Khon Kaen Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Fast-track Service for High-risk Pregnancies All pregnant women face the risks posed by disorders and diseases they have before becoming pregnant, during pregnancy or during labor. These pregnant women are considered to be a high-risk group requiring speedy, high quality care from obstetricians and midwives with knowledge and expertise. The public health care service of Thailand is delivered at various levels: primary health care, secondary health care and tertiary health care, respectively. The system is designed to ensure that people receive services in their neighborhoods from the primary health care service, if appropriate. If there are complications or specialized expertise is needed, patients are referred to the next level of the health care system. However, Thailand, which is a developing country, has a shortage of obstetricians in hospitals, so there are differences in the potential care offered by each hospital. The United Nations has set the Millennium Development Goals (MDGs), of which the target 4.A and 5.A call for the reduction of child mortality and maternal mortality ratio by three quarters between 1990 and 2015. Maternal death from pregnancy and childbirth is still a major problem in Thailand. It has been shown that this is the result of the inadequate management of labor and the presence of associated diseases in pregnancy. Blood loss, high blood pressure during pregnancy and infection are the three most common causes of maternal death. According to the data for the year 2012, the population served by the district health services of the 4 provinces in our region (Khon Kaen, Roi-et, Mahasarakam and Kalasin) is 5,003,067 and of these, 1,464,669 persons were women of reproductive age. Only 12 out of 66 hospitals in the 4 provincial health services have specialist obstetricians (18%). When pregnant women have serious problems during labor and need to be in the care of an experienced obstetrician, they have to be transferred to Khon Kaen Hospital. However, under the previous system, these patients were treated as general emergencies and sent initially to the accident and emergency department where they were assessed by a nurse and an emergency room doctor before being transferred to the obstetric department. As a result, these pregnant women had to provide the same information several times, causing delays in accessing the care they needed. This adversely affected the outcomes for the high-risk pregnant woman and the fetus. For example, in 2004, a pregnant woman referred from a community hospital with a baby with a prolapsed cord suffered significant delays in management, including the lack of coordination with the Khon Kaen Hospital to prepare for emergency surgery, so that the baby lost its life. Patients who receive their initial assesment in district hospitals come from poor rural communities where awareness of problems related to pregnancy is very limited, especially among men.

B. Strategic Approach

 2. What was the solution?
In order to address the problem of delay in referring and taking care of high-risk pregnant women, Khon Kaen Hospital, which is a tertiary care hospital receiving patients from all the hospitals in the network, has created a speedy, high quality system for high-risk pregnant women. The objectives of the system are to: 1) increase the access to the system and reduce complications, disability and death in mothers and infants, 2) develop the ability of doctors and nurses in the hospitals in the network to assess symptoms, diagnose and assist in emergencies, and to refer high-risk pregnant women in an appropriate and timely manner, 3) evaluate the new system to ensure its continuous and effective operation. The development comprises 3 key elements: 1) provision of a fast-track service for high-risk pregnant women to ensure rapid access to appropriate services and optimize the coordination among service providers, 2) development of personnel in the care of high- risk pregnant women and 3) strengthening of the network. Organizing the fast-track service for high-risk pregnant women involved reducing the steps in the referral process by creating a multidisciplinary team working together to integrate the service and in particular eliminate the time wasted in the emergency room. In the past, high-risk pregnant women received the same care as of other emergency patients, but the fast-track service provides direct access to care, including the operating room, delivery room and intensive care unit immediately. It also includes the optimization of the preparation of pregnant women before they are sent to Khon Kaen Hospital. Human resource development in the care of high-risk pregnant women requires the creation of experts who are able to screen and diagnose the risks of pregnant women and administer the appropriate treatment and, when urgent referral is required, to ensure that patients receive quick and appropriate treatment. However, in Thailand, it is impossible to have obstetricians in all hospitals. Therefore, enhancing the potential of practitioners and registered nurses to have competencies in primary care management of high-risk pregnant women is very important. The development of the potential of health care volunteers in the community to have accurate knowledge of screening and referral of patients is also required. They need to provide knowledge management and to prepare guidelines which are suitable for the context of care for high-risk pregnant women in the area, and regular review of the knowledge and skills. Strengthening of the network can be achieved by allowing stakeholders at all levels of the network to participate in the development plan, including all procedures and practices. There is a need for a learning forum for exchanging ideas, funding to support the development of the network, setting the structure of operation as a network. Khon Kaen Hospital also serves as a mentor providing 24-hour consultation to the staff of the hospitals in the network.

 3. How did the initiative solve the problem and improve people’s lives?
In the past, the high-risk pregnant women were referred from a community hospital to Khon Kaen Hospital with no information being provided in advance, so there were delays in providing services. As a result, Khon Kaen Hospital organized a fast-track high-risk pregnancy service in order to handle with emergency situations in high-risk pregnant women. The fast track focuses on best practices, fast services and safe referral. It consists of 3 major components: 1) increasing of effective communication channels by coordinating among doctors via a Hotline of the delivery room, 2) reducing the steps required to reach to the delivery room, the operating room or intensive care unit and 3) increasing the effectiveness of the service processes which includes the preparation of the equipment, medications and blood as well as increasing the capacity of personnel involved in the care of high-risk pregnant women from the community level to the tertiary care hospital.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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).

