of obstetric emergencies in uganda through case management …€¦ · of obstetric emergencies in...

Q U A L I T Y

A S S U R A N C E

P R O J E C T

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Improving the Managementof Obstetric Emergencies

in Uganda throughCase Management MapsBarbara Kerstiëns, Agel Akii, Nazarius Mbona,

Abby Zziwwa, and Wendy Newcomer Edson

February 2004

O P E R A T I O N S R E S E A R C H R E S U L T S

The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development(USAID) under Contract Number GPH-C-00-02-00004-00. The project serves developing countrieseligible for USAID assistance, USAID Missions and Bureaus, and other agencies and nongovernmentalorganizations that cooperate with USAID. QAP offers technical assistance in the management of qualityassurance and workforce development in healthcare, helping develop feasible, affordable approaches tocomprehensive change in health service delivery. The project team includes prime contractor UniversityResearch Co., LLC (URC), Initiatives Inc., and Joint Commission Resources, Inc. The work described inthis report was carried out by the Quality Assurance Project under USAID Contract Number HRN-C-00-96-90013, managed by the Center for Human Services, URC’s nonprofit affiliate, in partnership with JointCommission Resources, Inc. and Johns Hopkins University.

O P E R A T I O N S R E S E A R C H R E S U L T S

Continued on page 31

Table of ContentsABBREVIATIONS .................................................................................................... 1

I. INTRODUCTION.............................................................................................. 1

II. BACKGROUND ............................................................................................... 2

III. THE INTERVENTIONS ..................................................................................... 2A. Planning and Implementing the First Intervention ..................................... 3

Phase 1: Defining the Project ..................................................................... 3Phase 2: Developing the CMM................................................................... 5Phase 3: Implementation ............................................................................ 7Phase 4: Monitoring and Evaluation .......................................................... 8

B. Planning and Implementing the Second CMM (PPH) ............................... 8Phase 1: Defining the Project ..................................................................... 8Phase 2: Developing the CMM................................................................... 8Phase 3: Implementation ............................................................................ 9Phase 4: Monitoring and Evaluation .......................................................... 9

IV. EVALUATION METHODOLOGY ...................................................................... 9A. Research Design ........................................................................................ 9B. Study Sample .............................................................................................. 9C. Process and Outcome Indicators ............................................................ 10D. Data Collection Instruments and Procedures .......................................... 10E. Data Analysis ............................................................................................ 11

V. RESULTS ....................................................................................................... 11A. Comparability of Study Groups ................................................................ 11B. Use of CMM .............................................................................................. 12C. Performance According to Standards ..................................................... 12D. Patient Outcomes ..................................................................................... 15E. Resource Use ........................................................................................... 15F. Providers’ Attitudes and Perspectives ..................................................... 15

VI. DISCUSSION AND CONCLUSIONS ............................................................. 17

VII. RECOMMENDATIONS .................................................................................. 18

REFERENCES ....................................................................................................... 19

APPENDIX A: Case Management Map for Pre-Eclampsia ................................ 20

APPENDIX B: Instructions for Case Management Map for Pre-eclampsia ....... 22

APPENDIX C: Case Management Map for Postpartum Hemorrhage ................ 24

APPENDIX D: Instructions for Case Management Mapfor Postpartum Hemorrhage ........................................................ 28

Improving the Management ofObstetric Emergencies in Ugandathrough Case Management Maps

Abstract

In this study, Uganda’s Jinja Hospitaland the Quality Assurance Projectdeveloped and implemented casemanagement maps (CMMs) for twodistinct pregnancy-related conditions:pregnancy-induced hypertensive dis-orders (PIHD) and postpartum hem-orrhage (PPH). CMMs are pre-printedforms that serve as job aids to helpprompt members of the healthcareteam to perform required tasks. AtJinja the tasks on the CMM for PIHDreflected a new protocol of care thathospital staff and management hadadopted as part of the developmentof the CMM. Jinja’s CMMs list downthe left side of a sheet of paper thetasks providers must accomplish fora particular condition, and they listacross the top a timeline (e.g., hourly,daily) when the tasks must be accom-plished.

The study measured adherence tothree care standards and patient out-comes for both intervention conditionsduring the 12 months before the intro-duction of each CMM and during the12 months afterward. The care stan-dards for PIHD were proteinuria onadmission, blood pressure three timesdaily, and propanolol on admission; forPPH they were hemoglobin test onadmission, complete blood countdaily, and iron and folic acid daily. Thesample sizes for PIHD were 36 casesbefore and 50 after; for PPH they were20 cases before and 10 after.

Before and after measurements werealso obtained for a comparison (con-trol) condition, acute pelvic inflamma-tory disease (PID), for which no CMMwas developed. PID was chosen as

List of Tables and Figures

Table 1 CMM Development Process .................................................................. 3

Figure 1 Timeline for Implementing Activities for thePIHD and PPH Interventions ................................................................. 4

Table 2 Example of a CMM Format Presented to Jinja Staff ............................. 5

Table 3 Monitoring Indicators for CMM for PIHD ............................................... 7

Table 4 Key Tasks for Each Obstetric Condition ............................................. 10

Table 5 Characteristics of Women with PHID by Study Group ....................... 11

Table 6 Characteristics of Women with PPH by Study Group ........................ 12

Table 7 Characteristics of Women with Acute PID by Study Group ............... 13

Table 8 Percentage of Cases Performed According to Standards forNormal Management, Before and After Implementation.................... 13

Figure 2 Increases in Percentage of the Three Normal ManagementTasks Performed to Standard .............................................................. 14

Figure 3 PIHD: Percentage of Pooled Key Tasks Completed Correctly forNormal Management Before and After Introduction of CMM ............ 14

Figure 4 PPH: Percentage of Pooled Key Tasks Completed Correctly forNormal Management Before and After Introduction of CMM ............ 14

Figure 5 PID: Percentage of Pooled Key Tasks Completed Correctly forNormal Management Before and After Introduction of CMMsfor Other Diagnoses ............................................................................ 15

Table 9 Patient Outcomes Resulting from the PIHD CMM .............................. 15

Table 10 Length of Hospital Stay by Diagnosis, in Days .................................. 16

Case management maps (CMMs)are about teamwork: Congratulationsto the members of the two CMMdevelopment teams. This study wasalso about teamwork, so the firstauthor would like to express herappreciation to all the authors fortheir unfailing dedication to thatapproach, and especially to Dr. AgelAkii for his collaboration andleadership and to Nazarius Mbonafor his dedication and skills.

Last, but not least, thanks to SisterBabyerabira and her staff in thematernity ward, without whom wewould have no results to show.

Acknowledgements

The authors would like to thankProfessor Richard H. Morrow whoseknowledge, experience, andcontinuous support made this studypossible. We would also like to thankProfessor Gilbert Burnham forsuggesting the initial idea for thestudy. Professor Francis Omaswaplayed a unique role, as he ac-cepted this novel idea and identifiedthe setting and people with whomthe study was conducted. BartonBurkhalter of the Quality AssuranceProject was also instrumental inhelping prepare the study’s finalreport.

Recommended citation

Kerstiëns B, Akii A, Mbona N,Zziwwa A, and Edson WN. 2004.Improving the Management ofObstetric Emergencies in Ugandathrough Case Management Maps.Operations Research ResultsBethesda, MD: Published for theU.S. Agency for InternationalDevelopment (USAID) by the QualityAssurance Project (QAP).

About this series

The Operations Research Resultsseries presents the results of countryor methodological research thatQAP is circulating to encouragediscussion and comment within theinternational development commu-nity. Please visit www.qaproject.orgfor information on other QAPoperations research studies.

Case Management Maps: Uganda ■ 1

Barbara Kerstiëns, Agel Akii, Nazarius Mbona, Abby Zziwwa,and Wendy Newcomer Edson

Improving the Management of ObstetricEmergencies in Uganda throughCase Management Maps

List of AbbreviationsBP Blood pressure

CBC Complete blood count

CMM Case management map

Hb Hemoglobin

MgSO4 Magnesium sulfate

NA Not applicable

OPD Outpatient department

PIHD Pregnancy-inducedhypertensive disorder

PID Pelvic inflammatory disease

PPH Postpartum hemorrhage

QAP Quality Assurance Project

RR Relative risk

SD Standard deviation

Temp Temperature taken

USAID US Agency for InternationalDevelopment

WHO World Health Organization

I. Introduction

A case management map (CMM) isa type of critical pathway thatinforms healthcare workers what todo and when to do it for a specificdiagnosis. Critical pathways wereintroduced in U.S. hospitals in 1991to reduce costs by streamlining careand improving the efficiency of caregiven by multiple professionals in ahospital (Coffey et al. 1992). Theydefine the optimal sequencing andtiming of interventions by physi-cians, nurses, and other staff for aparticular diagnosis in order toimprove resource use, maximize thequality of care, and minimize delays.Critical pathways are commonlyused in U.S. hospitals but not inhospitals in developing countries.Other terms for critical pathwayinclude critical paths, Care Maps®,and care pathways.

Thus, CMMs are a type of job aid forhealthcare workers. Other types ofjob aids for healthcare workers arecounseling cards, reminder cards,and clinical algorithms (Edson et al.2002; Edson et al. 2003; Edward-Rajand Phiri 2002; Tavrow et al. 2002).Job aids have been shown toimprove healthcare provider perfor-mance according to standards(Knebel et al. 2000; Lahie et al.2001), but job aids alone do not

ensure high performance. Alsoneeded are competent and moti-vated providers and a healthcaresystem that supports and rewardsgood performance. Job aids workbest as a memory aide whenperformance can be enhanced byimproving either skill or knowledge.Job aids used in training candecrease training time. A job aidmay be useful if a task is complexand performed infrequently andthere are severe consequences ifthe job is not done right. Barriers tothe use of job aids are a lack of timeto refer to one and social/culturalissues that may affect credibility andtrust in a client/provider relationship.

The CMMs developed for this studyrelate to two conditions that mayresult from pregnancy: pregnancy-induced hypertensive disorder(PIHD) and postpartum hemorrhage(PPH). These CMMs can function asa job aid, a medical record, and/or ateaching aid. In addition to sequenc-ing various interventions, theyprovide spaces where providersshould record the results of tests(such as blood pressure), the timethe test was taken, and their initials.Care is documented on a grid withthe rows containing care activities(e.g., monitoring, treatment, medica-tion, diet, patient counseling) andthe columns indicating time (e.g.,hour, day, month). The timeline foractivities is not as specific as it isfor pathways used in developedcountries, where some informationon intermediate and end outcomesis annotated on the pathway.

2 ■ Case Management Maps: Uganda

II. Background

Maternal mortality is perhaps themost important cause of loss ofhealthy life years in Uganda, acause that could be readily reducedthrough improved quality of care.One of the reasons why the maternalmortality rate is still appallingly highis the poor performance accordingto standards of essential obstetriccare once women arrive at ahospital. At the 500-bed JinjaHospital in 1998, there were 3,919deliveries and 30 maternal deaths.More than half of those deaths werelikely preventable with bettermanagement of obstetric complica-tions such as pre-eclampsia,hemorrhage, and sepsis both at thehealth center and hospital levels.During that year, 57 patients wereadmitted with pre-eclampsia, ofwhom five died. Pre-eclampsia is aserious complication of pregnancyor delivery that, if ineffectivelytreated, can lead to eclampsia anddeath. Management of pre-eclamp-sia requires that many interdepen-dent services be provided to thepatient. If they are not appropriatelycoordinated and scheduled, thequality of care decreases with thepossibility of fatal outcome for eitherthe mother or newborn.

