Cristian Erick Cuevas-Guerrero,1 Beatriz Adriana Urbina-Aguilar,2 Elsa Alvarado-Gallegos1
1Instituto Mexicano del Seguro Social, Hospital General de Zona 1 con Medicina Familiar; 2Universidad Autónoma de San Luis Potosí, Facultad de Enfermería, Unidad de Posgrado e Investigación. San Luis Potosí, San Luis Potosí, México
Registro Comité Local de Investigación y Ética en Investigación en Salud No. 42: R-2015-2402-37
Correspondence: Cristian Erick Cuevas-Guerrero
Received: December 14th 2015
Judged: Marc 27th 2016
Accepted: June 22nd 2016
Introduction: Maternal mortality is a global public health problem that has not been resolved, so strategies are needed to ensure emergency obstetric care, the Immediate Response Team (ERI) is a multidisciplinary care strategy which coordinates activities, care and management.
Objective: To evaluate trough the organizational context, the mode of operation, strengths and weaknesses of the rapid response team from the perspective of the actors involved.
Methods: Qualitative evaluation with 18 participants of management and operational levels selected through convenience sampling. Semi-structured interviews were audio recorded and after their informed consent were transcribed. An analysis of thematic content was conducted.
Results: Four dimensions were identified: 1) Human resources, prospects of a humanized equipment and service attitude; 2) Working conditions, factors that favor the attention of urgency; 3) Strengths, friendly side of care to users, and 4) Areas of opportunity, areas for improvement to ensure the success of care.
Conclusions: Members of the immediate response team perform their duties according to the steps of the critical path: a) Identify; b) Address; c) Transfer, and d) Provide feedbac. There are well-defined steps to follow when identifying an obstetric emergency, in addition to have well-defined human resources responsible for activating the code.
Keywords: Maternal mortality; Perinatal mortality; Pregnancy complications; Pre-eclampsia
The Millennium Development Goals (MDGs)5 aim to improve maternal health, however, despite the efforts of international institutions, it has not been possible to reduce maternal mortality by three-quarters between 1990 and 2015 (MDG 5A) or to achieve universal access to reproductive health by 2015 (MDG 5B).1
In the global context, 99% of maternal deaths correspond to developing countries and more than half of these deaths occur in fragile environments and humanitarian crisis countries. In 2015, the maternal mortality ratio was 239 per 100,000 live births, while in developed countries, it was only 12 per 100,000 live births. The great disparities exist not only between countries, but also within one country, among women with high and low incomes, and between the rural and urban population.
On average, women in developing countries have many more pregnancies than those of developed countries, so the risk of death related to motherhood throughout life is 1 in 4,900 in developed countries, and 1 in 180 in developing countries. In the latter, adolescents under 15 make up the group at highest risk of maternal mortality due to complications of pregnancy and childbirth.2
Undoubtedly, maternal mortality (MM) is a multifactorial problem; pregnancy and childbirth are not diseases, but 85% of maternal deaths are potentially preventable and are closely related to poor hygiene, poverty, malnutrition and lack of knowledge. We have identified three types of delays that may affect the likelihood that a woman or her child survive to an obstetric emergency. The first is identified with the time that a pregnant woman takes to get to the specialized medical care unit, because of women’s lack of knowledge about the need for urgent care and the decision-making of the family. The second has to do with access to health services in order of geographical, economic or structural access, and due to lack of resources and lack of appropriate facilities for emergency care. The third is receiving appropriate interventions once they access the health unit, as a result of a lack of human resources and equipment to provide timely, effective care.3
Therefore, the health system's response to the challenge of maternal mortality has resulted in various actions, which although they have contributed to their decline, have not achieved the expected results to ensure that the goals can be achieved. One strategy that has been implemented includes monitoring, preventing high-risk pregnancies, and diagnosis and treatment of complications during and after pregnancy. On the other hand, given the need to provide care to pregnant women with a system rapid response care system, a strategy for the multidisciplinary care of obstetric emergencies (blood pressure, bleeding and sepsis), the rapid response team was implemented. In obstetrics this has been called mater, and it aims to prevent and/or reduce maternal and perinatal mortality by three actions: a) Identify; b) Treat, and c) Transport (Table I). The multidisciplinary team of health professionals, consisting of an OB-GYN, nurse, intensive internist, pediatrician, anesthetist, social worker, laboratory and ultrasound, all trained in obstetric emergency,4 all optimize the care system and the hospital resources.
