Context
HUM is a 300-bed partners in health -supported tertiary care facility. It has a large maternity service that encompasses one-third of the campus, including outpatient OB and GYN services, ~60 inpatient beds with surge capacity on antenatal, gynaecological and postpartum wards, a woman’s health emergency ward and ~30 beds on L&D. Over 500 deliveries occur every month, many of which are high-risk referrals made to the institution. The 16-bed NICU is located within the maternity block, facilitating easy referrals for premature and sick newborns.11 Haïti recorded its first COVID-19 cases in March 2020.12 Following urgent action to mobilise and provide isolation and treatment for the population affection, HUM, located in the Central Plateau Department of Haiti, was one of the first institutions selected in partnership with the Ministry of Health13 as having the capacity to provide the level of care necessary in a country that has a total of 124 Intensive Care Unit (ICU) bed nationally.14
Intervention
The Six-Sigma/ DMAIC quality improvement methodology (Define, Measure, Analyse, Improve and Control)15 was used in this project as the problem was urgent and centred around the process of patient flow in the institution. It also demanded rapid results given the urgency of the situation. As Six-Sigma DMAIC is defined by the Institute for Healthcare Improvement ‘speed and results are key ingredients to building Six Sigma momentum inside an organisation, and projects should be sized to assure team success and project closure inside reasonable time limits’,15 this approach was used to build on the motivation of the task force team while documenting and gathering data throughout.
The Maternity Task Force team was created by hospital leadership to address the urgent needs on the L&D unit regarding overcrowding and lack of NICU space. The team was composed of nurses and medical doctors from the maternity and paediatrics wards, in addition to non-medical personnel such as data collectors, and HUM quality improvement committee representatives.
Two urgent problems were identified by the Task Force; the indicators were clearly defined with fixed objectives set.
Postpartum women were laying on the floor in the labor and delivery unit.
Sick neonates were receiving paediatric care on maternity services.
The first of the teams’ quality improvement goals was to eliminate the number of postpartum women on L&D ward who did not have a bed and were laying directly on the floor with their newborns. An average of 14% of postpartum women who had given birth vaginally were boarding on the floor with their newborns before the intervention. The objective of this quality improvement Task Force was to reduce from 14% to 0%, the numbers of postpartum women on the floor between August and October 2020 (figure 2). It is an ethical and moral obligation to respect the dignity and the rights to provide good quality of care for these women and their newborns.
The second problem identified was the lack of space in the 16-bed NICU to ensure the management of all sick newborns needing care. An average of 33% of the total number of newborns on the services before the intervention, were sick and should have been cared for in the NICU. The second objective of the Task Force was to reduce the numbers of sick newborns receiving medical care on maternity services from 33% to less than 10% between August and October 2020 (figure 3). These newborns, including premature infants, stayed in the service with their mothers on post partum, L&D or sometimes the Antenatal ward, due to lack of bed space in NICU or paediatric wards where they would have received more appropriate care and less risk of exposure to nosocomial infections or SARS COVID-19 impacting neonatal mortality.6 10
Reflective of our baseline data, the Maternity Task Force team identified and isolated the primary causes of the two indicator using a qualitative approach. Process flow charts (figures 4 and 5) as well as Ishikawa diagrams (figures 6 and 7) were used to analyse the causes contributing to the problems identified. These tools allowed the team to better identify and target significant causes in order to focus on the most important causes that contributed to the resulting improvement.
Figure 4Flow chart diagram 1 mothers on the floor in L&D. L&D, labour and delivery.
Figure 5Flow chart diagram 2 neonates receiving paediatric care on maternity services.
Figure 6Ishikawa diagram 1 mothers on the floor in L&D. L&D, labour and delivery.
Figure 7Ishikawa diagram 2 neonates receiving paediatric care on maternity services.