The Ministry of Health in Ugandaasked the Quality Assurance Project(QAP) to assist in developing,implementing, and evaluating CMMsat Jinja Hospital for the managementof PIHD1 and PPH,2 in order toimprove the quality of care for theseconditions.

The objectives of the study weretwofold:

■ To develop, introduce, and useCMMs for management ofobstetric complications, specifi-cally PIHD and PPH.

■ To measure the effect of the useof the CMMs on compliance withstandards, patient outcome,resource use, and providersatisfaction.

Principal investigator BarbaraKerstiëns, MD, MPH, led the studyand undertook this work for QAP asa consultant to The Johns HopkinsUniversity School of Hygiene andPublic Health, then a QAP partner.A multi-disciplinary team of hospitalstaff developed the CMMs, workinglargely on their own under theleadership of co-principal investiga-tor Dr. Agel Akii, an obstetrics/gynecology specialist consultant,and with guidance from the non-resident principal investigator.Medical Statistician Nazarius Mbonaconducted the data analysis, andMedical Anthropologist Dr. AbbyZziwwa conducted the qualitativestudy on provider satisfaction.

The strategy to develop and imple-ment job aids was based on theprincipal investigator’s personalexperience, Mozena and Black(1996), and elements from thequality design of health servicesmethodology developed by QAP.

The CMM development process hadfour phases, each with two or moresteps, as outlined in Table 1 anddetailed in Section III.

1 Pregnancy-induced hypertensive disorders (PIHDs) manifest as high blood pressure and other symptoms. PIHD can cause pre-eclampsia, which can lead to eclampsia, convulsions, and maternal death. Pre-eclampsia is usually the admitting diagnosis. This papersometimes uses “PIHD” for convenience (and especially for brevity in the tables and figures) where “pre-eclampsia” may be thetechnically correct term.

2 Postpartum hemorrhage (PPH) is excessive vaginal bleeding that can occur after giving birth or having an abortion. Potentially fatal tothe mother, it has four main causes: uterine atony, retained placenta, lacerations of cervix/uterus, and coagulation defects.

III. The Interventions

Each intervention had six parts:(1) developing of a case manage-ment map, (2) training in how to usethe map, (3) introduction and use ofthe map, (4) acquisition of missingsupplies and equipment needed totreat patients in accordance with thetreatment protocol, (5) defining andmonitoring indicators to measure theeffect of the CMM, and (6) revisingthe CMM to improve it based onexperience.

The intervention was applied to twopotentially fatal conditions: preg-nancy-induced hypertensivedisorder (PIHD), including pre-eclampsia, and postpartum hemor-rhage (PPH). The protocol for PIHDhad to be updated, adding anotheractivity to the six listed above. Thetiming for implementation of theactivities was sequential, with thePIHD-related activities beginning sixmonths before the PPH-relatedactivities. This enabled healthcaremanagers to introduce changes onthe ward progressively and withcontrol over the development andintroduction process. A recordreview was conducted in August of1998 to collect baseline informationon the treatment of PIHD, PPH, andsepsis (postabortion, postpartum,and post-caesarean section). InSeptember 1999, the standards ofcare were communicated for thethree conditions. We introduced thestandards for PIHD via the CMM. Weintroduced standards for the othertwo conditions through a staffmeeting and the distribution of the


Table 1

CMM Development Process

Phase 1: Defining the Project

Step 1: Select the diagnosis

Step 2: Select the team

Step 3:Define the scope of the case management map

Phase 2: Developing the CMM

Step 1: Describe the current case management process

Step 2: Define CMM format

The principal and co-principal investigators selected a diagnosis.

The multi-disciplinary team defined the scope of the CMM for each diagnosis.

The team analyzed the existing case management process at Jinja.

The team decided on the purpose and elements of the CMM and designed its format. For PIHD theteam decided to adapt the national Uganda PIHD case management guidelines and Safe Mother-hood guidelines as the basis for the CMM, a challenging task that involved the entire team.

Step 3: Develop a draft CMM

Step 4: Define indicators for monitoring and identifyperson(s) responsible for collecting data

Phase 3: Implementation

Step 1: Prepare for implementation A two-day training session was held for the staff. This process was undertaken twice: from April toJune 1999 for the CMM for PIHD, and between November 1999 and February 2000 for the CMMfor PPH.

Step 2: Implement

Phase 4: Monitoring and Evaluation

Step 1: Monitor

Step 2: Problem solve

The study team developed a monitoring plan and study protocol for assessing the impact of theCMMs on compliance with standards, patient outcomes, resource use, and provider satisfaction.Data were collected until September 2000.

written clinical protocol. Figure 1shows the timeline.

A. Planning andImplementing the FirstInterventionThe principal investigator developeda methodology to guide the projectleaders in implementing the study.The methodology mapped the steps(and their expected results) thatwould allow a multidisciplinary teamto fully implement the intervention inaccordance with the six activities.

This section describes the experi-ence in developing the CMM forPIHD. It follows the four-phase CMMmethodology developed by theprincipal investigator and outlined inthe Background Section. Section B,below, sketches the same processfor PPH, noting only the informativedifferences between the two experi-ences.

Phase I: Defining the ProjectIn defining the project, the principaland co-principal investigatorscollaborated with the head nurse on

three steps that defined and startedthe project.

Step 1: Select the diagnosis.Developing a CMM requires select-ing a condition on the basis ofcertain criteria. First, it should behigh risk, high volume, or problemprone. Second, case managementhas to be possible. Third, thetreatment should involve more thantwo staff.

Risk. Working with Head MaternityNurse Sister Babyerabira, theprincipal and co-principal investiga-


Figure 1

Timeline for Implementing Activities for thePIHD and PPH Interventions

Activities

Pre-eclampsia

Revise protocol

Develop CMM

Training

Use CMM*

PPH

Communicate protocol

Develop CMM

Training

Use CMM

A M J J A S O N D J F M A M J J A S1999 2000

* Use started 6/10/99; final US-printed CMMs arrived in October 1999.

tors began the process of selectinga condition, aware that a high-riskobstetric complication would beselected. The World Health Organi-zation (WHO) and others recognizePIHD, PPH, and sepsis as leadingcauses of death among obstetriccomplications. Jinja’s files did notprovide much information on the riskof these conditions specific to thehospital: 32 deaths were recorded in1997, but only 10 files were found.Of those 10 cases, one woman diedof eclampsia, three of PPH, andthree of sepsis. The paucity ofstatistics provided little reliableinformation on the relative risk atJinja among these three conditions.

Volume. Volume was nearly equal forall three conditions. The recordreview of 1997 files found 51 casesof PIHD, 41 cases of hemorrhageoccurring after abortion or givingbirth, and 51 of sepsis resulting fromabortion or giving birth.

Problem proneness. Although CMMsare most beneficial when used forconditions that are prone to prob-lems if not managed correctly, anexcess of problems can inhibit aCMM’s success, especially ahospital’s first CMM. Thus, eventhough Dr. Agel Akii and SisterBabyerabira thought a CMM couldhelp overcome care problemsrelated to PHID and PPH, they wereconcerned that even with a CMM,staff might not be able to overcomethe PPH-related problems. Part ofthe concern was that the treatmentof PPH often requires blood transfu-sion, but blood is frequently lacking.They felt that it would be better tohave staff begin with a CMM for atreatment that they could fullyprovide.

Possibility of case management.Some treatments are so complicatedthat it is unlikely that a CMM could

be created that would describe theappropriate treatment clearly, ortreatments can be so simple that aCMM adds nothing. Neither was thecase with PIHD or PPH. It wasthought that management of bothconditions could benefit from aCMM.

Two or more staff. All three condi-tions under consideration involvemore than two staff.

Pre-eclampsia was selected as thefirst illness for which a CMM wouldbe developed. The case definitionwas “Any woman presenting with ablood pressure of 140/90 mm Hg ormore and/or signs of proteinuria,headache, and dizziness.” (WHO1997) We discussed our plan withco-operating agencies (SafeMotherhood, UNICEF, and JHPIEGO)for their advice on our decisions

thus far and confirmed that we wereproceeding in the correct direction.

Step 2: Select the team. Selectingthe team that would implement theCMM resulted in representation ofthe professionals involved in themanagement of pre-eclampsia: anobstetrical/gynecology specialist, amedical officer, the head nurse anddeputy head nurse in maternity, twointern doctors, a pharmacist, and asenior laboratory technician.Representation of all professionalsinvolved in the process of care is notalways possible but is thought to beideal.

Step 3: Define the scope of thecase management map. Definingthe scope of the CMM meantdetermining when treatment inaccordance with the CMM wouldbegin and end, what activities wouldbe included, and which areas of


treatment would be addressed. Wedecided to focus on the manage-ment of suspected pre-eclampsiaand PIHD from admission to dis-charge.

Phase 2: Developing the CMMPhases 2 through 4 were performedby the implementation team, led bythe co-principal investigator with theadvice and guidance of the principalinvestigator. In this phase, the studyteam participated in meetings,gathered and analyzed informationbetween meetings, and madedecisions to put the words andgraphics for the CMM on paper,making it ready for actual use,although in draft form. The co-principal investigator and col-leagues undertook four steps tobring implementation to the point ofintroducing the CMM on the ward.

Step 1: Describe the current casemanagement process. The teamdeveloped a description of thecurrent process of management byrecording the elements that werethen part of management for pre-eclampsia. These elements includedthe individual or team that per-formed each activity, the system forrecording activities, and problemsbeing encountered in managing pre-eclampsia. Treatment activitiesincluded consultations, monitoring,tests, treatments, medications, diet,physical activity, and patient andfamily education. The system forrecording activities indicated whatinformation should be recorded inthe patient file, what documentsshould be stored in the patient file,and what should be recorded inother data collection systems. Next,the team brainstormed (e.g., aired

opinions about what happened andwhen under the then-currenttreatment) and flowcharted the then-current process.

Step 2: Define CMM format.Defining the format was challengingfor Jinja staff because they wereunfamiliar with CMMs. This informa-tion gap was bridged by presentinga table similar to Table 2. Thispresentation helped the teamconceptualize what their CMM wouldlook like. Note that activities arelisted down the left-hand side of thepage and that time proceeds fromthe left side to the right. The teamdecided that the map should fit inthe patient file and that the papershould (a) be thick so as not to teareasily and (b) be two differentcolors—one for the first page andanother for subsequent pages.