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Reduction of the mortality rate of mothers and children: The development of fast track high-risk pregnancy service has reduced the duplication service provision by establishing effective communication between community hospitals and the Khon Kaen Hospital. It allows high-risk pregnant women to access to the services quickly and efficiently, so that the mortality of mothers and children can be reduced. During the years between 2004 and 2013, the numbers of high-risk pregnancy 15,166 were successfully treated. In the year 2013, the numbers of high-risk pregnancy1, 088 were safely transferred to give birth at Khon Kaen Hospital, including 3 to 6 cases a day from one province. Development of human resources and enchantment of the network of care for high-risk pregnant women: Constantly available training has increased the capacity of personnel and knowledge management has led to a greater understanding of problems and correct and safe practices. Community hospital staffs have become aware of the importance of obstetric care and have helped develop quality care for pregnant women which are appropriate to its own context. Those who specialise in the care of high-risk pregnant women can transfer knowledge and practical training to the personnel in their area. They in turn become confident that they have the skills to care for high-risk pregnant women in their area. Chumphae Hospital, which is a community hospital, developed its service so that it is able to accommodate referrals from six community hospitals nearby, improving access to the medical services in areas remote from Khon Kaen. Constructing the model service system: The development of a fast-track service at Khon Kaen Hospital and the development of the associated clinical network led to this service model being extended to the provincial hospitals in the 3 neighbouring provinces (Roi-Et, Mahasarakham and Kalasin). The model has since been expanded to include 66 hospitals. Data show that 99 percent of high-risk pregnant women from the hospitals in the 4 provinces are now referred to larger hospitals appropriately. The knowledge management and the exchange of learning coordinated from Khon Kaen Hospital has led to the dissemination the effective and proper guidelines of care for high-risk pregnant women within the 4 provinces and can now be used by the hospitals outside the network as well as those within it. This is the way to share resources for maximum benefits. Due to the development of other hospitals in the network to care for high-risk pregnant women, the number referred to the Khon Kaen Hospital in the years 2011 to 2013 decreased from 1,514 to 1,180. The model has been used in the service plan of the Ministry of Health covering the rest of the country.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Although it began in Khon Kaen Province and was initially extended to the three neighbouring provinces, the fast-track high-risk pregnancy service model has now been implemented nationally. As established in the original service model, the main responsible persons include the doctor and the head nurse in the delivery room of the regional hospital obstetric unit. Budgets have been allocated to support the operation of the fast-track high-risk pregnancy services, to supply equipment and support training of personnel, initially from the annual budgets of the National Health Security Office and the Ministry of Health, and related networks, such as the National Institute for Medical Emergencies, the Thai Health Promotion Foundation, the Local Administrative Organizations. Now however, this project is included in the annual budget allocation of the National Health Security Office. The service started at Khon Kaen Hospital was the first service network for high-risk pregnant women in Thailand of the National Health. This model has been extended to the rest of Thailand and could very easily be implemented in other countries with economies comparable to that of Thailand. The operation has been praised in the international arena by Professor Charle Mock, WHO Geneva, who stated that this service “encompasses the spectrum of care from the community to tertiary care. Likewise, it comprehensively encompasses care for several different conditions that require emergency care (trauma, cardiac, neurological pediatric, high risk pregnancy). There are certainly synergies between addressing these together.” Finally, having the operation’s guidelines in writing allows personnel to have an understanding of the operation and as a result the maternal and infant mortality rates can be reduced substantially. It has been designated by the Department of Medical Services to be part of the policy of extending services for quality delivery of the care for women to all hospitals nationwide. It is also a model for education and training for emergency medical services, both domestic and international.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Addressing the organization’s policy: The development of a fast-track high-risk pregnancy service involved changes in management systems involving many parties. It is necessary for individuals at all levels of management to recognize the importance of the development of a service like the fast-track high risk pregnancy service and incorporate it into the policy of the organization. This leads to cooperation of personnel at all levels. Defining clear roles for the key responsible persons is important in achieving the provision of quality services to mothers and babies. Involvement of the personnel and all levels of the network: Every step of the operation should allow everyone to feel involved and to allow personnel to feel that they are a part of a team. Mentoring and positive communication: Over 10 years of continuous operation, Khon Kaen Hospital has supported the network in various areas, such as academic knowledge, the development of service units and the skills of personnel, the care service system provided for high-risk pregnant women, sharing resources such as equipment and obtaining budgets. Moreover, advice is available 24 hours a day using many channels, such as phone, E-mail and the ‘Line’ program. Furthermore, creating a good working relationship is a priority. When there are problems, review of the operation is undertaken and constructive suggestions are made. In the past, the maternity services were reactive rather than proactive. By providing care for women before they get pregnant, as well as allowing the community and organizations to be involved in the service from the beginning, the problems associated with high-risk pregnancies can be more effectively managed. It is gratifying for the team is to see both mother and child safe. As one of the high-risk pregnant women put it: "it is like death and rebirth. Thank you for making me alive and could see my child”. When maternity care is successful, the whole family can have a happy and healthy life. Parents can look after their children, and the children will be important manpower in the development of the country in the future.

Contact Information

Institution Name:   Khon Kaen Hospital
Institution Type:   Government Department  
Contact Person:   Dr. Thitiporn Siriwachirachai
Title:   Head of department of Obstetrics and Gynecology  
Telephone/ Fax:   +6643237964 ,+66812628694
Institution's / Project's Website:  
E-mail:   dthitiporn@gmail.com  
Address:   54,56 Srichan Road
Postal Code:   40000
City:   Muang
State/Province:   Khon Kaen
Country:  

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