Panel Discussion

Perinatal Death Audit

Panelists

Dr. Amitha Indersen

Dr. Mahita Reddy

Dr. Pradeep

Dr. Prajnya

Dr. Rama Rao

Moderators

Dr. Fahmida Banu

Dr. Deepak Chawla

Dr Prajnya RanganathMD Pediatrics (JIPMER, Pondicherry)

DM Medical Genetics (SGPGIMS, Lucknow)

Associate Professor and Head,

Department of Medical Genetics,Nizam’s Institute of Medical Sciences, Hyderabad

Areas of Interest: Clinical dysmorphology, Genetic Neuromuscular Disorders, Non-immune fetalhydrops

Professor Department of Neonatology

Government Medical college, Chandigarh

Section Editor (Neonatology), IJPAssociate Editor, BMC Pediatrics

Areas of interestResearch methods

Systematic reviews and guidelinesQuality improvementDr Deepak Chawla

PHOTO

Professor & NeonatologistRamaiah Medical college,

Bangalore

DM(Neonatology) PGI

Nursing education & Innovations Dr. Pradeep GCM

Dr. AmithaAnderson

Fetal Medicine Consultant ,Apollo Cradle Hospitals,

Hyderabad. M.D.(Obstetrics & Gynaecology)Post doctoral Fellow in Fetal MedicineFellow in advanced Obstetric and Gynaecological Ultrasound

Special interest : Fetal growth restriction,Multiple pregnancy

Dr Prajnya RanganathMD Pediatrics (JIPMER, Pondicherry)

DM Medical Genetics (SGPGIMS, Lucknow)

Associate Professor and Head,

Department of Medical Genetics,Nizam’s Institute of Medical Sciences, Hyderabad

Areas of Interest: Clinical dysmorphology, Genetic Neuromuscular Disorders, Non-immune fetalhydrops

Dr. Venkata Rama Rao PaturiMD (Paed) MRCP(UK) MRCPCH(UK) FRCPCH(UK)

FRCP(Edin,UK) FRCPI(Ireland) CCT (Paediatrics, UK)

Dip. Allergy(UK)

Head of Children’s Services & Director,

Andhra Hospitals, Vijayawada, Andhra Pradesh

Consultant Neonatal & Paediatric Intensivist, MRCPCH (UK) examiner

Secretary NNF AP State

Chief organising Secretary, South NEOCON 2019

Andhra Hospitals:

Centre of excellence for Fetal, Maternity,

Neonatal, Paediatric intensive care

services, Paediatric cardiology, Paediatric

cardiac surgery & ECMO

Research – Noninvasive Ventilation

Area of Interest – Advanced Ventilation

CONSULTANT – GYNAECOLOGY AND OBSTETRICS APOLLO CRADLE, JUBILEE HILLS

ASSOCIATE PROFESSOR – OBGY - OMC

MD – OBSTETRICS & GYNAECOLOGY, DGO, FELLOW OF INDIAN COLLEGE OF OBSTETRICS AND

GYNAECOLOGY (FICOG)

HIGH RISK PREGNANCY, ADOLESCENT GYNAECOLOGY AND LAPAROSCOPIC SURGERY

Dr. Mahita Reddy

What is perinatal audit?

• Dr Amitha

• Dr Pradeep

What is perinatal audit?

• “The systematic, critical analysis of the quality of perinatal care, including the procedures used for diagnosis and treatment, the use of resources and the resultant outcome and quality of life for women and their babies”

Are there different types of perinatal audits? How frequently audits should be done?• Dr Mahita

Are there different types of perinatal audits? How frequently audits should be done?• What is focus?

• Case-based audit/sentinel-event based audit

• Care-practice audit

• Satisfaction audit

• Structure audit

• Frequency• How common is adverse event?

• Regular with short event-audit-feedback turnover

In a hospital who all should be involved in the process of perinatal audit? • Dr Rama Rao

In a hospital who all should be involved in the process of perinatal audit? • Internal audit versus external audit

• Everyone involved in the perinatal care process• ?Referring physician

Case 1

• A 27-year-old woman was referred from district hospital to a medical college with intrahepatic cholestasis of pregnancy at 38 weeks of gestation. Labor was induced. After 6 h, meconium-stained amniotic fluid and fetal bradycardia were noted and an emergency C-section was done.

