AIM PPH Program - Lessons Learned PTT 11Aug24 FINAL (1).pptx

AIM ( Alliance for Innovation in Maternity health) program introduction and lesson Learnt in Afghanistan

1. 1 Alliance for Innovation in Maternal Health (AIM) Program Improving Emergency Obstetrical Care in Afghanistan ASSISTANCE FOR FAMILIES AND INDIGENT AFGHANS TO THRIVE (AFIAT) Lessons Learned: AFIAT Postpartum Hemorrhage Training Program

2. AFIAT Safety Programs: Lessons Learned AFIAT patient safety programs address three common causes of maternal morbidity and mortality in Afghanistan: Postpartum hemorrhage (PPH), Pre-eclampsia (PEE), and complications from Cesarean birth. Each program utilizes the framework developed by the Alliance for Innovation in Maternal Health (AIM) Program. AFIAT safety programs utilize evidence based “safety bundles” of best clinical practices that focus on prevention, early recognition, and rapid response to common medical and surgical conditions. AIM programs also integrate patient safety training with clinical education to promote professional behaviors and can reduce clinical errors. The AIM PPH program has reduced maternal morbidity and mortality from PPH in both low and high resource settings. AFIAT’s Safe Cesarean Surgery program reduces the risk of adverse clinical events by adopting the routine use of WHO Infection Prevention (IP) practices, safety checklists, and PPH prevention protocols. AIM Programs have been successfully introduced in 14 AFIAT-targeted provinces across three phases, encompassing 45 healthcare facilities located in AFIAT-targeted provinces.

3. 3 ASSISTANCE FOR FAMILIES AND INDIGENT AFGHANS TO THRIVE (AFIAT)

4. CLINICAL OUTCOMES AFTER AIM PPH TRAINING IN MALAWI 1 4 P=0.02 ASSISTANCE FOR FAMILIES AND INDIGENT AFGHANS TO THRIVE (AFIAT) AIM training was conducted in a large referral hospital in Malawi. 1635 patient records were reviewed 3 months before AIM training and six months after training. Maternal mortality due to postpartum hemorrhage was reduced by 82% (p<.05) 1 Chang et al: Obstet Gynecol 2019;133:507–14

5. 5 Area 25 Community Health Center (Malawi) Long Term Impact (2016-2020) 1 ASSISTANCE FOR FAMILIES AND INDIGENT AFGHANS TO THRIVE (AFIAT) 1 2020 FIGO African Regional Congress Symposium

6. AFIAT Program for Postpartum Hemorrhage and Pre-eclampsia Five Step Process for AIM Program I mplementation Pre-Implementation Assessments Health Facility Readiness Assessment Tool AHRQ Hospital Survey of Patient Safety (HSOPS) Establishment of an AIM Action Committee AIM PPH Bundle and AIM Pre-eclampsia Bundle Training Program for facility staff Data Tracking and Data Review Implementation of a Low Dose High Frequency (LDHF) Skills Lab Training Program

7. AIM PPH Program Pre-Implementation Facility Assessment Essential medications must be readily available, including oxytocin and misoprostol. There must be a reliable cold chain system. Foley catheters must be available for monitoring urine output and for condom catheters. There must be ready access to blood in the facility or at a nearby referral hospital. Transport service must be readily available for an emergency transfer to a higher level of care. There must be a reliable communication system to consult with a referral facility or specialist. There should be a minimum of two skilled health providers available at each shift.

8. Guidelines for Conducting Patient Safety Surveys A baseline safety survey should be performed prio r to the implementation of the AIM PPH program, the AIM Pre-eclampsia program, or the AFIAT Safe C-Section program. Survey p articipants should receive standardized instructions to avoid bias or erroneous information. Safety surveys should be distributed to all health care workers in staff position types 1-13 (see the AHRQ Safety Survey in APPENDIX A and B). The survey should be conducted over a minimum of two days to provide adequate opportunities for all eligible staff to participate. A consent form must be signed prior to distributing the survey. The survey form should be conducted anonymously, with no identifiable marks on the response form. Any related documents that contain confidential information should be stored in a locked and secure location. Follow up safety surveys should be conducted every six months and under the same conditions as the baseline surveys.