Step 3: Develop a draft CMM.Developing a draft CMM involveddeciding what text should appear on

the page, which cells in the tableshould be used for staff notation,etc. The team developed a clinicalprotocol for the management of pre-eclampsia, using as resources thedraft national guideline on themanagement of hypertensivedisorders during pregnancy,international guidelines from SafeMotherhood, and benchmarking.3

The team used the new protocol todevelop a list of activities to beperformed daily. The list specifiedmonitoring, tests, medications, etc.,and indicated who, by cadre, wouldbe responsible for each activity. Theprotocol did not fully define all theactivities and the frequency of all theactivities that had to be undertakenas part of treatment, so the teamengaged in discussion about whatshould be done in areas where theprotocol was not fully suitable. Forinstance, the protocol indicated thatblood pressure (BP) should be taken

3 Benchmarking is a means to improve a product, process, service, etc.; it involves identifying successful examples from anothersetting(s) and adapting the elements of those examples to the setting being improved. In this case, the principal investigator consultedexperts in the use of CMMs at The Johns Hopkins Hospital in Baltimore, MD.

Table 2

Example of a CMM Format Presented to Jinja Staff

Condition:

Timeline

Activities Day 1 Day 2 Day 3 Day 4

Consultations

Assessment

Treatment

Medication

Diet

Activity

Counseling


hourly, which was not feasible atJinja. To balance the desirable andthe feasible, the team agreed thatBP should be taken three times aday. A second example relates tothe urine protein test, normally doneby the laboratory. The team, whichincluded the senior laboratorytechnician, decided to teachselected staff members to conductthese tests.

The team was careful to make theCMM as easy to follow as possible.For instance, they decided that notonly would BP be taken thrice daily,but also that this activity wouldoccur with the change of shift and atthe same time that the fetal heartrate was assessed. This plancomplemented the CMM in remind-ing staff of the timing of theirresponsibilities. The team alsodiscussed problems related to drugstock-outs, broken equipment, andother issues that were resolved laterand are discussed below.

The team identified critical events,which are the signs and symptomsthat occur over the course of anillness that call for a change indiagnosis and/or therapy. Forinstance, convulsions (progressionto eclampsia) are a critical event forpre-eclampsia (and other illnesses)because they cause high risk to thepatient. The team identified convul-sions as a critical event and threeothers: blood pressure not loweringafter two days of treatment, fetalheart rate either increasing or

decreasing, and newborn notbreastfed. For each type of criticalevent, the team outlined how thecondition should be managed insuch event. The team developed thedraft CMM and an accompanyinginstruction sheet,4 which comple-ment each other to remind staffwhich actions must be taken andwhen, providing extra detail oncritical events. Lastly, the teamdecided that the pre-eclampsiaCMM should include a problem list;patient outcomes; and dischargeinformation, such as the follow-upappointment.

At this point, the draft CMM for pre-eclampsia looked similar to the finalversion (presented in Appendix A,the instruction sheet is in AppendixB). The final was 11" x 17.5" (foldedto 8.5" x 11" to fit in a file folder) andon heavy, colored paper. It alsodiffers slightly from the draft in bothtext and graphics because ofchanges made after a brief trialperiod.

Step 4: Define indicators formonitoring and identify person(s)responsible for collecting data.Indicators would show whether theCMM was effective in improving staffperformance to standards andpatient outcomes and whether thestaff were effective in implementingthe CMM. The team limited thenumber of indicators so that record-ing and collecting data would not beburdensome, and they were carefulto select indictors that could be

monitored over a sustained period.The four staff performance indica-tors were:

■ For assessment, proteinuria teston admission;

■ For monitoring, blood pressuremeasured three times per day;

■ For treatment, propanolol pre-scribed on admission, giventwice a day for at least two days;

■ For critical event management,magnesium sulfate (MgSO4)

5

given in the event of convulsion.

They also identified five otherindicators that were intended tocomplement the staff performanceindicators and measure the overalluse and impact of the CMM. Threeapplied to both PIHD and PPH andtwo applied to PIHD only:

■ Percentage of CMMs correctlycompleted (all CMMs),

■ Number of times per month whenpropanolol and MgSO4 were outof stock (PIHD only),

■ Percentage of patients admittedfor pre-eclampsia who pro-gressed to eclampsia (PIHDonly),

■ Percentage of staff who knowhow to use the CMM (all CMMs),and

■ Case fatality rate (all CMMs).

For these five indicators the teamidentified a data source, frequency

4 Written in a reader-friendly tone, the instruction sheet reminds staff why using the CMM is beneficial, how to use it, and how to treatpre-eclampsia. It opens with a definition of pre-eclampsia and then states, “This Case Management Map (CMM) is designed to help youmanage a patient with pre-eclampsia. To manage a patient well, we need to know several things, we need to monitor several things, andwe need to write this down so others can know what the patient’s situation is, what has been done and can help us manage the patient.”The instruction sheet then reminds staff to perform certain activities, such as requesting the patient’s name upon admission, checking BPthrice daily, and monitoring for convulsions and indicating on the CMM whether convulsions occurred.

5 MgSO4 is used to treat pre-eclamptic patients who have a convulsion, a life-threatening event that, among other things, signals that apre-eclamptic patient is becoming eclamptic, or critically ill. Diazepam was Uganda’s first-choice drug for convulsions at the time of thestudy, but our benchmarking had revealed that MgSO4 would be more effective.


of collection, and person respon-sible. Table 3 shows these indica-tors, sorted according to themonitoring timing.

Phase 3: ImplementationThe third phase of the plannedmethodology had two steps: Preparefor implementation and the imple-mentation itself. During this phase,staff who had not yet learned of theCMM would not only becomefamiliar with it, but also begin towork with it.

Step 1: Prepare for Implementa-tion. The team developed animplementation plan. They identifiedmajor changes linked with theadoption of the CMM and the staff,by cadre, who would be affected bythe change. For example, physi-cians would be affected by stan-dardization of the types of drugs tobe used, and midwives would beaffected by having to measure

Table 3

Monitoring Indicators for CMM for PIHD

Indicator

Indicators to monitor continuously

Percentage of CMMs correctly completed

Source of Data

CMMs

Frequency of Collection

Every 2 weeks for the first twomonths; monthly thereafter

Monthly

Person Responsible

Case manager

Number of times a month when propanolol andMgSO

4 were out of stock

Percentage of patients admitted for pre-eclampsiawho progressed to eclampsia

Indicator to monitor initially only

Percentage of staff who know how to use the CMM

Pharmacy stock cards Pharmacist

CMM Monthly Medical officer

Interview initially; laterretrospectively review CMMs

Indicator to monitor later

Case fatality rate from PIHD CMM

Weekly

Semi-annually

Co-principal investigator or casemanager

Co-principal investigator and themedical officer

proteinuria in newly admitted PIHDpatients and take their BP thricedaily.

During a staff meeting, the principalinvestigator explained the rationalefor using a CMM. A two-day trainingin both the new protocol for pre-eclampsia and using the CMM waspresented in May 1999. This wasalso the time to ensure that thenecessary resources were availableto follow the protocol. Propanolol(Inderal , Aldomet ) was recom-mended to replace alpha-methyl-dopa to be given at admission andthereafter to control BP. Adequatesupplies of propanolol had to beassured. We recognized that MgSO4

and blood pressure cuffs were not inplace and had to find ways toacquire them. Jinja received adonation of MgSO4, temporarilysolving the problem and allowing thestudy to proceed without MgSO4

procurement difficulties. When the

national guideline on PIHD wassubsequently revised to allow for theuse of MgSO4 in treating eclampsia,this drug became more readilyavailable.

We also needed blood pressurecuffs and, finding no other way toacquire them, the co-principalinvestigator purchased them withpersonal funds.

Step 2: Implement. The CMM, still indraft format, was introduced on thematernity ward on June 10, 1999. Itrequired several major changes toexisting hospital practices, includingstandardizing drugs, close monitor-ing of maternal blood pressure,testing urine protein on the ward,and recording of and initiallingactions taken. Some staff wereresistant to the changes; theirconcerns were presented at the staffand problem-solving meetingsdescribed in Phase 4.


Phase 4: Monitoring andEvaluationIn this two-step phase, the imple-mentation team set in motion theplan to determine whether theirefforts proved effective.

Step 1: Monitoring. SisterBabyerabira supervised and helpedstaff in using the CMM correctly. Shethought about ways the CMM couldbe changed to make treating pre-eclampsia easier, and she recordedthe number of CMMs used and thenumber correctly filled out.

Step 2: Problem solving. Problemsolving began after a month of CMMuse at a staff meeting where usersdiscussed the CMM experience. Theusage indicator showed that somestaff did not sign off on their tasks.Two measures were taken toaddress this shortcoming. First, staffwere reminded why this step isimportant in treating and monitoringeach patient. Second, the CMMformat was redesigned to makesigning off easier.

Another problem was that thephysicians were not performing thehyperreflexia test—called for by thenew protocol. This matter wasaddressed through a redesign of theCMM. We also redesigned theinstruction sheet to correct perfor-mance errors discussed at staffmeetings.

B. Planning and Imple-menting the Second CMMThis section describes the develop-ment of the CMM for PPH andfocuses on differences from theexperience of the first CMM. Onemajor difference was that Dr. AgelAkii and other staff managed thedevelopment and implementation ofthe second CMM largely on theirown. Another was that progress

proceeded much more quickly sincestaff was familiar with the concept ofa CMM and the processes involvedin developing and implementingone. While the first developmentprocess was quite formal, carefullyfollowing each step in order, thesecond was less so. The secondCMM was developed during fourmeetings, whereas the first took six.To start, we reviewed our notes onwhat had happened the first timeand contemplated what would bedifferent, what we should do differ-ently, and similar concepts.

Phase 1: Defining the ProjectStep 1: Select the diagnosis. Ourearlier discussions had led us tobelieve that PPH should be thesecond condition treated with aCMM. Though not high volume, itwas even more high risk than pre-eclampsia and more problem pronebecause of the frequent shortage ofblood. It did prove more difficult tomap, as discussed below, but doingso appeared feasible. Lastly, PPHrequires more than two people fortreating patients. The standards ofcare were communicated for PPHduring a staff meeting in September1999. The case definition was “Anywoman presenting after delivery withvaginal bleeding of 500 ml. or lessthan 500 ml. if signs of deteriorationof general status are present.” (WHO1997)

Step 2: Select the team. The PPHimplementation team was similar tothe pre-eclampsia team except thata different medical officer partici-pated, the pharmacist was notincluded because drug supply is nota difficulty in treating PPH, and threeinterns were added to the team.

Step 3: Define the scope of theCMM. Admission and dischargewere again selected as the start andend points of the treatment.

Phase 2: Developing the CMMPhase 2 required three meetings.

Step 1: Describe the currentmanagement process. At onemeeting, the team discussed thescope of the CMM and flowchartedthe current management process.

Step 2: Define the CMM format.CMM format and content were topicsof the next meeting. At this point, theteam reached its greatest diversionfrom its previous experience. Theyfaced the problem that PPH has fourmain causes (uterine atony, retainedplacenta, lacerations of cervix/uterus, and coagulation defects),whose treatments could not all fit onone sheet of paper (even 11" x17.5"). They decided to divide themap into three sections: admission,treatment, and discharge. Theystandardized the first and thirdsections (admission and discharge)on the CMM and precisely de-scribed treatment for each of thefour causes in the second section.Each treatment was printed onseparate sheets that could beselected on the basis of the causepresenting, and then that sheetwould be attached to the patient’sCMM.

