Patient safety in maternity hospitals in Finland

The number of delivery units in Finland has been decreasing and care has been centralized to larger units. The main reasons for this are: the decreasing number of babies born annually, the legislation for 24/7 readiness for emergency Caesarean section and the legislation to close units with less than 1000 annual deliveries. To improve the obstetric care in Finland, this study investigated the influence of delivery unit size and physician on-call arrangements on the outcomes of low-risk deliveries, evaluated the impact of time and day of birth on neonatal asphyxia and intrapartum and early neonatal mortality, examined the effect of increased hospital volume on maternal and perinatal outcome in a high-volume delivery unit, and demonstrated the rate and causes of pregnancy-associated mortality. The risk of asphyxia was lower in units having ≥2000 deliveries annually (17/1000) than in university hospitals (21/1000) (AOR 0.83, 95% CI 0.78–0.89). Compared with university hospitals, in units having 1000-1999 annual deliveries, intrapartum mortality rate was higher (2.4/1000 vs. 2.9/1000) (AOR 1.31, 95% CI 1.07–1.61); this was also the case for units in which physicians were at home when on-call (3.0/1000) (AOR 1.25, 95% CI 1.02–1.52). The risk of asphyxia was higher (ARR 1.23, 95% CI 1.15–1.30) outside office hours (22.7/1000) than during office hours (18.4/1000). In emergency Caesarean sections, the risk of asphyxia was higher outside office hours (60.7/1000) than during office hours (52.9/1000, ARR 1.17, 95% CI 1.02–1.34). Instrumental vaginal delivery had higher risk of intrapartum and early neonatal mortality outside office hours (1.9/1000) than during office hours (0.6/1000, ARR 3.31, 95% CI 1.01–10.82). As the number of deliveries increased in the high-volume unit, the proportion of babies receiving 5-minute Apgar score <7 increased from 1.2% to 2.1% (AOR 1.67, 95% CI 1.36–2.05), newborn transfers to SCN or NICU increased from 7.3% to 8.1% (AOR 1.11, 95% CI 1.02–1.22), and third- and fourth-degree perineal tears increased from 1.4% to 2.0% (AOR 1.47, 95% CI 1.19–1.82). Pregnancy-associated mortality decreased from 37.8/100 000 in 1987-2000 to 28.4/100 000 in 2001-2012 (ARR 0.75, 95% CI 0.65–0.88). Mortality rate for suicides was highest (21.8/100 000) after termination of pregnancy and lowest in ongoing pregnancies or right after birth (3.3/100 000). In conclusion, severe adverse obstetric outcomes are rare in Finnish maternity hospitals. Delivery units must have an on-call doctor present at all times. Risk of neonatal asphyxia is higher outside office hours than during office hours in all hospital volumes and in all on-call arrangements. Increasing obstetric volume in a high-volume unit can affect both maternal and perinatal outcomes. The high suicide mortality rate after induced abortion is alarming.Jotta synnytystoiminnan turvallisuutta ja raskaana olevien naisten hoitoa voitaisiin edelleen kehittää Suomessa, tämän tutkimuksen tarkoituksena oli saada tietoa erikokoisten synnytysyksiköiden potilasturvallisuudesta ja vertailla eri tavoilla järjestettyä lääkärien päivystystoimintaa. Tutkimus vertaili myös virka-ajan ja päivystysajan vaikutusta vastasyntyneen vointiin. Lisäksi tutkittiin synnyttäjien määrän suuren nousun vaikutusta synnyttäjien ja syntyvien lasten turvallisuuteen Kätilöopiston sairaalassa ja raskauteen liittyviä kuolemia Suomessa. Matalan riskin synnytyksissä syntymänaikaista hapenpuutetta esiintyi vähemmän yksiköissä, joissa oli ≥2000 synnytystä vuosittain (17/1000) kuin yliopistosairaaloissa (21/1000). Yliopistosairaaloissa esiintyi kuitenkin vähemmän syntymänaikaisia kuolemia (2,4/1000) kuin yksiköissä, joissa oli 1000-1999 synnytystä vuosittain (3,0/1000) tai yksiköissä, joissa lääkäri saattoi päivystää kotona (2,9/1000). Syntymänaikaista hapenpuutetta esiintyi enemmän päivystysaikaan (22,7/1000) kuin virka-aikaan (18.4/1000). Päivystyskeisarinleikkaukseen päivystysaikana liittyi enemmän syntymänaikaista hapenpuutetta (60,7/1000) verrattuna virka-aikaan (52,9/1000). Päivystysaikana tapahtuvaan imukuppi- tai pihtiasvusteiseen alatiesynnytyksen liittyi enemmän kuolemia synnytyksen aikana tai seitsemän vuorokauden kuluessa syntymästä (1,9/1000) verrattuna näihin synnytyksiin virka-aikana (0,6/1000). Samaan aikaan kun yksisikiöisten synnytysten määrä Kätilöopiston sairaalassa lisääntyi 39% niiden lasten osuus, jotka saivat alle seitsemän Apgar-pistettä viiden minuutin iässä lisääntyi 1,2%:sta 2,1%:iin. Vastasyntyneiden siirto valvonta- tai tehohoitoyksikköön lisääntyi 7,3%:sta 8,1%:iin ja synnyttäjien kolmannen ja neljännen asteen välilihan repeämien osuus nousi 1,4%:sta 2,0%:iin. Vuosina 2001–2012 raskauteen liittyvä kuolleisuus oli 28,4/100 000 synnytystä, mikä oli selkeästi matalampi kuin vuosina 1987–2000, jolloin kuolleisuus oli 37,8/100 000. Itsemurhakuolleisuus oli korkein raskauden keskeytyksen jälkeen (21,8/100 000) ja matalin synnytyksiin päättyvissä raskauksissa ja raskaana olevien keskuudessa (3,3/100 000). Yhteenvetona voidaan sanoa, että vakavat synnytykseen liittyvät poikkeavat lopputulemat ovat harvinaisia suomalaisissa synnytyssairaaloissa. Löydösten perusteella voidaan suositella päivystävän lääkärin jatkuvaa läsnäoloa synnytyssairaalassa. Päivystysaikaiseen synnytykseen liittyy lisääntynyt riski syntymänaikaiseen hapenpuutteeseen kaikissa synnytyssairaaloissa. Synnyttäjien määrän lisääminen suuressa synnytyssairaalassa voi lisätä sekä vastasyntyneeseen että synnyttäjään liittyvien ei-toivottujen tapahtumien suhteellista osuutta. Itsemurhia raskauden keskeytyksen jälkeen on hälyttävän paljon