9. The AIM Action Committee (AAC) The AIM Action Committee (AAC) consists of local facility staff who are trained as trainers and are committed to the implementation and effectiveness of the AIM programs. The staff should be selected from district hospitals, provincial hospitals, and comprehensi v e health centers (CHCs) in the province. A strong and engaged AAC team leader will increase the likelihood of achieving good outcomes. Agendas and minutes of AAC meetings should be prepared in a timely manner and disseminated prior to AAC meetings. The AAC chair should designate specific “focal points” who will be responsible for achieving specific objectives of subcommittees (see next slide). The minutes of AAC meetings should be completed shortly after the meeting, and should identify the focal points responsible for achieving specific objectives. The QBL focal point must actively promote and monitor the consistent use of the Quantification of Blood Loss (QBL) tracker . The AAC designated focal point must support the collection, accuracy, utilization and dissemination of relevant clinical data. The AAC should i dentify and eliminate structural or process barriers that will might with the effectiveness of the program.

10. AIM Action Committee Subcommittees AIM PPH Program Safe Surgery Data Collection Low Dose, High Frequency (LDHF) Skills Lab Program AIM Pre-E Program Pre-Eclampsia and Eclampsia (PE-E) Data Collection Low Dose, High Frequency (LDHF) Skills Lab Program Implementation and monitoring of OPD tracker QBL MPDSR Hemorrhagic Cart PPH Data Collection Inventory of Misoprostol &Ergometrine Low Dose, High Frequency (LDHF) Skills Lab Program Safe Surgery Program

11. Low Dose High Frequency Skills Training One-time training interventions to improve health care provider skills do not result in long term retention. T he use of repetitive and interactive learning sessions with immediate feedback from trained mentors results in more sustained clinical knowledge and skills. The use of proficiency checklists that measure improvements in learning and technical skills are essential tools to monitor individual clinical improvements. Low dose, high frequency, mentorship-based skills labs should be readily accessible to all staff for at least six weeks after the formal AIM training.

12. AIM PPH Skills Lab Centers S kills lab centers should be established in the district or provincial hospital or a nearby skills lab center Experienced mentors conduct scheduled training sessions for a minimum of six weeks Unstaffed practice sessions should also be available to hospital and health center staff Proficiency checklists should be used to objectively assess each staff member’s performance of each technical skill. An electronic “LDHF tracker” is available to monitor progress and address staff deficiencies The AIM Action Committee received monthly reports on staff performance. Consider refresher training every six months to train new staff members.

13. Essential Skills in the 3 AIM programs PPH Pre-Eclampsia/Eclampsia Safe C-Section surgery -QBL -Bedside coagulation test -Uterine compression - Uterine Balloon Tamponade -Manual Removal of Placenta -Aortic compression -Repair of vaginal laceration -Repair of cervical laceration -B-Lynch suture -Non-pneumatic Anti Shock Garnment (NASG) -Effective communication -Monitoring vital signs -Analyzing urine -Drawing blood for lab results -Routine Physical Exam of pregnant woman -Left lateral position -Fluid balance-Monitoring intake -Medication administration -QBL -Infection prevention abdominal cleansing -Infection prevention vaginal cleansing -insertion Foley Catheter -WHO SS checklist role play -B-Lynch suture

14. Association between Safety Culture and Clinical Quality Improvement 18 months after AIM PPH training: AHRQ HSOPS 1 scores in overall patient safety increased in two out of three AFIAT targeted provinces. Increasing safety scores were associated with a significant reduction in the incidence of postpartum hemorrhage. Declining s afety scores were associated with an inc rease in the rate of P PH. Key changes in facilities with increases in overall safety culture: Strong communication and teamwork skills among health care workers. A non-punitive attitude towards individual clinical errors. A management team that listens to staff and supports them. 1 Agency for Healthcare Research and Quality - Hospital Survey on Patient Safety p= NS P <.05 p= NS

15. How does the AIM –PPH Program Improve Clinical Outcomes? The AIM Program improves outcomes by building clinical knowledge and skills over 5 key phases of the program

16. Case Lesson: Reducing PPH in Nangarhar Province

17. Conclusions The AIM PPH program, the AIM Pre-eclampsia program and the Safe Cesarean Section address three causes of maternal morbidity and mortality. The AIM Action Committee is the principal driver of these three QI interventions and must provide strong direction and oversight. Overtime, AAC committee is integrated in the QI committee of the HF. Rapid cycle, reliable data is required to deliver the clinical information necessary to improve outcomes. The use of LDHF mentorship sessions should be available for at least six weeks after formal classroom staff training has been completed.