Step 3: Develop CMM. The secondCMM was drafted; it looks much likethe first: large, heavy paper; differentcolors for the first page and subse-quent pages, and table format withactivities down the left and timeproceeding from left to right acrossthe top. The biggest difference isthat it has a longer instruction sheet.

Step 4: Define the indicators formonitoring and person(s) respon-sible for collecting data. The teamdefined four indicators of staffperformance to standard for PPH:

■ For assessment, hemoglobin teston admission;


■ For monitoring, vaginal blood losschecked daily;

■ For treatment, iron and folic acid(or Inferon®) prescribed duringstay;

■ For critical event management,transfusion given (or prescribed)in case of Hb<5g/l or shock.

Four other indicators were used tomeasure overall use and impact ofthe PPH CMM (shown in Table 3). Ofthe four, three applied equally to allobstetric complications, and onewas specifically related to PPH. Theywere:

■ Percentage of CMM correctlycompleted (all CMMs);

■ Times per month when iron andfolic acid (or Inferon®) are out ofstock (PPH only);

■ Percentage of staff who knowhow to use the CMM (all CMMs);and

■ Case fatality rate (all CMMs).

Phase 3: ImplementationStep 1: Prepare implementation ofCMM. The team prepared a two-daytraining workshop for the secondCMM, and team members learned ina fourth meeting how to participateas facilitators during the workshop.Plans were made to ensure thatneeded supplies and medicationswould be available, including ironand folic acid, X-pen Gentramycin,Amoxicillin, and Metronidazole.During training, the instruction sheetwas used to highlight changes in thetreatment protocol. Training againincluded small groups practicingcompleting the CMM.

Step 2: Implement CMM. The CMMwas implemented in February 2000,shortly after training and threemonths after the developmentprocess began.

Phase 4: Monitoring andEvaluationStep 1: Monitoring. The CMM teammet weekly after implementation,inviting a few people from the staff,to discuss problems in implementa-tion.

Step 2: Problem solving. Onemonth after implementation, ageneral meeting was held with theteam members and all staff toassess progress and problems. Aproblem-solving session was held,and feedback from the indicatorswas given to the staff.

IV. EvaluationMethodology

A. Research DesignEach study objective had its ownstudy design. A descriptive methodwas used to document the method-ology of developing and implement-ing a CMM. A quasi-experimental(before/after) design and a descrip-tive design were used to measurethe effect of the CMM use onperformance according to stan-dards, patient outcome, resourceuse, and provider satisfaction. Thedocumentation method was used todemonstrate that the effects onpatient outcome and resource useare dependent on compliance withstandards. The expectations werethat performance according tostandards of clinical care wouldimprove, case fatality rate woulddecrease, average length of staywould decrease, and providers’attitudes and perspectives wouldchange. We thought the differentlength of use for each CMM (eightmonths for PPH versus 12 for PIHD)might also result in different effectson performance to standards.

A simple before/after study wasdeemed insufficient to test theintervention and adequately demon-strate the effect of the use of a CMM:Contamination was an issue, asPIHD and PPH were managed onthe same ward. That is, staff whohad worked with the CMM for PIHDmight show an increased perfor-mance in managing PPH, anincrease not creditable to the PPHmap. To address this, we decided tohave a control group of patientsadmitted to the gynecological wardwho also had a serious condition.Our rationale was that the nursingstaff was different, avoiding contami-nation. The head of the ward was theco-principal investigator of thisstudy, which was advantageous:Since the same person communi-cated standards to both groups,consistent communication across allthree conditions was ensured. Thecontrol group consisted of patientswith acute pelvic inflammatorydisease (PID). Their records wereabstracted for performance accord-ing to standards.

B. Study SampleThe study sample comprised allpatients hospitalized with PIHD orPPH in the maternity ward and allpatients with PID in the gynecologi-cal ward. Inclusion criteria weredefined as:

PIHD: “Any woman pregnant, inlabor or having recently delivered,presenting with or developing a BPof 140/90 or more and/or edema,signs of proteinuria, headache,dizziness but without convulsions”(WHO 1997).

PPH: “Any woman presenting withvaginal bleeding of 500 ml. or lessthan 500 ml. if signs of deteriorationof general status, after delivery”(WHO 1997).


Acute PID: “Any woman presentingwith low abdominal pain, vaginaldischarge, tenderness or guardingat pelvic examination and fever(38.5 C)” (Holmes et al. 1990).

Patients admitted for the above-mentioned conditions from June 15,1998, to June 14, 1999 (12 monthsbefore the introduction of the pre-eclampsia CMM), and from Septem-ber 15, 1999, to September 14, 2000(12 months after the introduction ofthe first CMM), were included in thestudy. The period June 15, 1999, toSeptember 14, 1999, was a transi-tion period during which the pre-eclampsia CMM was being intro-duced.

C. Process and OutcomeIndicatorsWe measured four categories ofindicators: performance accordingto standards, patient outcomes,resource use, and provider attitudesand perspectives.

Performance according to stan-dards. The management of eachcondition differs, so designing a wayto compare performance acrossconditions was challenging. Foreach condition, we identified “keytasks” that, if not performed accord-ing to standard, would compromisethe clinical decision-making processand sound case management. Thecriteria used to select tasks were:similar types of staff (e.g., nurses,physicians, lab technicians) wereinvolved in the performance of theselected tasks, and each selectedtask had to require about the sameamount of work. Four key tasks wereselected for each condition (Table4).6 Three relate to normal manage-ment. We chose one task from eachof three categories: assessment,patient monitoring, and treatment.The fourth task related to themanagement of a critical eventduring hospitalization.

Patient outcomes. Case fatality ratewas the main indicator of patientoutcome. For PIHD, we also in-

6 Obviously, the management of a patient requires more than four important tasks, but for our purposes we restricted the number studiedto four.

Table 4

Key Tasks for Each Obstetric Condition

Type of Management Function

Assessment

PIHD

Proteinuria test on admission

PPH

Hemoglobin (Hb) test on admission

Acute PID

Complete blood count (CBC) onadmission

Temperature taken twice a dayVaginal blood loss checked dailyBlood pressure measured three timesa day

Propanolol prescribed on admission,given twice a day for at least 2 days

Monitoring

Iron and folic acid (or Inferon®)prescribed during stay

3 antibiotics prescribed concur-rently during stay (Gentamycin,Metronidazole, and Ampicillin orPenicillin)

Laparotomy performed in case ofperitonitis or pelvic abscess

Treatment

Treatment/critical event

Transfusion given (or prescribed)in case of Hb<5g/l or shock

MgSO4 given in case of convulsion

Normal management

Management ofcritical event

cluded neonatal outcome (propor-tion of stillbirths) and the percentageof women progressing from pre-eclampsia to eclampsia.

Resource use. Resource use wasmeasured by length of hospital stay.

Provider attitudes and perspec-tives. Provider attitudes andperspectives toward CMM use wereassessed with a qualitative surveyadministered to doctors, midwives,and senior nursing officers. Thesurvey assessed the ease ordifficulty providers had in using theCMM; perceived effects of the CMMon providers, including changes incommunication among them; andprovider satisfaction with the CMM.

D. Data CollectionInstruments and ProceduresA tool was developed to abstractrecorded data on process andoutcome indicators from a retrospec-tive review of medical records for thethree diagnoses. The tool was usedto collect data on provider perfor-


mance according to standards andon patient outcomes for all patientsadmitted with suspicion of eachcondition during a period before theCMM was introduced (called the“before” period) and again during aperiod after its introduction (calledthe “after” period).

The pre-eclampsia CMM wasintroduced in June 1999, so data onPIHD and PID patients were ob-tained for the 12-month period June15, 1998, through June 14, 1999(before), and the 12-month periodSeptember 15, 1999, throughSeptember 14, 2000 (after). A thirdround of data collection obtainedfollow-up data on PIHD performanceto standards during the periodSeptember 2000 to January 2001.The PPH CMM was officially intro-duced in February 2000, approxi-mately eight months after theintroduction of the pre-eclampsiaCMM, but was being used informallyfor a while before its official introduc-tion. Before data on PPH were alsocollected during the same 12-monthperiod as PIHD and PID (June 15,1998, through June 14, 1999), butafter data were obtained only for the8.5-month period from January 1,2000, through September 14, 2000,and compared to PID for the 12-month after period September 15,1999, through September 14, 2000.The numbers of cases encounteredin the retrospective record review inthese periods were: PIHD (before =36, after = 50, follow-up = 21), PPH(before = 20, after = 10), PID (before= 37, after = 29).

In addition to the record-abstractingtool, an event-tracking chart wasused to document all changes instaffing, the facility, the blood bank,collaborating agencies, and accessduring 1999 and 2000. Dr. AbbyZziwwa, the medical anthropologist,

developed a survey for providers toassess provider satisfaction with theCMM. The provider survey obtainedopinions from 11 providers on theuse of the CMMs.

E. Data AnalysisData from the record abstractionwere keyed into EPI Info from therecord abstraction tools. Proportionsand relative risk (RR) were calcu-lated for the process and outcomeindicators.

V. Results

A. Comparability of StudyGroupsFor each of the diagnoses, wecompared the sample of womenhospitalized before the CMM wasintroduced with the sample ofwomen hospitalized afterward. ForPIHD the before and after groupsdid not differ significantly on placeof residence, mean age, referralsource, parity, or diastolic bloodpressure on admission (Table 5).

Table 5

Characteristics of Women with PIHD by Study Group

Before CMM (N = 36) After CMM (N = 50) Test of Significance

Place of residence:*Jinja District:Metro Jinja 9 (25.7%) 16 (32.0) Chi-sq = 3.10Rural Jinja 13 (37.1%) 24 (48.0%) p>0.2Outside Jinja District:Mukono 10 (28.6%) 8 (16.0%)Others (Iganga, Kamuli) 3 (8.6%) 2 (4.0%)

Age in years: Mean [SD] 24.1 [6.4] 24.2 [6.0] T-test: t>0.2

Age categories:<18 years 5 (13.9%) 2 (4.0%) p>0.218–34 years 30 (83.3%) 47 (94.0%)35+ years 1 (2.8%) 1 (2.0%)

Referral source:Self 13 (36.1%) 23 (46.0%) Chi-square = 0.84Medical staff 23 (63.9%) 27 (54.0%) p = 0.36Jinja OPD as % of total 8 (22.0%) 15 (30.0%)

Parity: Mean [SD] 3.2 [3.2] 3 [2.9] T-test: t = 0.3 p>0.2

Gravida-para:Primi 19/36 (52.8%) 21/50 (42%) p = 0.182–5 9/36 (25.0%) 22/50 (44%)Multi (>5) 8/36 (22.2%) 7/50 (14%)

Diastolic BP on admission:Mean [SD] 102.5 [15.9]** 99.7 [13.3]*** p>0.2Median 100 100

* Comparison between two groups (Jinja District and outside: p = 0.07); ** Recorded for 32/36patients = 89%; *** Recorded for 47/50 patients = 94%; “SD” means standard deviation; “OPD”means outpatient department.


However, the before group had morepatients from outside Jinja District.Although this difference is notsignificant, there may have been atendency to admit more patientsfrom Jinja District itself.