• Baby was born with severe birth asphyxia (Apgar 0/2/2) and died at 2 h of age

• What should be audited in such a case?• Obstetrics - Dr Mahita Reddy

• Pediatrics/Neonatology – Dr Rama Rao

• Against what standards of care one would judge the care provided?• Dr Prajnya

• Are these standards similar for every health setting?• Dr Prajnya

• Dr Mahita Reddy

• What should be audited in such a case?• Antenatal and intrapartum fetal monitoring – method, frequency, assessment

• Resuscitation – who, how

• Against what standards of care one would judge the care provided?• Clinical practice guidelines

• NRP

• Are these standards similar for every health setting?• Resource-limited versus resourceful settings

Blame game

• How to avoid blame game in inter-departmental or inter-unit audits?• Dr Rama Rao

Blame game

• How to avoid blame game in inter-departmental or inter-unit audits?• Chaired by experienced clinician

• Use of objective criteria to audit

• Focus on system rather than individuals

• Focus on problem-solving

Steps of perinatal audit

• What should be the steps of perinatal audit? What happens after the audit panel has met, audited the case and reached its conclusions?

• Dr Amitha

Near-misses

• What if instead of death baby developed HIE-2 and survived? Should audit be done even in near-miss cases?

• Dr Pradeep

• Dr Amitha

Near misses

• Frequency of events

• Maternal versus neonatal

Case 2

• A baby is born at 32 weeks of gestation with a birth weight of 1200 g. Mother had history of PTPROM for 14 days and had GDM.

• Baby did not any resuscitation at birth and was admitted in NICU for mild respiratory distress needing NCPAP. Blood culture was sterile, and baby remained stable till D8.

• On D8 baby developed features of late onset sepsis, deteriorated rapidly and died within 24 h. Blood culture grew Klebsiella.

Audit process

• How do you conduct audit of this type of case when death is not within few hours of birth and care to be reviewed is confined to a time period of within few hours of labor, resuscitation and resuscitation care?

• Dr Rama Rao

Audit process

• How do you conduct audit of this type of case when death is not within few hours of birth and care to be reviewed is confined to a time period of within few hours of labor, resuscitation and resuscitation care?

• Audit of key healthcare processes – central line insertion, IV fluid preparation, hand hygiene

• Care process audit

Audit tools

• Are any tools available which facilitate doing the audit?• Dr Prajnya

Legal aspects

• What is legal aspect of such a case audit? If parents file a case, is hospital liable to or should provide the audit findings?

• Dr Pradeep

Case 3

• A 32 years third gravida with previous two uneventful deliveries at term gestation goes into spontaneous labor and gets admitted for safe confinement. In second stage of labor was noted to have severe fetal bradycardia

• Delivered a deeply asphyxiated baby with weight of 3.5 kg with cord around the neck 3 times and baby could not be resuscitated.

Auditing “Others”

• Should cord around the neck be reported in USG reports?

• Is this incident avoidable?, If avoidable, how?• Dr Mahita

Case 4

• A 30 year old woman is referred to a government medical college from a district hospital at 28 weeks of gestation with preterm labor. Dexamethasone was administered to mother and she delivered a baby 12 h after reaching the hospital.

• Baby weighed 1100 g at birth and developed respiratory distress soon after birth. Baby needed ventilatory care but could not be admitted in NICU due to lack of bed. Baby died at 24 h of age with respiratory failure.

Audit and structural issues

• How to conduct audit of this case?• Dr Pradeep

• If audit panel finds structural issues in the health system like lack of beds or shortage of human resources, what should it do?

• Dr Mahita

Audit and structural issues

• How to conduct audit of this case?• Structural audit

• Patient movement audit

• Iatrogenic complications audit

• If audit panel finds structural issues in the health system like lack of beds or shortage of human resources, what should it do?

• Make a case for more resources

Audit and family

• Should family be part of the audit?• Dr Amitha

• Should findings of the audit be disclosed to the family voluntarily or if they demand for it?

• Dr Rama Rao

Audit and family

• Should family be part of the audit?• May not be possible in current scenario

• Should findings of the audit be disclosed to the family voluntarily or if they demand for it?

• As a anonymous general recommendation

Case 5

• A female neonate is born at term gestation after elective C-section (previous C-section) with birth weight of 3000 g. Baby is roomed in with mother and discharged on day 3.

• On day 4 baby is brought dead to the hospital. According to parents, baby was bit lethargic since morning and then vomited once.

Unexplained deaths

• How do you audit home-based neonatal deaths?• Dr Pradeep

• Is there a role of genetic testing in ascertaining the cause of unexplained perinatal deaths?

• Can one perform a “metabolic autopsy”?• Dr Prajnya

Are audits effective?

• Among various tools for quality improvement, where audits stand?• Dr Amitha and Dr Pradeep

• Is there any evidence about effectiveness of audits?• Dr Amitha and Dr Pradeep