Improving Quality Together: A multidisciplinary quality improvement project for bladder care in obstetrics
IUGA Academy. Bisseling C. Jun 30, 2018; 212855; 423 Topic: Overactive Bladder
Catharina Bisseling
Catharina Bisseling

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Improving quality together: A multidisciplinary quality improvement project for bladder care in obstetrics

Bisseling, C1; Afshan, N1; Ashraf, M1

1: Department of Obstetrics and Gynaecology, Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, United Kingdom

Introduction: Both antenatal and postpartum urinary incontinence are recognised risk factors for urinary incontinence in later life. In order to reduce the risk of long term urinary incontinence our health board has a multidisciplinary guideline on bladder care in pregnancy in place. As part of clinical governance guidelines are subject to audit. Traditionally, audit is used to systematically analyse the quality of delivered health care. When audit results are not improving however, consideration should be given to a different approach to improve the care delivered. In this report we describe how we adopted a new approach to improve bladder care in obstetrics after repeatedly noticing disappointing audit results.

Objective: To describe the framework used to improve the quality of care delivered in the area of continence during pregnancy and childbirth, and to make recommendations on how to deliver consistent care over multiple hospital sites.

Methods: The multidisciplinary health board guideline on the promotion and maintenance of continence in obstetrics was audited against a retrospective random sample of deliveries at all four of the health board’s sites in June 2016. After the data was analysed and presented, the multidisciplinary team enrolled on an Improving Quality Together (IQT) project.

Results: This was the fourth audit of the guideline and covered all three disciplines involved in bladder care in pregnancy: maternity services, physiotherapy and continence advisory service.

The notes of 135 deliveries were audited, 28% of all deliveries in June 2016. Uptake of the antenatal recommendations was poor (13%) and one third of patients requiring an antenatal continence review attended. Intrapartum guidance was followed in 70%. Voiding documentation in the puerperium was completed in 71%, with 19% reported to have an abnormal postnatal void. None of the patients fulfilling criteria for referral to the continence service were referred. 83% of patients requiring physiotherapy review were referred with two thirds attending her appointment. As part of the IQT project the guideline was split up focussing primarily on intrapartum and postnatal bladder care. A ‘bladder care bundle’ was designed incorporating suggestions from a user survey, and implemented and analysed by a ‘Plan-Do-Study-Act’ (PDSA) cycle. The cycle showed 100% adherence.

Conclusions: Despite several updates of the continence in pregnancy guideline in the past, audit showed that compliance with the guideline had not improved. Audit may not be the most appropriate tool to improve patient care in this field however. Not only is the incidence of continence problems around pregnancy low, audit will only help to identify areas where care is substandard. Audit does not look at how to improve care and outcomes for patients. This is especially challenging when the service is delivered at multiple hospital sites and when multiple disciplines are involved. As part of an IQT project the team developed a ‘bladder care bundle’ which was introduced and analysed using a PDSA cycle to successfully increase compliance with the guideline and subsequently improve the quality of care delivered to patients.


Work supported by industry: no.

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