Documentation in Birthing Services; A Track and Trigger indicator on the Partogram

Andrea Dodd, Project Officer, Mercy Health, Professor Sue McDonald La Trobe University/Mercy Health, Tegan Bassett, Clinical Midwife Specialist, Mercy Health, Monique Johnstone, Acting Birthing Services Manager, Mercy Health Melbourne, Australia

Next Step: Our team is continuing to implement changes to enhance documentation on the partogram to ensure clinical safety for the woman and the fetus

• Regular audits

• Inclusion of a ‘track and trigger’ for FHR in second stage

• Further education with staff on the correct place to document maternal and fetal observations in labour. Education for staff around the role of the second midwife at the birth

• A regular, ongoing education program with staff regarding the minimum data set of maternal and fetal observations according to the protocol

• Further analysis of the data to identify any potential improvements in maternal, infant outcomes associated with early identification of deterioration using the ‘track and trigger’ chart

Results: x 50% Increase in documentation of FHR in second stage

x Clinically significant increase in the number of code pink calls (obstetric emergency) post implementation of the revised partogram

x 10% decline in documentation of the specified minimum set for observations required in first stage of labour from October 2014 to June 2016

Original partogram

Discussion: • The initial spike in October 2014 was likely due to the close proximity in timing of the National Standards Accreditation. The significant reduction in documentation in March 2016

is likely to have been due to the timing of new medical and midwifery staff commencing who were not as yet familiar with the documentation

• Staff adherence to documentation of observations in the first stage of labour remains an issue. This may be compounded by the co- utilisation of other charts, such as the

epidural chart and cardiotocograph (CTG) used to monitor FHR in labour.

• The audit revealed that staff document most observations in other areas of the history, including a significant reliance on using the CTG as a form of documentation rather than

documenting the FHR and other observations on the partogram

• The colour zones highlighting when observations fall within a ‘trigger zone’ for action assisted staff to easily recognise deterioration. Staff indicated a lower threshold for seeking

obstetric review as observations moved towards or entered a trigger zone. This was supported by the increase in the number of code pink calls made between October 14 to

March 16.

Background: Tertiary Birthing Services are unpredictable environments complicated by large staffing pools with varying expertise. Ensuring clinical safety for women and

neonates is of paramount importance. The original partogram documents intrapartum maternal and fetal observations. To support this documentation there is a

standard protocol for the minimum requirement of observations in labour. This documentation should prompt early identification and response to deterioration

reducing morbidity and mortality. Track and trigger charts are used in medical, surgical and postnatal settings. Track and trigger charts have been being shown to

significantly improve identification and response to clinical deterioration however, have rarely been adopted for intrapartum use despite being shown to significantly

improve identification and responses to clinical deterioration.

Problem: The 2014 National Standards audit revealed inconsistencies with documentation of maternal and fetal observations in labour. The primary indicator was

documentation of second stage Fetal Heart Rate (FHR) and the secondary indicator was all other maternal and fetal observations. These inconsistencies may have

lead to unrecognised deterioration in the maternal or fetal condition.

Primary Aims: • Improve documentation of Fetal Heart Rate (FHR) in second stage by 30% within 12 months x Remodelling of the original partogram to include changes to second stage FHR documentation

x Evaluation of a ‘track and trigger’ chart integrated into the original partogram for all other observations.

Method: • Audits of 40 Histories at specific time points occurred against the protocol.

• Consult with staff to design and implement a new colour coded track and trigger partogram

x Education staff for new partogram trial

x Evaluate the tool through;

• reviewing emergency code data

• Seeking formal feedback from staff

• Auditing compliance with documentation

Revised partogram

Colour track and trigger observations

Defined area to document 2nd stage

observations