The 20 patients in the PPH beforegroup did not differ significantly fromthe 10 patients in the PPH aftergroup with respect to place ofresidence, mean age, referralsource, parity, or place of delivery(Table 6).

For PID (the control illness), the 37patients in the before group did notdiffer significantly from the 29 in theafter group with respect to place ofresidence, mean age, referralsource, or parity (Table 7).

B. Use of CMMObstetric staff began using the CMMfor pre-eclampsia after implementa-tion on June 10, 1999. During thefollowing three months (until Sep-tember 14, 1999), 64 women wereadmitted with suspicion of PIHD. Ofthese, 63 (98.4%) had the new CMMused in the management of theircases. This indicates that the CMMwas universally accepted and usedfor essentially all of the pre-eclamp-sia patients.

C. Performance Accordingto StandardsKey tasks for normal management ofeach condition (see Table 4) wereused as indicators to measureperformance according to stan-dards. It is likely that there wasunderreporting during the beforeperiod that was reduced in the afterperiods, which, if correct, wouldmean that the increases were lessthan reported here. The results ofthese measurements follow and arein Table 8.

Table 6

Characteristics of Women with PPH by Study Group


Place of residence:*Jinja District:Metro Jinja 4 (20.0%) 1 (10.0%)Rural Jinja 110 (50.0%) 3 (30.0%))Outside Jinja District:Mukono 1 6 (30.0%) 2 (20.0%)Others (Iganga, Kamuli) 0 (0.0%) 4 (4.0%) Fisher exact

(regrouped) p = 0.12

Age in years: Mean [SD] 25.6 [6.2] 24.5 [6]

Age categories:<18 years 1 (5.0%) 1 (10%)18–34 years 17 (85.0%) 9 (90%) p>0.235+ years 2 (10.0%) 0 (regrouped))

Referral source:Self 12 (60.0%) 8 (80%)Trained medical staff 8 (40.0%) 2 (20%) Fisher exact p = 0.25

Parity: Mean [SD] 4.2 [2.6] 4.0 [2.9]

Parity:Primi 4 (20%) 2 (20%)2–5 9 (45%) 4 (40%) p>0.2>5 7 (35%) 4 (40%)

Place of DeliveryHome 2/19 (10.5%) 2 (20%) Home vs. all others:

p>0.2Hospital unit/maternity 11/19 (58%) 2 (20%)Jinja Maternity 6/19 (31.5%) 6 (60%) Jinja maternity vs. all

others:Fisher exact(1-tailed) p = 0.14

Pregnancy-InducedHypertensive DisordersAll indicators of provider perfor-mance for PIHD experienced largeand highly significant improvementsafter the introduction of CMM (Table8). The observed changes reflect amix of actual increases in monitoringblood pressure and urine proteinplus improvements in recording.....When managed with the help of a

CMM, patients were almost twice aslikely to have a proteinuria test doneon admission (RR = 1.95; [1.31–2.91]) and 25 times more likely tohave their blood pressure takenthree times a day (RR = 25.75 [3.71–178.35]). They were four times morelikely to be prescribed propanolol onadmission and for at least two daysas the drug of first choice (RR =4.25, [2.81–8.24]).


Table 7

Characteristics of Women with Acute PID by Study Group


Place of residence:*Jinja District:Metro Jinja 6 (16.2%) 5 (17.2%) Chi-sq = 0.71;

df = 3; p>0.20Rural Jinja 16 (43.2%) 10 (34.5%)Outside Jinja District:Mukono 7 (18.9%) 7 (24.1%)Elsewhere 8 (21.6%) 7 (24.1%)

Age in years: Mean [SD] 31.4 [9.9] 30.1 [7.9] t = 0.55; p>0.2

Age categories:<18 years 0/36 (0.0%) 1/28 (3.6%) p = 01418–34 years 22/36 (61.1%) 21/28 (75.0%)35+ years 14/36 (38.9%) 6/28 (21.4%

Referral source:Self 30 (81.1%) 21 (72.4%) Chi-sq = 0.70Trained staff 7 (18.9%) 8 (27.6%) p>0.2

Parity: Mean [SD] 33.4 [2.3] 3.3 [2.5] T-test: t = 0.15 p>0.2

* Comparison between two groups (Jinja District and outside Jinja: p = 0.29).

Postpartum HemorrhageFor the management of postpartumhemorrhage, the difference inperformance is not significant. Thismay be due to the small numbersinvolved: Only 10 patients presentedafter CMM implementation. However,the indicators for the investigationand monitoring of PPH both show anupward trend, with performancerising higher the longer the CMMwas in effect. The trend is significantfor hemoglobin tests performed onadmission (RR: 1.52; [0.52–4.43],Fisher exact p>0.2 [1 tailed]), andfor vaginal blood loss checked daily(RR = 3 [0.42<RR<17.16], X2 Fisherexact: p = 0.15 [1 tailed]). However,no trend was observed for thetreatment indicator (iron and folicacid, or Inferon®): (RR = 0.33 [0.05–2.41], X2 Fisher exact: p = 0.23 [1tailed]).

Table 8

Percentage of Cases Performed According to Standards for Normal Management,Before and After Implementation

BEFORE AFTER Diagnosis/ Task N Number Correct Percent Correct N Number Correct Percent Correct RR Significance Level

PIHD (program)Urine test 27 13 48.1 50 47 94.0 1.95 P<0.001BP thrice per day 33 1 3.0 50 39 78.0 25.75 P<0.001Propanolol 33 7 21.2 50 45 90.0 4.25 P<.001SUM/POOLED 93 21 22.6 150 131 87.3

PPH (program)Hemoglobin test 19 5 26.3 10 4 40.0 1.52 p>0.2Blood loss 4 1 25.0 8 6 75.0 3 p = 0.15Iron & Folic acid 20 6 30.0 10 1 10.0 0.33 p = 0.23SUM/POOLED 43 12 27.9 28 11 39.3

PID (control)CBC 37 1 2.7 29 0 0 0 p>0.2Temp twice per day 37 0 0 29 0 0 03 antibiotics 37 16 43.2 29 18 62.1 1.44 p = 0.2SUM/POOLED 111 17 15.3 87 18 20.7

N is the sample size for the task (e.g., urine test once, BP three times) that should have been performed. “Temp” means “temperature taken.”


1009080706050403020100

Before After

Acute Pelvic InflammatoryDiseaseThe management of patients in thecontrol group did not differ signifi-cantly before and after (Table 8). Theperformance of a complete bloodcount on admission did not changesignificantly (X2 p>0.2). Temperaturewas never taken twice a day in bothgroups. Ampicillin (or Penicillin),Gentamycin, and Metronidazolewere more likely to be given jointlyand parentally on admission afterthe communication of the treatmentprotocol (RR = 1.44 [0.9–2.29]),but not to a significant degree(X2 p = 0.2).

Number of Tasks PerformedCorrectlyStaff using the CMM to managePIHD patients were 19 times morelikely to perform all three key tasksthan if no CMM was used (RR =19.44 [2.77–136.56], X2 p<0.001;see Table 8). For the PPH and PIDgroups, staff never performed allthree key tasks, so no comparisonscould be made. Staff were also morelikely to perform at least one keytask following the introduction of theCMM. For PIHD patients it was fivetimes more likely after introduction ofthe CMM than before (X2 p<0.001,RR = 4.94 [2.53–9.62]), and for PPHpatients it was twice as likely withthe CMM (X2 Fisher exact: p= 0.01[1-tailed], RR = 2.25 [1.27–4.00]).There was no significant differencein the correct performance of one ormore key tasks for PID patients inthe two time periods (X2 p>0.2).

Figure 2 depicts the averagenumber of tasks performed tostandard for the three conditionsbefore and after introduction of themaps. It shows that the increase inperformance was largest for PIHD(from 22.6% to 87.3%), while for PPHperformance increased but not

significantly; and for PIH, the controlcondition, it increased only a smallamount.

Pooled Key TasksWe computed the number of tasks(out of three) performed to standardfor each case. Figures 3, 4, and 5show the distribution of the numberof tasks performed correctly (0–3)before and after introduction. Moretasks were performed to standardafter introduction than before for allthree conditions. For PIHD, no taskswere performed correctly for mostcases (81%) before, whereas afterintroduction, most cases had two(28%) or three (54%) cases per-formed correctly (see Figure 3). ForPPH, most cases had none or onetask performed to standard before,compared to one or two tasksperformed correctly after (see Figure4). For PIH, all cases before andafter had none or one case per-formed to standard, and never 2 or 3(see Figure 5).

Figure 2

Increase in Percentage of theThree Normal Management

Tasks Performed to Standard

Percent

PIHD PPH PID

Figure 3

PIHD: Percentage of PooledKey Tasks CompletedCorrectly for Normal

Management Before andAfter Introduction of CMM

100908070605040302010

0

Before (n = 93) After (n = 150)

Percent

0 1 2 3

Tasks performed correctly: Protein urea test onadmission, BP 3x/d, proponolol

20.722.6

87.3

27.939.3

15.354

81

4 14 4 328

3

Figure 4

PPH: Percentage of PooledKey Tasks CompletedCorrectly for Normal

Management Before andAfter Introduction of CMM

8070605040302010

0


Percent

0 1 2 3

0 0

60

11

35

68

5 21

Tasks performed correctly: Hb test onadmission, blood loss checked daily, iron andfolic acid


80706050403020100


Percent

0 1 2 3

Figure 5

PID: Number of Pooled KeyTasks Completed Correctlyfor Normal Management

Before and AfterIntroduction of CMMs for

Other Diagnoses

54

0 0 0 0

624638

Tasks performed correctly: CBC on admission,temp 2x/d, 3 antibiotics parentally

D. Patient OutcomesPregnancy-InducedHypertensive DisordersNeonatal outcome (percentage ofstillbirths), maternal outcome(percentage of women with pre-eclampsia proceeding to eclamp-sia), and case fatality rate weremeasured for each diagnosis.Patient outcome data were notcollected for pre-eclampsia patientswho were discharged beforedelivery or left the hospital againstmedical advice, so sample sizes forpatient outcome indicators werereduced accordingly. For the womenwho stayed in the hospital, all threeoutcome rates improved afterintroduction of the CMM, but noimprovement was statisticallysignificant (Table 9).

Table 9

Patient Outcomes Resulting from the PIHD CMM

Indicator Before (6/98–5/99) After (9/99–8/00) Relative Risk

Patient outcomesCases that progressed to eclampsia* 11.1% (4/36) 8.0% (4/50) 0.72, p = 0.45

Stillbirths to women admitted for 38.1% (8/21) 16.2% (6/37) 0.43, p = 0.06pre-eclampsia*

Case fatality rate 5.9% (2/34) 4.1% (2/49) 0.69

* Some patients were discharged before delivery or left the hospital against medical advice, causing areduction in sample size.

Postpartum HemorrhageDuring the study period, eightwomen with PPH died: one beforethe CMM protocol was designed orintroduced, two after it was de-signed but before its introduction,and five after it was put in use. Thisabrupt increase in deaths from PPHjust as the CMM was introduced isdifficult to interpret. It is difficult toimagine how the use of a CMMmight have contributed to thosedeaths. These five deaths occurredshortly after admission.

