key: cord-0938857-kav8z82g authors: Rana, Anubhuti; Sharma, K. Aparna; Kulshrestha, Saumya; Khanna, Puneet; Bhatla, Neerja; Kumar, Sunesh; Trikha, Anjan title: Establishing communication with relatives of admitted obstetrical patients with COVID‐19 infection during COVID‐19 pandemic: A quality improvement initiative date: 2022-02-25 journal: Int J Gynaecol Obstet DOI: 10.1002/ijgo.14134 sha: 59486e678c57789621df859e16e32f15e284ca63 doc_id: 938857 cord_uid: kav8z82g OBJECTIVES: To establish communication with relatives of obstetrical patients with coronavirus disease 2019 (COVID‐19) admitted to an isolation ward by systematic use of quality improvement tools during the COVID‐19 pandemic as there were many challenges in communicating with relatives. METHODS: The study was conducted in the Department of Obstetrics and Gynecology at a tertiary‐care teaching hospital based on four systematic steps of Point of Care Improvement methodology. After identifying the problem, a quality improvement team was constituted, which formed a specific aim. After root‐cause analysis with fishbone tool, three Plan‐Do‐Study‐Act (PDSA) cycles with various interventions were planned. RESULTS: The outcome was measured as percentage of relatives of obstetrical patients admitted to the hospital with COVID‐19 who were counseled about vital patient‐related information. The baseline percentage of counseling of relatives of COVID‐19‐positive obstetrical patients admitted to the hospital was 14% per day. After three PDSA cycles, the target of 66.5% was achieved. CONCLUSION: Communication with the relatives of COVID‐19‐positive obstetrical patients admitted to isolation wards in the hospital could be easily streamlined without any additional resources using the principles of quality improvement during the COVID‐19 pandemic. isolation protocols, and the physical barriers imposed by the personal protective equipment (PPE) have all contributed to a decrease in interaction between patients and the healthcare providers. In such a scenario, daily communication and clinical counseling sessions have become nonexistent, especially in COVID-19 wards as relatives were unable to meet the treating doctors to obtain updates on the condition of the patients, so compounding their anxiety. Moreover, there was no set protocol for clinical counseling as opposed to counseling in person at the time of hospital admission or during visiting hours before the pandemic. The present work was conducted to establishing essential and effective communication with patients and their relatives in the setting of a COVID-19 ward among obstetrical patients using quality improvement principles. 2,4 All the COVID-19-positive pregnant or postpartum women at the All India Institute of Medical Sciences, New Delhi who required admission for management of labor or obstetrical complications were admitted to the Trauma Centre, All India Institute of Medical Sciences, New Delhi. It was a stressful time for them as no attendant was allowed to stay in the isolation ward with the patient. Visitors were also not allowed during this time. The patients and their families were anxious about the effect of COVID-19 on the pregnancy and the baby. The use of PPE by the resident doctors at all times was also perceived as a barrier for interpersonal communications by the patients because the usual non-verbal cues were masked. Family members were also unable to meet the treating doctors to obtain updates on the condition of the patients, adding to their anxiety. In addition, there was no set protocol for this situation as opposed to counseling in person at the time of hospital admission or during visiting hours before the pandemic. Effective doctor-patient communication is the key to resolving fear, stress, and anxiety among patients and their relatives. Before the pandemic, the patients and their relatives were counseled about relevant clinical information and were updated about their condition in person during visiting hours. However, this was not possible in person because no relatives were allowed in the isolation ward where obstetrical patients with COVID-19 were admitted. Therefore, the project aimed to establish communication with relatives of COVID-19-positive patients admitted to isolation wards by using the principles of quality improvement. Studies have shown that effective doctor-patient communication leads to improved patient satisfaction, follow up, and adherence to treatment. 5, 6 It has been seen that patients who stay alone in COVID-19 isolation wards without family members have increased stress and fear regarding the disease status, treatment, and prognosis and also about the daily activities of patients in the ward. 7 Relatives of critically ill patients are also at increased risk for depression (70%), anxiety (80%), and traumatic stress symptoms (57%). 