Browsing by Author "Horak, Tracey"

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    An investigation of blood transfusion practices in a regional obstetric hospital with no on-site blood bank
    (2023) Bengesai, Daniel; Horak, Tracey; Fawcus Susan
    Background This study aimed to investigate blood transfusion practices in a regional obstetric hospital with no on-site blood bank. Underpinning this research was the argument that principles of evidence-based medicine should apply to blood transfusions in the same way they do to any other clinical practice area. Considering the limited availability of resources (financial, human and blood products) and the ever-increasing and competing needs facing South Africa, the practices surrounding the use of blood and blood products must be audited. Method This study used a retrospective descriptive audit approach to collect data on blood transfusion management from Mowbray Maternity Hospital, a Regional Hospital in Metro West, Cape Town, which receives complicated obstetric patients from satellite Midwife Obstetric Units (MOUs) and District Hospitals. In addition, an in-depth folder review of two months was also conducted for 118 women to ascertain the precise obstetric indications and decision-making processes. Results During the study period, there were 10030 deliveries, of which 4734 (47, 2%) were caesarean deliveries, 5081(50.7%), were vaginal deliveries, and 215 (2.1%) were assisted deliveries. Only 781women received blood products; thus, the incidence of blood transfusion during this period was 7.8%. Red blood cell concentrate (including emergency red blood cell concentrate) was the most transfused blood product, followed by fresh frozen plasma, cryoprecipitate, and platelets. Approximately 12.6% of the patients received emergency red blood cells, reflecting acute postpartum haemorrhage while cross-matched red blood cell concentrate (RBC), was transfused to 82.2% of the women in the sample. The clinical area was not labelled for 24.1% (n=189) of patients who received blood products. 58% of the blood transfusions were done after hours. Overall, different transfusion patterns were observed for women who received multiple blood products. The in-depth folder review on 118 patients indicated that the leading cause for blood transfusion was postpartum haemorrhage secondary to uterine atony, which accounted for viii 38.1 % of the transfusions. The range of the pretransfusion Hb was 4-9g/dl, with a mean of 6.51(SD±0.07), suggesting that all the women who received blood products were anaemic. Conclusion Overall, the results from this study indicate that the transfusion of blood products was in line with international practice, where RBC is the most transfused product, followed by FFP other products. Regarding the transfusion rate, although it was higher than in most developed countries, it was much lower than in other low-and medium-income countries. However, while a low rate of PPH and blood transfusion rate is preferable, it also indicates thatphysicians have fewer opportunities to train by self-experience. Therefore, the use of protocolsremains central to effective PPH management and the improvement of the quality of care at MMH, and this should be coupled with routine, retrospective audits, as in the case of this study. The specific reasons for blood transfusions also need to be explored in more detail so as to improve patient care accordingly. For instance, the fact that a significant proportion of women who received blood products were diagnosed with anaemia reinforces the need for early detection of and treatment of antepartum anaemia as well as increasing the use of parenteral iron. The results from this study also suggest that data management issues need to be considered, particularly the siloed nature of the data. It is recommended that MMH establish a unified and integrated system for capturing and managing data quality and storage.
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    Audit Of Peri-Operative Care As Part Of The Enhanced Recovery Model For Caesarean Delivery
    (2022) Blumenthal, Abigail; Fawcus, Susan; Horak, Tracey
    Introduction Mowbray Maternity Hospital (MMH) is a secondary level hospital serving a large population with low socioeconomic status. Around 10000 deliveries are done per year of which 40-50% are delivered by caesarean section (CS). There is much literature on peri-operative care for caesarean sections, under the model of fast-track surgery also known as Enhanced Recovery After Surgery (ERAS). ERAS protocols have antenatal, intra-operative and post-operative components. This audit aimed to evaluate how successfully MMH adheres to local and international guidelines for peri-operative care around elective caesarean section according to the ERAS model. It is hoped this will form the first step in a quality-improvement intervention resulting in better quality, evidence-based care appropriate for the low-resource setting. Materials & Methods: Women were invited to participate in the study in MMH postnatal ward between 24 and 48 hours after elective CS. Once consented, a structured questionnaire and data collection sheet was used to interview women and remaining details were obtained from the patient record. This covered four aspects of ERAS programmes: 1. peri-operative hydration and nutrition 2. peri-operative analgesia 3. time interval postoperatively until removal of intravenous lines and urinary catheterisation 4. time interval until first mobilisation The initial planned sample size was 50 women however after the start of the covid pandemic when in-person interviews were no longer possible, a folder audit was undertaken of the remaining files. A decision was made to therefore increase the sample size to increase the value of the data obtained from the folder audit given that there was to be more limited data from patient interviews. Anonymised data was entered into a secure online database using REDCap (Research Electronic Data Capture system). Data entry was verified by double entering all data. In total 75 folders were reviewed, of which 35% were interviewed face-to-face. Findings The audit showed that 92% of patients received exactly the same number of doses (four 10mg doses) of morphine post-operatively with more variation in the dosing of simple oral analgesics and no use of NSAIDs. It showed that 85% of patients had high pain scores (3 or more out of 5) in the first 24 hours post caesarean section but 85% also reported they were mildly or very happy with their pain management post-operatively. The audit highlighted that many patients were nilper-os for prolonged periods of time peri-operatively; on average 23 hours without food and 19 hours without oral fluid. Drips and catheters were removed on average at 12.5 hours post- operatively; and mobilisation occurred on average at 12 hours with few delays; the standard deviation was less than 1 hour. Conclusions The audit confirmed that Mowbray Maternity Hospital has good adherence to certain ERAS protocols. It confirmed that most patients were happy with their pain control despite often reporting high levels of pain. However, it highlighted several deficiencies such as poor use of regular simple oral analgesia and the lengthy duration of time for which many patients were fasted which could impact on general satisfaction with care, not to mention possible negative effects on tissue healing.