| 4. In which ways is the initiative creative and innovative?
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In 2004, Khon Kaen Hospital introduced a strategy called “Development of a Service System for High-risk Pregnancies". The new fast-track system was established with the emphasis on the creation of a multidisciplinary team. A meeting to discuss the treatment and referral of high-risk pregnant women from the hospitals in the network was organized. The delivery room at Khon Kaen Hospital was chosen to be the operation center for coordinating the care provided to high-risk pregnant women. The provision of interventions such as surgery, anesthesia, blood transfusion and laboratory tests was also discussed. These measures have reduced the steps in the service pathway from 10 to 4 steps and reduced the delay in receiving care to 15 minutes.
In 2004-2005, the new service was established in Khon Kaen Province, and included 22 hospitals. This was done in cooperation with the Committee of Maternal and Child Health, Khon Kaen Province, of which Prof. Dr. Pisake Lumbiganon was the president. The guidelines for care given to high-risk pregnant women (Edition 1), which was to be used in all the hospitals in the province, were written. Training to develop the competencies of doctors and nurses in the community hospitals was organized every year.
In 2007-2008, the high-risk pregnancy fast track service was extended to cover 4 provinces with 66 community hospitals in a managed clinical network. The high-risk pregnancy fast track service model developed by Khon Kaen Hospital was used to achieve this. Moreover, Khon Kaen Hospital was integrated with the emergency system for referral of pregnant women by using an emergency hotline (1669) to arrange transfer of pregnant women in the community to the hospital 24 hours a day.
In 2009-2012, Khon Kaen Hospital cooperated with the Thai Maternal and Child Health Network to extend this service model to 20 provinces throughout the country. “The Manual for Medical Treatment Provided for High-risk Pregnant Women, Area Health Service” was created. Also, both theoretical and practical conferences were held in order to increase the abilities of doctors and registered nurses. Training health care volunteers in the various districts of Khon Kaen province also enhanced health surveillance for high-risk pregnant women in the community. In collaboration with the Office of Public Health, Khon Kaen a project to supervise and evaluate the quality of work in maternal and child health and the care system for high-risk pregnant women in the community hospitals around Khon Kaen province was established. In addition, a database and the data storage system were developed. In 2001, the system of forwarding and collating information about high-risk pregnant women in Khon Kaen province via (I-refer) through http://refer.khonkaenhospital.org was established.
In 2013, a meeting of the 4 provinces in the network was held to create “The Manual for Caring for High-risk Pregnant Women and Gynecological Diseases” (Edition 3). The content was improved as necessary content and processes were added. Staff development continued on a regular basis. Intensive courses and workshops providing real-situation modeling were also provided to allow doctors and registered nurses to develop skills for managing obstetric emergencies appropriately.
In 2014, in cooperation with the National Health Security Office, "the service network for high-risk pregnant women" was established. This was the first service network for high-risk pregnant women in the country. It was established in order to provide a model for expanding the health service network throughout the country.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The development of the fast track high-risk pregnancy service is characterised by teamwork and emphasis on the participation of the parties of the network. The network is coordinated by the team at Khon Kaen Hospital.
The community network includes health care volunteers from 7,941 villages, local administrative organizations and 600 sub-district part-time ambulance services. Network members are responsible for screening, surveillance and providing first aid for high-risk pregnant women and also referring them to the expert obstetrics emergency services.
The district network comprises the community hospital and 66 Committees for District Maternal and Child Health. Their responsibilities are to develop the service system and provide care to high-risk pregnant women according to the manual.
The provincial network consists of the Maternal and Child Health Services for the 4 provinces. They organize learning forums for sharing ideas and control the quality of maternal and child services.
The national network includes the National Health Security Office, which develops the service networks for diseases with high mortality rates and disease-related problems in the area by firstly establishing service networks for high-risk pregnant women throughout the country and supporting the ongoing operating budget every year.
The National Institution for Emergency Medicine and the Emergency ambulance hotline (1669) will provide first aid and quickly deliver high-risk pregnant women from the community to hospitals. The Ministry of Health Policy defines the policy for obstetric health services (Thai maternal and child health network) and has participated in expanding the network to care for high-risk pregnant women to cover 20 provinces across the country.
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| 6. How was the strategy implemented and what resources were mobilized?
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The resources used in operating fast-track high-risk pregnancy care system are as follows.
Personnel: 1) The multidisciplinary team includes obstetricians, pediatricians, anesthesiologists, doctors in emergency rooms, psychiatrists, nurses in labor rooms, nurses in emergency rooms, nurses in operation rooms, nurse anesthetists, patient escort transfer officers, blood banks, and social workers, who work as volunteers without payment. At present, the operation is included in the working system of each service unit.
2) The Provincial Maternal and Child Health Committee assists in the supervision and improvement of service quality.
3) The Provincial Public Health Office supports and coordinates the operation of the network.
4) The Area Health Service provides the budget.
5) The District Maternal and Child Health Committee sets the policy and develops the fast track high-risk pregnancy plan of the network.
6) The National Institution for Emergency Medicine, Local Administrative Organizations and sub-district ambulance teams support the rescue personnel in transferring high-risk pregnant women from home to the hospital by using the medical emergency system and hotline (1669).
7) The community supports the health care volunteers and the community leaders in monitoring health care for pregnant women.