|Table I. ABC process for the multidisciplinary action in an obstetric emergency.5|
The Instituto Mexicano del Seguro Social (IMSS) in 2010, incorporated the Immediate Response Team (IRT) into health care units that support obstetric care (in north, central and southern Mexico). The immediate response system has three components: 1) the specific criteria for notification and activation of the response team; 2) Immediate Response Team; 3) the administrative and quality component.
To carry out the implementation of IRT, it is important to consider the presence of facilitating factors such as the IRT timing and the paradigm shift due to the participation of operational and managerial staff in sending the report. Also, limiting factors such as delay in treating obstetric emergencies in decision-making by the medical team and lack of proper equipment, mainly because of the shortage of human resources in hospitals.5 In Hospital de Gineco-Obstetricia 3 del Centro Médico Nacional La Raza, a device with a network of light and sound signals was installed to alert all operational and admissions management services, emergency obstetrics surgery, operating rooms, admission headquarters, obstetrics and anesthesia, and the common area of the governing body. The efficiency of the device decreases the time for which the IRT is activated, and actions corresponding to an obstetric emergency are carried out accordingly. It significantly decreases maternal morbidity and fetal mortality.6
Therefore, the IRT is a model of care and hospital strategy for the multidisciplinary event of obstetric emergency, to provide care and treatment to pregnant women with hypertensive pregnancy, obstetric hemorrhage and related perinatal infections.
It is pertinent to carry out a qualitative health policy assessment to determine the organizational context, mode of operation, and strengths and weaknesses of the implementation strategy of the rapid response team from the perspective of the actors involved. The aim is to structure an administrative, managerial guide to redirect objectives and restructure health programs. In this sense, the active participation of professional nursing through transdisciplinary initiatives is important to improve health, human rights and international relationships.7,8
Qualitative study through assessing IRT's strategy from the perspective of the public servants involved, who make up various categories directly or indirectly involved in the process of care of pregnant women. The organizational context in which the IRT is implemented allowed examination of the implementation of the strategy and identification of health strategy strengths and weaknesses. The perspectives of the actors involved in the IRT were explored through four dimensions and subcategories, which contributed elements to carry out the evaluation.
Study participants were selected for convenience under the criteria of voluntary participation. Since they are already in the context of the study, members of the Immediate Response Team were chosen from the operational and managerial level, who were steady employees with > 6 months in emergency obstetric services of a second level hospital in the state of San Luis Potosi.
The ethical principles of respect for autonomy, self-determination and guarantee of confidentiality of information were considered.
As for information collection, semi-structured, individualized interviews were conducted with 18 healthcare workers. These were from the nursing, medicine, and social work areas, as well as medical assistants and laboratory technicians. To identify the perspectives of informants, we followed a semi-structured interview guide with 6 open questions to allow respondents to express anything related to the implementation of IRT (Table II). The interviews were audio recorded and later transcribed. In order to carry out the qualitative-thematic analysis, data processing was carried out in four stages: segmentation, coding, categorization and theming.
|Table II. Semi-structured interview guide|
|Telme about the purpose of the code mater|
|Telme about the structure of the mater code strategy|
|Describe the processes and activities carried out in this strategy|
|Telme about your roles and functions performed in the mater code and how you relate to other actors in the implementation|
|From your perspective, telme the strengths that you see in the mater code strategy|
|From your perspective, what are the areas of opportunity of the mater code strategy|
The study group consisted of 13 women and 5 men, between 28 and 52 years of age. After thematic qualitative analysis, four dimensions were identified:
Human resources: Perspectives of a humanistic team with a service attitude. In this dimension, the findings show the perception that the multidisciplinary team has of the IRT implementation, identifying the perspective of the actors and referring to: the path of life (the way to ensure maternal and child survival); obstetric emergency (the experience of the key emerging situations in sensitizing staff with humanism), the IRT as an urgent resolution of pregnancy through the multidisciplinary team; purposes: self-taught knowledge acquired through necessity to improve emergency care; working conditions: factors encouraging urgent care; strengths: the bright side of care to users; and areas of opportunity: areas for improvement to ensure successful care (Table III).