Retained placenta was the cause offive of the eight (63%) deaths fromPPH. In these cases, the patientsdelivered at home and either arrivedtoo late in the maternity ward toobtain a blood transfusion beforedying (3/5) or else a blood transfu-sion could not be given for lack ofblood (2/5). Of the five deaths thatoccurred during CMM use, twofollowed the pattern just described,one presented with coagulationdisorders after an intrauterine fetaldeath, one died of cerebral malaria,and one suffered a cervical tear afterthe delivery of twins where bloodtransfusion was prescribed but nonewas available.

Acute Pelvic InflammatoryDiseaseThere was only one death in thisgroup during the study period.

E. Resource UseFor patients with pre-eclampsia, theaverage length of stay increasedwith use of the CMM from 11.3 to17.4 days. For PPH patients itdecreased from 4.6 to 2.9 days(Table 10).

F. Providers’ Attitudes andPerspectivesEleven providers (two doctors, foursenior nursing officers, and fivemidwives) were interviewed to elicittheir perspectives on the introduc-tion and use of the CMM for PIHD(Sebina-Zziwwa 2001).

All providers appreciated themanagement of PIHD through theuse of a CMM. They found it easy touse and thought it contributed tobetter availability of medicines. Inaddition some said that it:

■ Fostered self-confidence amongproviders (less consultation withhigher-ranking staff);


■ Gave patients confidence innurses, which improved commu-nication;

■ Revealed more than a writtenreport would;

■ Allowed easy planning of activi-ties and interventions withpatients;

■ Energized the staff. Nurses,laboratory technicians, andpharmacists were all morecareful, and the nursing staff canrun the ward more smoothly andeffectively;

Table 10

Length of Hospital Stay by Diagnosis, in Days

During CMM During CMM Significance of Before-During Diagnosis Statistic Before CMM (Entire Stay) (CMM Stay Only)1 (Entire Stay) Difference2

PIHD N 29 50 50 Mean 11.3 17.4 8.1 p = 0.079

SD 13.0 15.5 6.7 F = 3.15Median 8 12 NA

PPH N 17 10 10 Mean 4.6 2.9 1.4 p = 0.40

SD 5.2 5.4 2.6 F = 0.65Median 3 0.5 NA

PID (with outlier)3 37 NA NA Mean 8.2 NA NA p = 0.54

SD 17.4 NA NA Median 5 NA NA

PID (without outlier)3 36 NA NA Mean 4.9 NA NA p = 0.30

SD 2.4 NA NA Median 5 NA NA

■ Made staff feel that maternalmorbidity/mortality had de-creased;

■ Did not decrease workload on theward because not all staff meetCMM requirements;

■ Changed communication andattitude of staff when monitoringpatients;

■ Increased the number of PIHDpatients, perhaps due to Jinja’senhanced reputation and/orpatients’ better understanding ofpre-eclampsia.

1 During the use of the CMM, we differentiated between the total length of stay in the hospital and that portion of the total stay during which a CMM was usedto manage care. For example, after PIHD patients’ blood pressure had normalized, they sometimes stayed in the ward because of another medical indication,or, if there were multiple pregnancies, PIHD developed while the patient was under observation on the ward. This column contains measurements only for theportion of the stay managed with a CMM.

2 Significance applies to the difference between the “Before” CMM length of stay and the entire “During” CMM length of stay.

3 One PID patient (“outlier”) stayed in the hospital a long time.

“NA” means not applicable.Some informants’ direct and per-sonal excitement were echoed interms of:

“It fosters closeness between patientand provider as patients inquiremore about their condition; theyeven request that their bloodpressure be taken.”

“Care on our ward has improved somuch that pre-eclamptic patientsfrom the private wing move to ourwing because of the proper man-agement through the CMM.”

“It has made the work easy; we canidentify mothers who need monitor-ing and take appropriate steps.”


“We now get fewer ‘fitting’ mothers.”

“I can work independently even inan outreach center because I havelearned the new variety of drugs togive; they were unknown to mebefore.”

Through visual plotting, somemothers and their attendants wereable to understand and appreciatehypertension in pregnancy as adangerous sign (disease). Theyreported,

“Once the mothers note and observeothers with charts, they are quick toaccept their condition.”

“Before, people thought thateclampsia was due to other things,7

but now they understand it better.”

Very few problems were mentioned.One related to increased workloadfor a few who found the bloodpressure recording demanding.They could not avoid it as they hadpreviously, when task performancedid not have to be regularly docu-mented. Another related to mothersnot willing to stay in the hospital,which makes fully applying the CMMimpossible. For PPH, there were alsoconcerns relating to the difficulty inidentifying abnormal bleeding. Atypical response was: “With PPH, itis difficult because bleeding afterbirth is normal and it is not easy totell heavy bleeding from normal.”

We could interview only two patientswhose care had been managed witha CMM. One had delivered, and theother was being treated for pre-eclampsia related to a multiplepregnancy. Both expressed theirsatisfaction and appreciated theregular attention from the staff.

VI. Discussion andConclusions

We believe that the improvement inperformance to standard in the PIHDgroup was due to the developmentand use of the CMM. We note thatperformance did not changesignificantly in the PPH or controlgroup.

The observed improvements in PIHDperformance are probably due to theprocess of developing the CMM andthe new protocol as well as the mapitself. The development processincluded many steps, several ofwhich are likely reasons for theapparent success of the interven-tion. The steps most likely to haveimproved staff performance arereviewing and modifying casemanagement standards; ensuringthat adequate drugs and equipment(i.e., blood pressure cuffs) areavailable; and possibly mostimportant, the involvement of keyhospital staff members. The resultingteam building and strong sense ofownership contributed to (1) theuniversal use of the CMM after it wasintroduced and (2) efforts to reducemedicine stockouts and find neededequipment and supplies. Thesuccess of the CMM in improvingthe quality of care is dependent on acontinuous supply of medicines,availability of necessary monitoringequipment, and sufficient physiciansto guarantee proper monitoring.

It is possible that the change inperformance was not really achange of performance per se, butsimply an improvement in documen-tation of performance. Betterrecording alone would be of somevalue, but there is good evidence

that the performance itself didindeed improve. This is supportedby several facts:

1. Recording of medications wasalways good at Jinja Hopspital.When the drug of choice formanaging PIHD changed fromalpha-methyl-dopa to propanolol,the frequency of notation did notchange, but the prescriptionpattern did.

2. In the qualitative survey of theproviders, one reported that theCMM “helps us to be moreconcerned and responsiblebecause everyone has a role toplay. We cannot be careless.Before, one could neglect to takethe blood pressure; now you haveto do it and sign that you did.”

3. The four indicators for PIHD thatimproved are very specific to pre-eclampsia care. They are notgeneral indicators that are likelyto be influenced by other condi-tions.

4. The performance indicators,outcome indicators, and provideropinions all reinforce one another.Thus, the improvement in patientoutcomes implies that theimprovement in provider perfor-mance is substantially due toactual improvements in monitor-ing and not just to improvementsin recording.

Patient management according toevidence-based clinical guidelinesshould lead to more favorablepatient outcomes. In this study, weobserved that with the CMM therewas a significant increase inperformance according to clinicalstandards as measured by theperformance of key tasks for PIHD.

7 This statement reflects a common local belief that pre-eclampsia and eclampsia are caused by adultery or witchcraft.


We therefore would expect a morefavorable patient outcome for PIHDpatients who are managed with aCMM. There was some evidencethat managing PIHD patients with aCMM resulted in a more favorablepatient outcome, as evidenced bythe trend toward fewer stillbirths,fewer progressions to convulsions,and fewer deaths while in thehospital. However, none of thesechanges was statistically significant.

Improvements in the performanceand outcome indicators for PPHwere not as clear-cut. Severalfactors may explain this. (1) Thesample of 10 was very small, makingone wonder if the CMM was used forall PPH patients during the studyperiod. (2) The increase in deathsfrom PPH that occurred at the timethe CMM was introduced is perplex-ing. The analysis indicates that PPHdue to a retained placenta was themost frequent reason for the hemor-rhage. Further analysis revealed thatthe five patients who died with PPHwere severely ill upon admission,and two had very difficult-to-manageand rare conditions—cerebralmalaria and coagulation defectsfollowing an intrauterine fetal death.The CMM for PPH does not stan-dardize for the management of theroot cause of hemorrhage, but itencourages a more thoroughassessment of the patient onadmission and more adequatefollow-up of the patient after theintervention on the root cause. (3)We explored the possibility of achange in referral patterns perhapsrelated either to intensified districthealth activities (which were indeedgoing on) or news of the improvedcare at Jinja Hospital, but found noclear evidence for such effects. (4)The PIHD CMM was introduced sixmonths before the CMM for PPH,and therefore had more time to be

effective. This suggests that theimpact of CMM on compliance mayincrease with time. Patient outcomesincreased significantly in PIHD withlonger time use, but did not increasein PPH. (5) Finally, it may be that theCMM is better suited to PIHD, whichresponds well to case management,than to PPH, an emergency withmultiple causes.

Limitations to this study include thesmall sample sizes, particularly inthe PPH group. The total number ofpatients involved during the 18months of observations was 86 forPIHD (36 before and 50 after) and30 for PPH (20 before and 10 after).Factors other than the program, asyet unanalyzed, may have contrib-uted to the observed improvements,especially activities occurring duringthe study period. Another concern isthe effect of the patients who left thehospital before delivery and forwhich we have no outcome data.Follow-up with these patients wouldindicate whether their absencebiased the results. Finally, it isimportant to remember that theintervention included both the CMMsand the development process. Forinstance, the local staff purchasedsupplies with their own funds toinsure the standards implicit in thePIHD CMM could be met; withoutthis part of the process, lessimprovement would likely haveresulted.

VII. Recommendations

This study has shown that casemanagement maps can be devel-oped and used in a developingcountry setting. They were wellreceived by the staff, who valued theCMMs both as a job aid and as amedical record.

The intervention improved compli-ance with clinical standards of carefor PIHD and to a lesser extent forPPH. Even in the face of a majorchange in the treatment protocol forPIHD, in which alpha-methyl-dopawas replaced by propanolol, thenew standards were fully followed.The study shows that CMMs,through the process of their devel-opment and subsequent use, can beuseful tools for the communication,adaptation, and adherence tonational clinical guidelines.

In the light of the achieved results,we recommend introducing the pre-eclampsia CMM in other settings,with one caveat. The substantialimprovement in performanceaccording to standard, along withthe improved understanding andenthusiastic acceptance by hospitalstaff are a strong argument forwidespread introduction of CMMs forPIHD care throughout Uganda andpossibly in other countries. However,it is important to determine therelative contributions of the CMMitself and the development processbefore widespread applicationbegins. We recommend its imple-mentation and evaluation in a settingwhere a larger study sample andmore reliable estimates are possibleso that the relative contribution ofthe CMM and the developmentprocess can be ascertained.

CMMs for other conditions besidesPIHD should be developed and,when successful, introduced widely.Further testing should be done withthis CMM for PPH to answer theseveral questions raised about thestudy methodology and its efficacy.Lastly, CMMs for other types of careand settings should be developedand evaluated in light of what waslearned in this study; they should beapplied when proven successful.