Budget: The budget is mostly spent on training for human resources development. At first, the financial support was received from Khon Kaen Hospital. After that, when the network was expanded across the province, it was funded by the Khon Kaen Public Health Committee for printing of documents and personnel training. Then when the network had been expanded to cover 4 provinces, the budget for developing the skills of personnel and manual preparation was supported by the National Health Security Office. It, finally, was added to the annual budget plan of the National Health Security Office. The budget allocated for tools and equipment is supported from the annual budget of the Ministry of Health. In 2012, medical equipment was distributed to the 4 provincial hospitals in the network. For example, Central Electronic Uterine Contraction and Fetal Monitoring machines were distributed to Roi-et Hospital, Mahasarakam Hospital and Kalasin Hospital. Ultrasound, Radiant warmer and Transport incubators were distributed to Khon Kaen Hospital.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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1) Access to the fast track high-risk pregnancy service: During the ten years that the fast track high-risk pregnancy service has been operating, the service pathway has been reduced from 10 steps to 4 and the delay between referral and provision of care in hospital has been reduced from 60-90 minutes to 15 minutes. The preparation of the operation room, intensive care equipment, blood and medicines are also been speeded up. Between 2011 and 2013, the maternal mortality rate in the province decreased from 11.1 to 10.3 per hundred thousand live births, and the mortality rate for newborns decreased from 5.4 to 4.31 per hundred thousand live births.
Patient satisfaction with the service is now high. For instance, there was a case of a mother with severe postpartum hemorrhage. She was given good care before returning home. She thanked the team and said “it was a prompt treatment. I felt like rebirth “. Another case was that of a mother who required an operation for delivery of her baby. Her older daughter thanked to the staff for the good care that she had received.
2) Human resource development: This was achieved by providing manuals (3 Editions) on the treatment and referral of high-risk pregnant women, the contents of which were obtained from brainstorming sessions with the participation of personnel at all levels in the network. A manual for the management of obstetric emergency courses was also created to enhance the skills of doctors and nurses each year. Between 2005 and 2008, 620 doctors and nurses were trained. Between 2009 and 2013, 923 doctors and nurses were trained while in 2014, 183 of them have so far trained. In addition, 262 health care volunteers and district ambulance service staff have been provided with training for in first aid for high-risk pregnant women. Evaluation of their performance indicates that 99 percent of them can now communicate effectively about referrals, and 98 percent can provide care before and during the referral process.
3) Strengthening the network: Between 2004 and 2013, the referral rate of high-risk pregnant women from district and provincial hospitals in the network increased year on year (15,166 cases in total). However, in 2013, the number of referrals fell 16.5 percent because Chumphae Hospital has established an obstetric department with three specialists and takes referrals from 6 nearby hospitals (245 cases so far).
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| 8. What were the most successful outputs and why was the initiative effective?
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The tracking systems used for monitoring each activity of the operation are as follows:
Fast track high risk pregnancy system: A check list is used to evaluate the efficiency of the reduction in the steps in the process, the delay before care is provided and the performance of the personnel with correct practices according to the guidelines every time there is a referral. An obstetrician assesses the results. Also, the program is used to analyze and process data concerning the referral of high-risk pregnant women, including monitoring and evaluation of health and complications involving both mothers and infants. Patient satisfaction with the service benchmarked, summarized and evaluated every month in order to present information to the Maternal and Child Health Committee every 3 months, or immediately in case of emergency.
Furthermore, monthly case conferences within the hospital by the involving members of the multidisciplinary team are held.
Human resource and network development: Meetings of Maternal and Child Health Committee are held every 3 months and meetings of the referral of high-risk pregnant women network of the 4 provinces are organized every 6 months in order to review and share knowledge concerning patients with severe complications. This is done to prevent repeat events. In addition, the collaborative learning forum of the network of the 4 provinces is also organized to share best practice, innovations and CQI every year.
The external evaluation committee includes the National Health Security Office, which evaluates the quality of service every year, and the Public Health Inspectors, Area Health Service which does an evaluation every 6 months.
The results of the evaluation, knowledge sharing and the problems from the implementation can be used to improve the clarity of communication in order to strengthen the network. The processes, the guidelines and the referral system can also be improved more effectively. Khon Kaen Hospital has an on-going role in supervising the local regional network and takes the lead in data analysis and service development.
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| 9. What were the main obstacles encountered and how were they overcome?
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The changes involving the doctors and the nurses working in the delivery room: Doctors and nurses working in the delivery rooms move frequently and new staff members do not understand the processes and have inadequate skills. Therefore, nurses coming to work in the delivery room of the community hospitals are now provided with short training courses on caring for high-risk pregnant women.
Cooperation in the implementing of the manual: It was found that staff members were reluctant to comply with the procedures in the manual because they had not participated in the preparation of the manual (Edition 1). This problem was solved by adding contributions from the 4 provinces in the network to subsequent editions (Edition 2 and 3).
The limitation of the number of beds in the intensive care unit (ICU): Previously, high-risk pregnant women with serious problems were not treated quickly. A meeting with the board of the intensive care unit of the hospital was held in order to provide timely care for high-risk pregnancy cases. This has allowed them to receive more expeditious intensive care was necessary.
Communication: Verbal communication via telephone was used in the early stages, so it was not possible to transfer image data, such as graphs of fetal heart or fetal ultrasound images. Therefore, the data is now sent via the Internet. However, in some hospitals in remote areas, the internet connection is unstable. So, communicating via Smart Phone is used to make the process more efficient.
Lack of modern medical equipment: This was a problem because the budget of each hospital is limited. However, now that the National Health Security Office has realized the importance of the operation, additional budget has been allocated to the hospitals in the 4 provinces for purchase of medical equipment needed to care for high-risk pregnant women.
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