|Table III. Dimension 1) Human resources, perspectives of a humanized team|
|Life path: the path to follow to maternaand infant surviva||[…] “To carry out the deployment of activities, the Immediate Response Team wilfollow well-defined steps, from the arrivaof a patient to definitive treatment. So when we are told to come to a patient in an emergent situation, the criticapath begins, defining the steps to provide the care we spoke about. From the vision of the management team we are able to establish relevant support according to the state of health of the patient involved. Care is monitored in order to define the appropriate treatment and posttreatment surveillance.” […]|
|Obstetric emergency: experiencing emergency situations, a key element in personaawareness of humanism||[…] “Each time a patient arrives at the department, we start running, because it is very stressfuto have a patient at risk of dying and not just her, but the child too. This helps us to love life with great affection, besides making us aware that we must be better each day to serve these patients” […]|
|The IRT: emergency resolution of pregnancy through the perspective of multidisciplinary team members||[…] “Thanks to this we can say we work together to save two lives: mother and child, and do our job very well, despite the fact that patient situations get serious and urgent. We alpitch in towards a satisfactory result” […]|
|Purposes: self-taught knowledge acquired by the need to improve emergency care||[…] “I researched because, as I say, I was a generanurse in 2011. We had just started to have obstetric issues. When I came back, I concentrated on the NICU and I heard: "An IRT was activated." Then I started to train as floor manager and was asked for an IRT information card, and I asked the boss: What is an IRT? I did not know what an IRT was, then I just had to start researching on the Internet” […]|
|IRT = Immediate Response Team|
Working conditions: factors that encourage emergency care. Identifying perspectives on how working conditions favor IRT implementation, also referring to the operating mode of communications, team self-perception, multidisciplinary relationships, and team support; the results refer to communication: as a culture of social interaction that strengthens the IRT; perception of the health team of ancillary diagnostic services: a misconception of staff providing direct care; sense of responsibility: characteristic of a proactive group (Table IV).
|Table IV. Dimension 2) Working conditions, factors that favor emergency care|
|Communication: a culture of sociainteraction that strengthens the IRT||[…] “We make every effort to communicate in the clearest way and I think that is not a factor in the problem, because alnecessary information is always communicated and is always available for all” […]|
|The perception of the health team on ancillary diagnostic services: a misconception of staff providing direct care||[…] “Sometimes laboratory staff does not help much because they take too long to deliver lab results and sometimes an entire shift can go by, and the fulresults don’t arrive” […]|
|Sense of responsibility: features of a proactive group||[…] “If I could change anything, unfortunately they are things that are beyond my reach. Resources do not depend on me, or at least not here in the lab, but a lack of resources makes you feehelpless because you can’t find anything. In the night shift there are many shortcomings and it limits us more, because they give us the materiaaccording to our needs. But for example, right now, we have a number of sample tubes left, and it is not sufficient because we have twice as many patients and it wilnot be enough. We don’t have anyone who helps us with supplies” […]|
Strengths: the bright side of patient care. This dimension identifies relevant aspects in relation to how staff, despite not having ideal conditions for implementing the IRT, performs its duties and concludes patient care successfully, showing aspects that strengthen the team and make it possible to limit maternal death. Staff dedication is an element that keeps IRT implementation up to date. Work experience is another element that makes care secure. Communication is the strength that enables integration of the healthcare team (Table V).
|Table V. Dimension 3) Strengths, the bright side of patient care|
|Staff dedication: an element that keeps IRT implementation up to date||[...] "We faito get what is required to help the patients in a timely way. Sometimes the necessary things have not reached us when we stabilize the patient with what we could. That's how we work, with many shortcomings, but the most important thing is to save both lives"[...]