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Outcomes of hospital-based managed care: A multivari-ate analysis of cost and quality. Obstetrics &Gynacology 86(5):809–14.

Coffey RJ, Richards JS, Remmert CS, LeRoy SS, SchovilleRR, and Baldwin PJ. 1992. An introduction to criticalpaths. Quality Management in Health Care 1:45–54.

Coffey R.J, Othman E, and Walters J. 1995. Extending theapplication of critical path methods. Quality Manage-ment in Health Care 3(2):14–29.

Edson W, Boucar M, Djbrina S, Mahamane I, and WareHW. 2003. Improving adherence to cotrimoxazole forthe treatment of childhood pneumonia in Niger. Opera-tions Research Report 2(10, revised). Bethesda, MD:Published for the U.S. Agency for International Develop-ment (USAID) by the Quality Assurance Project.

Edson WN, Koniz-Booher P, Boucar M, Djbrina S, andMahamane I. 2002. The role of ressearch in developingjob aids for pneumonia treatment in Niger. InternationalJournal for Quality in Health Care 14Supp1:35–45.

Edward-Raj A and Phiri RK. 2002. Assessing the function-ality of job aids in supporting the performance of IMCIproviders in Zambia. Operations Research Report 2(8).Bethesda, MD: Published for the U.S. Agency forInternational Development (USAID) by the QualityAssurance Project.

Gaucher EJ and Coffey RJ. 1993. Total Quality in HealthCare–From Theory to Practice. San Francisco: Jossey-Bass, Inc.

Holmes KK, Sparling PF, Mardh PA, Lemon SM, StammWE, Piot P, and Wasserheit JN (eds). 1990. SexuallyTransmitted Diseases, 2nd ed. New York: McGraw-Hill.

Jaggers L. 1996. Differentiation of critical pathways fromother health care management tools– Commentary.American Journal of Health-System Pharmacy 53,February 1 1996.

Knebel E, Lundahl S, Edward-Raj A, and Abdallah H. 2000.The use of manual job aids by health care providers:What do we know? Operations Research Issue Paper1(1). Bethesda, MD: Published for the U.S. Agency forInternational Development (USAID) by the QualityAssurance Project.

Lahie J, Burkhalter BR, Kelley E. 2001. Proceedings of aJob Aids Symposium, International Trade Center,Washington, DC. Bethesda, MD: Published for the U.S.Agency for International Development (USAID), theQuality Assurance Project, and the CORE group by theCenter for Human Services, May 24, 2001.

McCarthy J and Maine D. 1992. A framework for analyzingdeterminants of maternal mortality. Studies in FamilyPlanning 23(1):23–33.

Mozena J and Black S. 1996. Clinical guidelines develop-ment: An algorithm approach. Gaithersburg, MD: AspenPublishers.

Oberer D and Auckerman L. 1996. Best practice: Clinicalpathways for uncomplicated births. Best PractBenchmarking Health Care 1:43–50.

Omaswa F, Burnham G, Baingana G, Mwebesa H, andMorrow R. 1997. Introducing quality improvementmanagement methods into primary heath care servicesin Uganda. Bulletin of the World Health Organization75(2):155–61.

Pearson SD, Goulart-Fisher D, and Lee TH. 1996. Criticalpathways as a strategy for improving care: Problemsand potential. Annals of Internal Medicine. 125(5):427–28.

Schriefer J. 1994. The synergy of pathways and algo-rithms: Two tools work better than one. Joint Commis-sion Journal on Quality Improvement 20(9):949–54.

Schriefer J. 1995. Managing critical pathway variances.Quality Management in Health Care 3(2):30–42.

Sebina-Zziwwa A. 2001. Impact of the Introduction of CaseManagement Maps in the Emergency Obstetrical Carein Jinja Hospital Uganda. Makerere Institute of SocialResearch, Makerere University, Uganda.

Tavrow P, Shabahang J, and Makama S. 2002. Vendor-to-vendor education to improve malaria treatment by drugoutlets in Kenya. Operations Research Results 2(2).Bethesda, MD: Published for the U.S. Agency forInternational Development (USAID) by the QualityAssurance Project, Center for Human Services.

Tsuyuki RT, Teo KK, and Montague TJ, for The ClinicalQuality Improvement Network (CQIN) Investigators.1998. Influence of a Critical Path Management Tool inthe Treatment of Acute Myocardial Infarction. AmericanJournal of Managed Care 4(9):1243–51.

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Zander K. 1992. Critical pathways (Chapter 9) in Melun Mand Sinioris M, eds. Total quality management: Thehealth care pioneers. Chicago: American HospitalAssociation.


Appendix A: Case Management Map for Pre-Eclampsia

CaseManagementMap(CMM)

Serial / IP number

Identification number

Check 3x/dayBlood Pressure 200

180

160

140

120

100

80

60

Fetal Heart Rate170160150140130120110100

Convulsions*Initials ➾

Check 1x/dayEdemaWeight

HyperreflexiaProteinuria

GiveInderal 80 mg BD

Aldomet 250(-500 mg) tdsDiazepam 5 mg tds

CounselRestricted salt

Bedrest left sideBreastfed*

* or = Possibility of critical event

Check Newborn

Starting Page

200

180

160

140

120

100

80

60

Result Initial Result Initial Result Initial

D E NDate / /



Systolic

Diastolic

200

180

160

140

120

100

80

60

200

180

160

140

120

100

80

60

170160150140130120110100

170160150140130120110100

170160150140130120110100

Ed

Wght

HypR

Prot

Ind

Ald

Diaz

BrF*

Ed

Wght

HypR

Prot

Ind

Ald

Diaz

BrF*

Ed

Wght

HypR

Prot

Ind

Ald

Diaz

BrF*

Name

Date of admission / /

Referred ❏ yes ❏ no

/


D E NDate / /




D E NDate / /




D E NDate / /



Jinja Hospital – Maternity – 1999

Pregnancy Induced Hypertensive Disorders


Patient Outcome at Discharge (please circle correct statement) Date of DischargeAlive Death Absconded

If woman alive:Blood pressure mother: /

Type of delivery: Vaginal C-section Undelivered

Date of next appointment with medical officer or consultant:

Status newborn: Alive Death

/ /

Problems in the Management of the PatientDate Problem Reason Action

Critical Events Standard ActionComments Date Time1. Convulsion Call Doctor – Put I.V. drip – Prepare MgSulfate

2. Blood pressure not lowering after Combine with second line anti-hypertensive tabs2 days of correct treatment Aldomet 500 mg

3. Fetal heart rate >160 or <90/minute Fetal distress – Call Doctor – Prepare for C-section

4. Newborn not breastfed Examine child for hypothermia – Call Doctor

Magnesium Sulphate:4 gr I.V. – slow 5 minutes5 gm deep I.M. in each buttockHyporeflexiaUse Ca gluconateHepatic impairment

Dosage:

Side effects:

Contra-indication:Comments Date Time

Comments Date Time

Comments Date Time


Appendix B: Instructions for Case Management Map for Pre-eclampsia

Pre-eclampsia: any woman pregnant, in labor or havingrecently delivered, presenting with or developing a BP of140/90 or more and/or edema, signs of proteinuria,headache, dizziness. It is a serious condition of pregnancyor delivery.

This Case Management Map (CMM) is designed to helpyou manage a patient with pre-eclampsia. To manage apatient well, we need to know several things, we need tomonitor several things and we need to write this down soothers can know what the patient’s situation is, what hasbeen done and can help us manage the patient.

Page 1

On admission of the patient we take the pink starting page

1. We want to know general information about thepatient

■ Name of patient

■ Whether the patient is referred or not

■ The IP number

■ The date

Ask and fill in

2. Then we want to assess the patient

CHECK THREE TIMES A DAY

■ Check blood pressure 3 times a day

■ Check fetal heart rate 3 times a day (If the womanhas already has delivered this does not need to bedone of course)

■ Check for fits (convulsions) 3 times a day

Initial for these three points when done

Write down: No fits (convulsions) note (-)Fits (convulsions) note (+)

If she has fits, this is called a critical event. A criticalevent is those signs and symptoms occurring in apatient that entail changes of diagnose and/or therapy.We note it on the back of the page. Treatment has to beadapted.

CHECK ONCE A DAY

Weigh the patient every morning—write down weight

■ Check on edema

Write down: No edema: (-)Only ankle: (+)Ankle & Tibia: (++)Edema of the face: (+++)

Initial when done

■ Do a urine protein testtttt in the morning—write downresult

Write down: From + to +++

Initial when done

■ Check on hyperreflexia

Write down: No hyperreflexia (-)Hyperreflexia (+)

Initial when done

3. The patient needs medication

■ Give medicine as prescribed

Inderal and Diazepam will be given on admission

You will note that on the 3rd day after admission, thearea of BP is shaded. This is to remind you that ifafter 2 days of correct treatment the BP has notcome down, the treatment should be changed andAldomet added. This is called a critical event. Acritical event is those signs and symptoms occurringin a patient that entail changes of diagnose and/ortherapy.

Some drugs may not be available. This means thatthere is a problem. We go to the back of the pageand write down what the problem is, the date it hasoccurred and what we have done about it.

Initial when done

4. Now we have given her medication, it is importantfor her to understand what her condition is about.

Counsel the patient: Diet with restricted saltBed rest on left side

Initial when done


5. If woman has delivered, check the status of thenewborn each morning.

Initial when done

We use the follow-up page (yellow) if the starting pageis full. Do not forget to put the number on the follow-uppage (some patients stay a long time and may needmany follow-up sheets).

Page 2

This space allows us to describe problems that haveoccurred, critical events and if the patient is dischargedhave some information about her status.

1. Problems

If there is a problem that does not allow you to carryout the task—write down the date the problem occurs,what the problem is, and what has been done about it.Example: Diazepam may not be available or Aldomet

2. Critical events

A critical event is those signs and symptoms occurringin a patient that entail changes of diagnose and/ortherapy. In the case of pre-eclampsia, it may be that theBP is not lowering after 2 days of correct treatment, orthat she starts fitting or that the fetal heart is either lowor not heard. We note what the critical event is, when itoccurred, and what has been done.

3. Patient outcome at discharge

■ Write down if patient was alive, dead or hasabsconded

■ If alive, write down her blood pressure on discharge

■ Write down what type of delivery she has had

■ If she delivered on the ward, write the status of thebaby.


