Abstract:
BACKGROUND: Criteria-based audits (CBA) have been used to improve clinical
management in developed countries, but have only recently been introduced in the
developing world. This study discusses the use of a CBA to improve quality of
care among eclampsia patients admitted at a University teaching hospital in Dar
es Salaam Tanzania.
OBJECTIVE: The prevalence of eclampsia in MNH is high (≈6%) with the majority of
cases arriving after start of convulsions. In 2004-2005 the case-fatality rate in
eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric
data base). A criteria-based audit (CBA) was used to evaluate the quality of care
for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es
Salaam, Tanzania after implementation of recommendations of a previous audit.
METHODS: A CBA of eclampsia cases was conducted at MNH. Management practices were
evaluated using evidence-based criteria for appropriate care. The Ministry of
Health (MOH) guidelines, local management guidelines, the WHO manual supplemented
by the WHO Reproductive Health Library, standard textbooks, the Cochrane database
and reviews in peer reviewed journals were adopted. At the initial audit in 2006,
389 case notes were assessed and compared with the standards, gaps were
identified, recommendations made followed by implementation. A re-audit of 88
cases was conducted in 2009 and compared with the initial audit.
RESULTS: There was significant improvement in quality of patient management and
outcome between the initial and re-audit: Review of management plan by senior
staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001),
proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with
steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2
hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%;
P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0%
vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs.
39%; P=0.018). However, there was no significant change in terms of delivery
within 24 hours of admission (69% vs. 63%; P=0.33). There was significant
reduction of maternal deaths (7.7% vs. 0%; P=0.001).
CONCLUSION: CBA is applicable in low resource setting and can help to improve
quality of care in obstetrics including management of pre-eclampsia and
eclampsia.