|Work experience: an element that makes care secure||[...] "The advantage of this is that half the staff have a lot of experience. Some have more than 5 years, that's admirable because they know the treatment by heart and are ahead of many things" [...]|
|Communication: strength that permits the unity of the healthcare team||[...] "In terms of communication, the moment a patient arrives, it is reported immediately to the chief of nursing and medicamanagement. Thanks to this, they are very aware of the situation and communicate to other services to telthe treatment unit. Information travels very quickly, because once the patient reaches the hospitaor an emergency arises, the areas involved immediately find out"[...]|
Areas of Opportunity: These are the areas for improvement to ensure the success of care and create success stories. Among the areas identified as weak, and viewed from the perspective of the actors that implement aspects that may eventually limit the care process or create risks for care, three related aspects are identified: resources, elements that limit timely emergency obstetric care; and deficiency of resources are factors generating stress in the workplace; and training, a key factor in strengthening staff (Table VI).
|Table VI. Dimension 4) Areas of opportunity, areas for improvement to ensure the success of care and generate success stories|
|Resources: elements that limit timely emergency obstetric care||[...] "If you had the ideaconditions to provide emergency obstetric care, working conditions would be optimaand staff satisfaction at the units would increase as a method of motivation and the care that currently exists would be enhanced "[...]|
|Lack of resources: a cause of stress in the workplace||[...] "We do not act as we should, this situation could be due to lack of equipment from a specific, adequate service area, such as monitors; for example, sometimes they telus to check the blood pressure with the pulse, or because the device does not work. That's why we faito hear the pressure and because of that, we give a poor service and we get dissatisfied "[...]|
|Training: The master key to strengthening the direct care staff||[...] "Since I've been here in the service, no one has given me a training related to the topics that exist here, if I've learned things it's because I have dedicated myself to research on many subjects even from the meaning of IRT to what is done "[...]|
This study allowed us to identify and describe the conditions in which the IRT, itself based on the organizational context related to the critical path of obstetric care and institutional rules regulating obstetric care at the Instituto Mexicano del Seguro Social, is implemented. The methodology permits us to gain knowledge of the perspective of those involved in the implementation of the strategy and those involved in the IRT.
According to the evaluation, the analysis unit has a well-defined organizational context, policies and processes that govern emergency obstetric care. The context is of any patient care in emergency situations, even when providing comprehensive care is not possible, until the objective for which the IRT strategy was created is met. The organization has a visible impact on how people who work there play a role in and live the phenomenon. This has been shown in studies of various disciplines and is a constant for the health team. Such is the case of the study by Perez-Zapata,9 where it was shown that there is an association between organizational variables, job satisfaction, and staff productivity in an organization.
From the perspective of the actors involved, the management of obstetric emergencies is the unit of analysis; one of the comments often made is that they lack sufficient equipment to serve needs, such as a basic vital signs monitor (pulse oximetry, blood pressure, heart monitor, heart rate) for proper measurement of oxygen. In addition, the area where the situation takes place can lead to conflict, stress or discomfort in the staff in performing obstetric emergency activities, thereby referring to the study by Rodríguez-Angulo,10 where it becomes clear that care delay may be due to insufficient resources to meet the obstetric emergency.
The members of the rapid response team perform their duties according to the steps of the critical path:
a) identify; b) treat; c) transport; d) provide feedback. The steps to follow when identifying an obstetric emergency are clearly defined. Additionally identified are the human resources responsible for activating the code (gynecologists) that initiates the process of care, through direct communication with the rest of the multidisciplinary team. Therefore, communication is a vital element that favors the success of such strategies. This finding makes visible the transfer of information from the staff in and outside of the institution, to the delegation level, where a continuous feedback process takes place, an effective factor to the outcome of care.It was identified that, although the staff work in a context where the process of emergency obstetric care is regulated, they do not work in ideal conditions for obstetric care. However, they provide care with great humanity, dedication, commitment and teamwork, conditions that encourage the success of the process provided