Appendix C: Case Management Map for Postpartum Hemorrhage

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CaseManagementMap (CMM)

Serial / IP number


CheckBloodPressure

Temperature

Initials ➾

Counsel

= Possibility of critical event

Systolic

Diastolic

140

120

100

80

60

40

4039383736

Name

Referred ❏ yes ❏ no /


Post Partum Hemorrage

D E N

Systolic

Diastolic

140

120

100

80

60

40

CheckBloodPressure

4039383736

ConsciousnessPulse

Post Intervention Follow-upAdmission Interventionon Root Cause

Date / /Time

Date / /Time

RetainedPlacenta➾ Remove

140

120

100

80

60

40

ConsciousnessPulse

Initials ➾

CheckLab: HBCheck VaginalBlood Loss

GiveMedicine

Ferous Sulphate200 mg tds

Blood Transfusion

Prescribed:

If prescribed, given:

DetermineCauseRetained Placenta

Laceration/Tear

Atonic Uterus

Coagulation Defects

Laceration/Tear➾ Repair

Atonic Uterus➾ Bi manual Comp +*

CoagulationDefects➾ Fresh Blood*

CounselVaginal HygieneValue of Antenatal Careand Family Planning

Breastfed

Care of Cord

Result Initial

ConditionPossibility BloodTransfusion, SurgeryCheck NewbornBreastfedCare of Cord

Starting Page

Please referto appropriate

Guidelines

*see Guidelines

Initials ➾

check allthat apply

Date / /


Yes No Not Applicable

Yes No



Date / /



Yes No



Date / /



Yes No



D E N D E N

Result InitialLab TestHBGroup-X Matching

Check Newborn

X-Penicillin2 M I.V.

q.i.d.Gentamycin

80 mg I.V. tdsAmoxicilline

500 mg caps p.o. tdsMetronidazole

400 mg caps p.o. tds

Folic Acid 5 mgonce a day

1 2 3 4

please circlecorrect statement below




Critical Events Standard ActionComments Date Time1. Temperature elevated 24 hours Do BS - MPS

after intervention on root cause Look for features of puerperal sepsisAdapt treatment

2. Hemoglobin less than 5 mg% Transfuse Comments Date Time

Comments Date Time3. Severe vaginal blood loss after Call Doctor - review causesintervention on root cause


If woman alive:HB at discharge: /


/ /

Date of next appointment withmedical officer or consultant:

/ /

Problems in the Management of the Patient

Date Reason ActionTakenDrug Shortage No Blood Available OtherProblem


CaseManagementMap (CMM)

Serial / IP number


Temperature

Initials ➾

= Possibility of critical event

140

120

100

80

60

40

4039383736

Name

Referred ❏ yes ❏ no /


Post Partum Hemorrage

D E N

Systolic

Diastolic

140

120

100

80

60

40

CheckBloodPressure

4039383736

ConsciousnessPulse

Post Intervention Follow-up

CheckLab: HBCheck VaginalBlood Loss

Ferous Sulphate200 mg tds

Blood Transfusion

Prescribed:

If prescribed, given:

CounselCounsel at discharge onvalue of antenatal careand family planning

Breastfed

Care of Cord

Follow-up Page

Date / /



Yes No



Date / /



Yes No



Date / /



Yes No



D E N D E N

Check Newborn

Amoxicilline500 mg caps p.o. tds

Metronidazole400 mg caps p.o. tds

Folic Acid 5 mgonce a day




Date / /



Yes No



Date / /



Yes No



D E N D E N



Give Medicine


Critical Events Standard ActionComments Date Time1. Temperature elevated 24 hours Do BS - MPS

after intervention on root cause Look for features of puerperal sepsisAdapt treatment

2. Hemoglobin less than 5 mg% Transfuse Comments Date Time

Comments Date Time3. Severe vaginal blood loss after Call Doctor - review causesintervention on root cause


If woman alive:HB at discharge: /


/ /

Date of next appointment withmedical officer or consultant:

/ /

Problems in the Management of the Patient

Date Reason ActionTakenDrug Shortage No Blood Available OtherProblem


Postpartum Hemorrhage is the blood loss from the genitaltrack after delivery of the baby that is perceived by thehealth worker to be excessive, dangerous and canendanger the life of the woman.

This Case Management Map (CMM) is designed to helpyou manage a patient with Postpartum Hemorrhage (PPH).To manage a patient well, we need to know several things,we need to monitor several things and we need to writethis down so others can know what the patient’s situationis, what has been done and can help us manage thepatient.

Page 1

On admission of the patient, we take the green startingpage

1. We want to know general information about thepatient

■ Name of patient

■ Whether the patient is referred or not

■ The IP number

■ The date

As hemorrhage can kill if not acted upon

■ write time of admission

Ask and fill in

2. Then we want to assess the patient and know whatthe cause of the bleeding is

■ Check blood pressure

■ Check consciousness

Write down: Conscious: (+)Unconscious: (-)

■ Check pulse

Fill and Initial for these three points when done

■ Take blood for HB test, grouping and crossmatching

■ Determine why she is bleeding. Check all causesthat apply

Fill and Initial when done

Appendix D: Instructions for Case Management Map for Postpartum Hemorrhage

3. We want to explain to the mother and the family whather conditions is and what may need to be done toher

■ Counsel on condition and possibility of bloodtransfusion and surgery

Initial when done

4. We need to check how the newborn is doing

■ Check whether new-born is breastfed

■ Check how the cord has been cared for

Initial when done

Note: of course, if the baby has died during deliverythis does not apply—simply cross out that section

As we now know the cause of bleeding, we are going toIntervene on the root cause

(Either the midwife or the doctor will do this—they willfollow appropriate guidelines)

■ Write date and time of the intervention

■ Tick off the type of the intervention done on the patient

It is the person doing the intervention that writes it on theCMM

After the intervention we need to follow up on the patientas she is probably anemic, may have an infection or maycontinue with bleeding:

Post intervention follow-up

1. We want to check three times a day on importantsymptoms

■ Check Blood Pressure

■ Check Temperature

■ Check Consciousness

Write down: Conscious: (+)

Unconscious: (-)

■ Check Pulse

Initial when done


2. We will check once a day

■ Check Vaginal blood loss(is the woman still bleeding?)

Write down if vaginal blood loss is

Normal: (0)Moderate: (+)Severe: (++)

■ For the first day after the intervention, HB test will bedone.

Initial when done

(You will see that these areas are shaded light grey –this is to draw your attention to the fact that if the HB islow or the woman is bleeding this is a “Critical event”and action should be taken) A critical event is thosesigns and symptoms occurring in a patient that entailchanges of diagnose and/or therapy.


■ X-pen, Gentamycine will be given the first day to bereplaced by Amoxicilline and Metronidazole thesecond.

■ Routine wise Iron and Folic acid are prescribed

Initial each time the medicine is given

Depending on the situation of the mother, the Doctormay prescribe a blood transfusion.

■ Each day is checked if there is a blood transfusionprescribed. If it is, you circle yes.

■ As blood is sometimes not available, we now checkif it has been given. If not, we circle no. This meansthat there is a problem. We go to the back of thepage and write down what the problem is, the date ithas occurred and what we have done about it.

6. Now we have intervened on her hemorrhage, it isimportant that the patient maintains correct vaginalhygiene. We also want to talk about the value offamily planning so she can space her pregnanciesand antenatal care if she is pregnant.

■ Counsel on correct vaginal hygiene

■ Counsel on value of antenatal care and familyplanning




Initial when done

Note: of course, as before, if the baby has died duringdelivery this does not apply—simply cross out thatsection.

We use the follow-up page (white) if the patient stays formore than 4 days.

We need to continue to follow-up on the patient as she isprobably anemic, may have an infection or may continuewith bleeding:

Post intervention follow-up

1. We want to check three times a day on importantsymptoms

■ Check Blood Pressure

■ Check Temperature

■ Check Consciousness

■ Check Pulse

Initial when done

2. We will check once a day

■ Check Vaginal blood loss (is the woman stillbleeding?)

■ HB test will be done when requested by the doctor.

Initial when done

(You will see that these areas are shaded light grey—this is to draw your attention to the fact that if the HB islow or the woman is bleeding this is a “Critical event”and action should be taken). A critical event is thosesigns and symptoms occurring in a patient that entailchanges of diagnose and/or therapy.


■ Amoxicilline and Metronidazole are continued

■ Routine wise Iron and Folic acid are prescribed

■ Other drugs may be prescribed


Initial each time the medicine is given

Depending on the situation of the mother, the Doctormay prescribe a blood transfusion

■ Each day is checked if there is a blood transfusion isprescribed; if it is you circle yes.

■ As blood is sometimes not available, we now checkif it has been given. If not, we circle no. This meansthat there is a problem. We go to the back of thepage and write down what the problem is, the date ithas occurred and what we have done about it.

4. On the day the woman will be discharged we will toremind her about the value of family planning so shecan space her pregnancies and antenatal care if sheis pregnant.

■ On discharge, counsel on value of antenatal careand family planning




Initial when done

Note: of course, as before, if the baby has died duringdelivery this does not apply—simply cross out thatsection

Page 2

This space allows us to describe problems that haveoccurred, critical events and, if the patient is discharged,have some information about her status.

1. Problems

If there is a problem that does not allow you to carry outthe task - write down the date the problem occurs, whatthe problem is and what has been done about it.

Ex. Blood may not be available or gentamycine may not.

2. Critical events

A critical event is those signs and symptoms occurring in apatient that entail changes of diagnose and/or therapy. Inthe case of post partum hemorrhage it may be that thewoman develops fever, has a very low HB or severevaginal blood loss or. We note what the critical event is,when it occurred and what has been done.

3. Patient outcome at discharge

■ Write down if patient was alive, death or has ab-sconded

■ If alive, write down her hemoglobin

■ Annotate the status of the baby.


the control condition in part because it was treatedin the gynecological ward, physically separate fromthe maternity ward where PIHD and PPH weretreated. Different staff treated the intervention con-ditions and the control condition. The PID samplesizes were 37 cases before and 29 after.

The results with PIHD were clear. Pooled adherencefor all three normal management indicatorsincreased from 22.6% to 87.3% for PIHD; the differ-ence was highly significant. In contrast, pooledadherence for the PID comparison group rose onlyslightly from 15.3% to 20.7%. Patient outcomes alsoimproved for PIHD patients after the CMMs wereimplemented, but not so dramatically, nor were theystatistically significant. In the study sample, fewercases of pre-eclampsia progressed to eclampsia(11% before, 8% after), a highly desirable outcome.In addition, fewer stillbirths (38% before, 16% after)and fewer maternal deaths occurred (5.9% before,4.0% after, and 0.7% at follow-up a year later). Theseresults are probably due to the new protocol formanaging PIHD (including new medications and theCMM) and the process of developing and imple-menting the protocol and the CMM. Until therelative contribution of the CMM itself and its devel-opment process can be assessed, care should betaken in attempting to generalize the result to othersettings.

The results of the CMM for PPH were not so clear.Average adherence to the three care standards forPPH increased from 27.9% to 39.3% following theintroduction of this CMM; this increase was compa-rable in magnitude to the increase observed for PID,the control condition. The number of maternal deathsfrom PPH actually increased, from only one death inthe before period to five after. A careful analysis ofthese deaths did not explain the increase, but it mayhave been due in part to this CMM’s small samplesize and in part that staff may have needed moretime to gain proficiency in the use of the PPH CMM.

We conclude that for PIHD, the development anduse of CMMs clearly improved the process of careand perhaps patient outcomes. However, the impactof the PPH CMM on care and outcomes was smallat best. Before going to scale, information is neededabout which conditions benefit from CMMs andwhich do not, and about the relative contribution ofCMMs separate from the process of developingthem.

Abstract Continued

of obstetric emergencies in uganda through case management …€¦ · of obstetric emergencies in...

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