8 This project aimed to establish the practice of daily clinical counseling sessions with relatives of obstetrical patients with COVID-19 from the baseline to 70% over 4 weeks (October1 to October 28, 2020). A prospective quality improvement study was conducted in the Department of Obstetrics and Gynecology at a tertiary-care teaching institute of India. The study population included all obstetrical patients with COVID-19 admitted to the COVID-19 ward of the hospital from October 1 to October 28, 2020. Twenty COVID-19-positive obstetrical patients were admitted in the month of October 2020 and 25 in the month of November whose relatives were counseled about the clinical conditions on a daily basis. The Point of Care Quality Improvement model was used to sensitize the resident doctors to the quality improvement initiative and methodology. The four steps of quality improvement were introduced systematically. The first step was problem identification, making a team and forming an aim statement. The prob- The percentage of relatives of admitted obstetrical patients with COVID-19 infection for undergoing counseling about clinical condition daily was decided to be the process indicator. The data were collected manually on a daily basis by the COVID-19 team posted on duty. A checklist was made to ensure uniformity of content of counseling by all residents, which was filled for relatives of all admitted patients and collected at the end of each day ( Figure 2 ). Moreover, to ensure the satisfaction of the relatives of admitted COVID-19positive obstetrical patients about the information provided, a feedback form with four questions and approved by all team members was introduced. (Figure 3 ). The team decided to hold online meetings every afternoon initially for 2 weeks to review the data collected in the morning. Based on the inputs, several successive interventions were undertaken in the PDSA cycle and the next intervention was planned from the lesson learned from each cycle (Table 1) . A time series chart was made and multiple time periods before and after each intervention were evaluated (Figures 4 and 5) . SQUIRE 2.0 guidelines were followed for standardizing the documentation of the improvement project. The quality improvement team conducted daily clinical debriefing sessions for the patients admitted to the COVID-19 ward and their relatives. Feedback was obtained from the relatives of admitted COVID-19-positive obstetrical patients about the clinical debriefing sessions upon discharge or at the end of 1 week. This project was deemed an improvement study and local policy meant that ethical approval was not required. Intervention: Sensitization and forming a standard operating procedure. This weekly meeting was mediated by all the team members to encourage the residents to continue the project. The practice was then observed for 1 week and data were recorded for the same period. Intervention: Refining the process and timing of counseling. From the results of PDSA 1, it was observed that most relatives could not be contacted because there was no fixed time for the clinical rounds by the doctors. Moreover, the content of counseling was not well detailed in spite of high-risk consent taken about the patient's condition. There was no defined mechanism for feedback from the relatives. A few ideas for changes to overcome these problems in the second PDSA cycle were suggested by the team. It was decided to assign specific time slots for relative counseling instead of doing it at random times. In addition, a checklist detailing the content of counseling was implemented (Figure 2 ). This included the indication of admission, current pregnancy status, effect of COVID-19 on pregnancy and baby, and further management or discharge policy. A detailed proforma was also TA B L E 1 Plan-Do-Study-Act cycle as implemented for improving communication with relatives of COVID-19-positive obstetrical patients admitted in the hospital Intervention: Re-sensitization at time of duty changeover among residents. At the end of the second PDSA cycle it was noticed that not all relatives answered calls from landline/hospital mobile numbers. In All the authors (AR, KAS, SaK, PK, NB, SK, and AT) made substantial contributions to the conception of the study, the analysis of data and drafting the manuscript. All the authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals The Improvement Guide: A Practical Approach to Enhancing Organizational Performance Eliminate slogans and remove barriers to pride in work Quality improvement methods in clinical medicine Assessing competence in communication and interpersonal skills: the Kalamazoo II report Continuing concerns, new challenges, and next steps in physician-patient communication Needs and concerns of patients in isolation care units -learnings from COVID-19: A reflection A family information brochure and dedicated website to improve the ICU experience for patients' relatives: an Italian multicenter before-and-after study Establishing communication with relatives of admitted obstetrical patients with COVID-19 infection during COVID-19 pandemic: A quality improvement initiative The authors have no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study.