The Ishikawa, or cause and effect diagram, was used to help identify and analyse the root causes that contributed to the problems. Using the Ishikawa diagram for the first indicator, postpartum women lacking a bed, it was found that two of the primary contributory causes were environmental issues: lack of space on L&D, and a lack of bed turnover on this unit. Root causes identified under ‘people’, included a lack of nursing staff.
The process flow charts can be seen in figures 4 and 5. The flow chart in figure 4 for postpartum women prior to the start of the project ‘preintervention’ highlights the lack of bed space available on L&D for a newly postpartum woman. If no empty bed was available, she and her newborn stayed on the floor.
The flow chart in figure 5 for paediatric patients on maternity highlights the lack of bed space available in the NICU and paediatric wards in the ‘preintervention’ diagram. In this case, the premature and sick newborns stayed with their mothers and occupied beds for weeks at a time on the L&D service that necessitates a rapid bed turnover following normal uncomplicated deliveries.
The medical treatment for many of the premature and sick neonates lasts weeks to months, during which time they complete intravenous antibiotic and other medical treatment courses. This also increases the bed occupancy rate in the maternity service. After the mothers are discharged from hospitalised postpartum care, they continue to stay on the maternity unit with their sick neonates, which contributes to a backup of patients. Newly postpartum women consequently have to sleep on the floor therefore increasing the risk for nosocomial infections, overwhelming staff and thus compromising the quality of patient care and potentially clinical outcomes. It is important to note that the staff on L&D and postpartum are not trained in intensive neonatal care and are frequently overwhelmed with deliveries, postoperative mothers or mothers with severe pre-eclampsia/ eclampsia or other pathologies that merit intensive intrapartum and postpartum nursing care. Overcrowding in hospitals can severely impact inpatient mortality and clinical outcomes as mentioned previously.2 3
Measurements
For the first indicator, the number of postpartum women who did not have a bed (the numerator) was compared with the total number of postpartum women who delivered vaginally, in the maternity service (the denominator). The baseline for this first indicator (figure 2) was measured from June through August 2020 and showed an average of 14% of postpartum women admitted to the L&D ward following a vaginal delivery, did not have a bed. The objective of this first indicator was to have zero women sleeping on the floor in the HUM maternity service, between August and October 2020.
For the second indicator, sick newborns receiving paediatric care on maternity services, the numbers of sick newborns receiving paediatric treatment who stayed on the Maternity ward (the numerator), was compared with the total number of newborns in all of the maternity wards (denominator). The baseline for the second indicator (figure 3) was measured from June to August 2020 and revealed an average of 33% of newborns on the maternity ward were receiving paediatric care. The objective for this second indicator was to have less than 10% of the newborns admitted to the maternity ward, receiving paediatric treatment between August and October of 2020
Data collection methodology was carried out through the direct entry of data into an excel spreadsheet gathered from daily ‘What’sApp’ messages shared from nurse managers from L&D, postpartum and paediatrics wards, every work-day, not including holidays or weekends. This amounted to a total of 489 days over 2 years from 29 June 2020 to 30 June 2022. The data were verified and found after analysis that 94.5% of the data was complete for the time period evaluated. The data are gathered directly from nurse managers on the wards who pass through the services and personally verify several other indicators also shared on a daily basis including staffing ratios and critical patients, which is all shared electronically with hospital leadership every morning.
As part of the intervention to remove postpartum women and their newborns from the floor of L&D, a new ward of 17 beds with optimal resources was opened in mid-September 2020 ‘physiological post partum’ (PPP), which meant that the postpartum nurse manager began reporting data on this new service.
As part of the intervention to reduce the numbers of sick neonates on Labour & L&D and postpartum wards, a new ward of 16 beds with optimal resources was opened in mid-October 2020, step-down neonatal ICU (SNICU) and the paediatric nurse manager began reporting data on this new service.
Additionally, the numbers of deliveries per month was gathered from the monthly HUM ‘Reproductive Health’ report16–18 and can be seen in figure 1 to give perspective regarding the annual peak delivery periods.