key: cord-0946812-1ctb4cnk
authors: O'Carroll, J.; Zucco, L.; Warwick, E.; Carvalho, B.; Sultan, P.
title: P.67 Obstetric services during the COVID-19 pandemic: a national survey of standards of care
date: 2022-05-31
journal: International Journal of Obstetric Anesthesia
DOI: 10.1016/j.ijoa.2022.103363
sha: f7b4abfc6b8c33d4d0a161bc7ad98911222e543c
doc_id: 946812
cord_uid: 1ctb4cnk

nan

outcome data quality, and so we developed an electronic obstetric dashboard to automatically capture and report our neuraxial complications directly from the EPR. Methods: Development of the dashboard involved: (1) Local consensus to decide a quality metric core outcome set based on the GPAS standards for obstetric anaesthesia, RCoA QI Compendium, and OAA core indicator set Delphi study. ADP and post dural puncture headache (PDPH) rates were decided on as first priority. (2) Collaboration with the trust's business informatics (BI) team to find all patients with "dural tap" recorded as a complication in their procedure note, and patients with PDPH added to their EPR problem list. The results were displayed in a PowerBI (Microsoft) dashboard. (3) Validation of dashboard data against our paper-based system by manual review of anaesthetic records (Jan to Oct 2021), and adjustments to search queries. (4) Agreeing a local 'workflow' for recording complications on the EPR to optimise data quality, facilitated by producing a 'quick guide' for easy reference. (5) Continuous data quality monitoring and obtaining user feedback by labour ward data quality lead. Results: Our paper-based system found 12 patients with ADP and 32 with PDPH. The dashboard identified 10 patients with ADP and 11 with PDPH giving congruence of 83% and 33%, respectively. Discussion: For ADP, our dashboard shows an excellent data capture rate. Discrepancies were due to some complications being recorded as undetectable 'free text'. This was most apparent for PDPH. Introducing a standard workflow going forward will encourage recording of ADP and PDPH in a structured data format and we anticipate our detection rate to greatly improve. Our dashboard is a proof of concept which we believe shows the power of EPRs to generate continuous data for quality improvement. The issues we encountered were mainly due to inconsistency in data recording by clinicians; improving accuracy involves ongoing education of both permanent and rotating staff, and continuous monitoring of data quality which we believe requires a consultant data quality lead for obstetric anaesthesia. 

Introduction: Post-dural puncture headache (PDPH) is a common complication of neuraxial techniques and can result in significant morbidity. The Obstetric Anaesthetists' Association Has published guidelines on the management of PDPH [1] . We aimed to audit current practice in relation to these guidelines. Methods: An initial audit was conducted November 2019 to November 2020. Data were collected through notes review of all patients with known accidental dural puncture (ADP) or suspected PDPH. Changes to practice were made following the results of this audit with multidisciplinary consultation, which included introduction of anaesthetic follow-up for all patients and a checklist for induction of anaesthetic trainees to ensure PDPH follow-up was covered. Documented performance was re-audited from June 2021 to December 2021. Approval was obtained from the trust audit and clinical effectiveness department. Results: The table shows the results for women with suspected PDPH or known ADP included in the two audit periods. We analysed data from the subgroup of patients with recognised ADP at insertion of epidural. Daily reviews improved to 88% (from 56%), safety net advice improved to 100% (from 67%), communication to GP improved to 100% (from 44%) and future follow-up improved to 38% (from 11%). Introduction: The 2018 Obstetric Anaesthetists' Association (OAA) guidance on the management of post dural-puncture headache (PDPH) recommended ensuring the family doctor (GP) received notification of the diagnosis and consideration of patient follow-up at 1-2 months postpartum. Recent publications have suggested an increased incidence of longer term disabling headache symptoms in this patient cohort [1] . Recently released guidelines from the Obstetric Committee of the American Society of Anesthesiology (ASA) suggest follow-up until the patient is symptom-free [2] . Methods: We initiated a structured telephone follow-up of all patients diagnosed with PDPH at our institution from January 2020. An electronic patient record ensures a diagnosis of PDPH is sent to the GP on discharge when this is documented correctly in the record. We included appropriate hospital contact information for patients on an adapted version of the OAA-approved patient information sheet on PDPH available on labourpains.com. Following local audit committee approval we audited our practice over a two-year period.

Results: A total of 89 patients were identified with headache with 42 following an epidural needle puncture. 50 patients received an epidural blood patch. Only 66% had their PDPH diagnosis communicated via their hospital discharge letter but this improved over the second year of the audit. All 89 patients were phoned by a consultant anaesthetist between 6 weeks and 3 months postpartum. 74% of patients answered the telephone call. Few reported long-term sequelae with 5 reporting backache, one with auditory sequelae and one with headaches. Discussion: Our institution delivers 8500 mothers annually with an epidural rate of 67% and a caesarean section rate of 38%. We have an unremarkable incidence of PDPH for a teaching hospital. Follow-up revealed a low incidence of chronic symptoms. While the 2018 OAA recommendation is to consider long-term follow-up, our data suggest that following patients until they are asymptomatic is also a reasonable service goal. Good patient and GP information on PDPH and local lines of communication are essential given the potential for the more serious but rare neurological complications of dural puncture.

Chronic disabling postpartum headache after unintentional dural puncture during epidural anaesthesia: a prospective cohort study

Statement on Post-Dural Puncture Headache Management

Peripartum hyponatremia is not uncommon; however, it is underestimated and can have deleterious effects on mother and infant [1]. Dilutional hyponatremia is common in labour caused by excessive hypotonic fluids intake [2]. Accepted blood sodium level in pregnancy is 130-140 mmol/L compared to 135-145 mmol/L in the non-pregnant population [2]. Our hospital implemented new hyponatremia guidelines in November 2020, and we conducted this project to assess the efficiency and implementation of these guidelines in our labour ward