Improvement Stories

Fetal Health Surveillance:
Switching to Intermittent Auscultation

Contributor:
Sharon Dalrymple RN, BN, MEd, LCCE, FACCE
Clinical Nurse Educator
High River Hospital Community Maternity Program CNE
Community Maternity Unit, High River Hospital, High River Alberta

What did you set out to change or improve?
When the SOGC (Society of Obstetricians and Gynecologists of Canada) Fetal Health Surveillance (FHS) guidelines came out in 2007, our OB Core Team decided to adopt them wholeheartedly. Evidence supports the use of Intermittent Auscultation (IA) in appropriate situations and the SOGC guidelines gave many parameters that matched our Low Risk program and philosophy, here in High River, Alberta.

How did you change it? What new Policies, process and or practice did you put in place?
For our new practice launch, using the SOGC guidelines and a new policy on FHS from Calgary Zone, the Clinical Nurse Educator and one of the Family Physicians from the Low Risk Clinic teamed up to teach a series of four hour workshops to introduce the new concepts, definitions, processes (assessment of risk, how to do Intermittent Auscultation (IA), indications for moving from IA to Continuous Electronic Fetal Monitoring (EFM)) and interpretation of monitor strips).

There were close to 60 individuals to teach. 100% of ALL team members attended the workshops. The nurses were paid and the physicians attended on their own time. Dinner and refreshments were part of every session. Refresher courses were also offered and the same program is taught as part of orientation for each newly hired RNs or physicians/midwives.

A “go live” date was set to start the new process, a new outpatient form was designed to accommodate the risk assessment (based on SOGC research and review), the labor partogram and charting guidelines were changed to reflect the new terminology and process, and reference guides were designed to define the kinds of fetal heart patterns according to the new guidelines.

The follow up audit process for both team members and patients took more than a year to complete.

Who was involved in making the change and what was each person’s role?
The High River Maternity OB Core Team was the multidisciplinary care practice group who decided to adopt the SOGC recommendations. From there, the Clinical Nurse Educator (CNE) and a Family Physician from the Low Risk Clinic planned enough workshop sessions to accommodate everyone and sign-up sheets were set up. Everyone on the team was invited. Nursing staff were replaced as needed, so that eventually all RNs on the team could attend.

The four peer audit rounds post introduction of the new process involved all team members, the CNE and Unit Manager.

The group of 31 patients included in the patient questionnaire were asked mainly safety and satisfaction perception questions about the new monitoring process.

How did you determine if the change worked?
The audit process was very revealing. Within the first three months, a peer audit was conducted by all team members (60): each RN, family physician and OB did one audit of a chart from when the new program started, using predetermined items from the SOGC guidelines. They examined not only the new terminology, but also the decisions and communication around correct use of IA and EFM and interpretation of strips. There was a high uptake in all predetermined categories, with only 13 charts lacking in 1-3 items (out of 25). The rest of the item criteria were met.

The results of the initial audit round went into a reinforcement phase of education for ALL team members, and since all members did an audit, the uptake and consistency of the new process happened very quickly. The audit form was used again at the six month mark of the new program (50 charts) and by then there were very few tweaks to make to practice. All but one chart met the audit criteria; it revealed that appropriate action was not taken to switch from IA to CFM.

A separate, third audit was done by the CNE for all booked (23) (elective) Cesarean Section patients in the first six months, as one of the guidelines from SOGC recommended deleting the pre-op 20 minute fetal monitor strip in favor of IA pre-op and another IA just before the final prep in the OR. This new process was well received and used, probably because it made sense to the staff.

Finally a fourth audit was done on 12 random charts by the CNE and Unit Manager at the one year mark. The results of this chart audit met all audit criteria.

The audit process also allowed us to evaluate the usefulness of the charting forms: the new Outpatient form, the new Partogram and our Multidisciplinary notes. It confirmed that the Outpatient form and Partogram were very appropriate and consistent with the new SOGC guidelines.

The patient questionnaire/interviews acted as an outcome summary confirmation of the process changes. During their postpartum stay, fifteen questionnaires were returned and 16 other women were interviewed by the CNE and two staff nurses during the first six months of the change. Resounding responses reported that these women felt safer, better attended and listened to, more comfortable, able to move around freely in their labors, able to “do the stairs” and the shower longer, and that their caregivers communicated better amongst themselves and with the patient, because they were not so concentrated on the fetal strip.

What data did you collect?
Team members: We collected peer audit information on:

1. Which team member filled out the audit,

2. Correct use of new terminology,

3. Interpretation of the monitor strips,

4. Assessment of risk factors for monitoring type,

5. Evidence of clear written communication notes regarding management of the patient related to what type of fetal monitoring on:

   • outpatient form and

   • partogram, and

   • multidisciplinary notes,

6. Evidence of rationale to change the mode of monitoring for Atypical and Abnormal findings,

7. When CFM was stopped and started during the induction process, or in labor.

The C/S audit looked at outcomes of mother and baby and documentation by the RN of the fetal heart on both pre-op events.

Patient questionnaire/interviews used a set of predetermined questions related to safety, attention by the nurse, comfort, team functioning and family-centered care, with a group of 31 women. These women were ones who had received CFM at our facility with a previous child, but had IA in labor for this baby. They were able to compare their experiences and give us some feedback.