The Common Barriers and Facilitators for a Healthcare Organization Becoming a High Reliability Organization

Background: Implementing high reliability organization principles can enhance quality and safety in healthcare. Evidence-based instructions on how to effectively change the organizational culture in healthcare setting are required. Objectives: &nbsp;A systematic review investigating methods, facilitators, and barriers to assist healthcare organizations in becoming a high reliability organization. Method: Literature searches were performed in PubMed, MEDLINE, CINAHL-Complete, EMBASE, and Scopus for articles published between January 2012 and October 2017. The included articles were case reports, case studies, and protocol development studies on implementing high reliability organization principles. The articles were appraised using a modified Critical Appraisal Skills Programme tool. Thematic synthesis was conducted using manual coding.&nbsp; Results: Of the 14 eligible articles nine were case studies, four were case reports, and one was a framework development report. The study populations varied from whole healthcare systems to a single department of a hospital. The most common methods were supportive leadership, staff education, and analysing the safety events and sharing the knowledge. Cost was one of the barriers. Remuneration came in reduction of safety events and costs avoided. Conclusion Implementing high reliability organization principles in healthcare settings is slow and challenging, but doing so improves quality, resilience, and safety, thus increasing productivity

Effect of hospital size and on-call arrangements on intrapartum and early neonatal mortality among low-risk newborns in Finland

Objective: To evaluate the influence of delivery unit size and on-call staffing in the performance of low-risk deliveries in Finland. Study design: A population-based study of hospital size and level based on Medical Birth Register data. Population was all hospital births in Finland in 2005-2009. Inclusion criteria were singleton births (birth weight 2500 g or more) without major congenital anomalies or birth defects. Additionally, only intrapartum stillbirths were included. Birthweights and maternal background characteristics were adjusted for by logistic regression. Main outcome measures were intrapartum or early neonatal mortality, neonatal asphyxia and newborns' need for intensive care or transfer to other hospital and longer duration of care. On-call arrangements were asked from each of the hospitals. Results: Intrapartum mortality was higher in units where physicians were at home when on-call (OR 1.25; 95% CI 1.02-1.52). A tendency to a higher mortality was also recorded in non-university hospitals (OR 1.18; 95% CI 0.99-1.40). Early neonatal mortality was twofold in units with less than 1000 births annually (OR 2.11; 95% CI 0.97-4.56) and in units where physicians were at home when on-call (OR 1.85; 95% CI 0.91-3.76). These results did not reach statistical significance. No differences between the units were found regarding Apgar scores or umbilical cord pH. Conclusion: The differences in mortality rates between different level hospitals suggest that adverse outcomes during delivery should be studied in detail in relation to hospital characteristics, such as size or level, and more international studies determining obstetric patient safety indicators are required. (C) 2016 Elsevier Ireland Ltd. All rights reserved.Peer reviewe

The impact of increased number of low-risk deliveries on maternal and neonatal outcomes: A retrospective cohort study in Finland in 2011-2015

Objectives: Our aim was to demonstrate the influence of increased number of low-risk deliveries on obstetric and neonatal outcome. Study design: The study hospital was Katiloopisto Maternity Hospital in Helsinki. Simultaneously, we studied all three delivery units in the Helsinki region in the population-based analysis. The study population was singleton hospital deliveries occurring between 2011 and 2012, and 2014-2015. The study hospital included 11 237 and 15 637 births and the population-based group included 28 950 and 27 979 births. We compared outcome measures in different periods by calculating adjusted odds ratios (AOR). Main outcome measures were induced delivery, mode of delivery, third or fourth degree perinea, tear, Apgar score at five minutes 7 days, and perinatal death. Results: In the study hospital, induction rate increased from 22.4% to 24.8% (AOR 1.06, 95% CI; 1.00-1.12) while in the population-based analysis the rate decreased from 22.2% to 21.5% (AOR 0.96, 95% CI; 0.92-1.00). Percentage of neonatal transfers, low Apgar scores, and severe perineal tears increased both in study hospital and in population-based group. Changes in operative delivery rate and other adverse perinatal outcomes were statistically insignificant. Conclusions: Increasing the volume of a delivery unit does not compromise maternal or neonatal outcome. Specific characteristics of a delivery unit affect the volume outcome association. (C) 2018 Elsevier B.V. All rights reserved.Peer reviewe