients in the delivery suite, to ensure the improvements are monitored and sustained.
The sustaining improvements phase of this clinical practice improvement project is limited by lack of sufficient numbers of advanced practice midwives, which results in not all shifts being covered. This means that some women presenting with pregnancy concerns will be assessed and managed following the previous clinical process (Fig. 1). We recommend that the overall midwifery time and cost savings from this project could be realised and used to develop the future advanced practice midwives in the delivery suite. This would ensure a dedicated 24h service for the midwives managing outpatients in delivery suite model of care. We have recently advertised for more midwives to join this model.
Conclusion
Prior to the implementation of the re-designed clinical pathways there were four inter-related problems. First, women who presented to delivery suite with pregnancy concerns were waiting unnecessarily long times, because the process required that they each be seen by a doctor. Second, doctors were repeating the clinical assessments that midwives had already conducted thus wasting time and resources. Third, midwives who were capable of practising at an advanced level were being under utilised. Finally, doctors were having their time tied up providing care that could safely and effectively be provided by midwives with advanced practice skills.
We used a clinical practice improvement process to diagnose the factors that contributed to unnecessarily long waiting times for women. We then developed clinical pathways and standing orders for 12 outpatient presentations that would define the scope of the midwives advanced practice. Next we used an educational intervention to train the project midwives in the advanced skills that they would need. Only then was the new pathway implemented for the women who present with pregnancy concerns.
This project has demonstrated that it is possible to safely reduce the average length of stay for women presenting with pregnancy concerns without adverse outcomes or complaints. Women, midwives and doctors all evaluated the changed clinical processes positively. There has been a net saving in terms of clinicians’ time; both midwifery and medical. Using the knowledge and skills of advanced practice midwives has been the key contributor to these improved clinical and economic outcomes.
Acknowledgments
Project Team Members: Project sponsor – Conjoint Associate Professor Anne Saxton; Project Leader – Jennifer Haxton; Pilot Study Accredited Midwives – Margo Ashhurst-Smith, Liza Bettridge, Judith Downey, Fiona Harrison, Marianne Knox, Dorothy Kauter, Gwen McKenzie, Elizabeth Konieczny, Ros Kurthi, Marilyn Maccallum, Mary McGowan Patrica Pinder, Fiona O'Shannessy, Jane Shields, Barbara Stuart, Tracey Webb; Midwife Consultants – Jacqueline Allabyrne & Rosalee Shaw; Clinical Midwife Educator – Mandy Hunter; Birthing Services Co-coordinator – Christine Marsh; Midwifery Managers Birthing Services – Jane Crosbie, Sue Kuter, Lyn Kramer, and Lynelle Hill; Administrative Staff – Glynis Jarvis; Director of Obstetrics – Conjoint Associate Professor Andrew Bisits; Obstetric Registrar – Dr Felicity Park; Obstetrics & Gynaecology Business Manager & Database – Mr Tas Haitas; Hunter Area Pathology Service – Mr Bruce Tually; Quality Use of Medicines Committee – Obstetrics & Gynaecology Representative – Dr Thomas Tait. Hunter New England Health Performance Improvement Unit – Mr Robert McDonald; Emergency Services Clinical Nurse Consultant – Leanne Egan.
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PII: S1871-5192(09)00031-6
doi:10.1016/j.wombi.2009.04.001
Crown Copyright © 2009. Published by Elsevier Inc. All rights reserved.
