In January this year, the National Health Commission issued the "Technical Assessment Plan for the Treatment System for Critically Ill Pregnant Women", which requires that the technical assessment of the treatment system for critically ill pregnant women be carried out at different levels in accordance with the principle of localized management. The plan clearly states that by the end of September 2024, the first technical assessment of the treatment system for critically ill pregnant women will be fully completed. From 2025 onwards, by the end of June each year, the technical assessment of the critical maternal treatment system in the jurisdiction of the previous year will be completed. How do midwifery providers view this round of assessment? In the "preparation for the exam" stage, what work are being carried out by critical maternal treatment centers at all levels? What are the envisages for the expanded application of the assessment results? Recently, the reporter walked into the relevant medical and health institutions to find answers.
Ability and system are taken into account
Strengthen essential skills
The five colors of "green, yellow, orange, red, and purple" mark the pregnancy risk level of the mother.
Based on nearly 30 years of clinical experience, Xu Hongmei, director of the Department of Obstetrics and Gynecology of Beijing Fengtai District Critical Maternal Treatment Center and Beijing Fengtai Hospital, pointed out that critically ill pregnant women are not completely concentrated in large midwifery institutions. In fact, midwifery institutions at all levels may receive critically ill pregnant women, "even if pregnant women are marked 'green' throughout pregnancy, they may progress to 'red' due to rapid changes in their condition during childbirth, so improving the capacity and level of treatment of critically ill pregnant women is a mandatory requirement for midwifery institutions at all levels." Xu Hongmei said.
"The treatment of critically ill pregnant women focuses on timeliness and safety. It is not difficult to see from the "Plan" that this round of evaluation is not limited to assessing the treatment capacity. Chai Yun, director of the obstetrics department of Hangzhou Critical Maternal Treatment Center and Hangzhou Obstetrics and Gynecology Hospital in Zhejiang Province, believes that the treatment capacity and treatment network are indispensable, and only by taking into account both can the success rate of critical maternal treatment be significantly improved.
Chai Yun pointed out one of the major features of this round of evaluation. According to the plan, the evaluation indicators are composed of 28 indicators in three aspects: work effectiveness, construction and operation of the critical maternal treatment system, and construction and management of critical maternal treatment centers.
"A considerable part of these 28 indicators come from medical quality control indicators, which have always been the focus of obstetric professional monitoring, and from the perspective of midwifery institutions, there is not much pressure." Chai Yun said that the assessment work is mainly based on data and information assessment (the time node is from January 1 to December 31 of the previous year), combined with the necessary on-site assessment, in the provinces where the information construction meets the standard, it will basically not cause additional burden to midwifery institutions. "Taking my hospital as an example, relying on the hospital's smart medical information management platform, the data required for the assessment can be directly extracted, analyzed and generated, and a round of self-assessment can be carried out in advance before the evaluation starts." Chai Yun said.
Reading the "Plan" carefully, Xu Hongmei also felt quite calm. "In the past decade, the Beijing maternal and child health system has been regularly carrying out simulation drills and discussion of difficult cases against more detailed indicators, and has continuously improved the treatment process by reviewing the treatment process of critically ill pregnant women. This round of assessment is a reinforcement of essential obstetric skills. Xu Hongmei said.
Horizontal and vertical resource linkage
Activate the treatment network
Many midwifery institutions hope to use this round of assessment to further improve the safety and security of mothers and babies.
"After analysis, we still have room for improvement in the indicator of 'rapid response team reaction time'." Chai Yun said that the "plan" requires that the emergency team of critically ill pregnant women should not take more than 10 minutes from call to arrival. In the Hangzhou Obstetrics and Gynecology Hospital, where she works, it is difficult for other specialties other than obstetrics and anesthesiology to be on duty 24 hours a day. "It has been calculated in the hospital that the obstetrics and anesthesiology departments are in place for about 5 minutes, while other specialties are slightly late." Chai Yun introduced.
This indicator is calculated by averaging a sample sample of a subordinate. In Chai Yun's view, this suggests that on the one hand, it is necessary to improve the ability of obstetric treatment to buy time for other specialties to be in place; On the other hand, it is necessary to strengthen the organization and scheduling of rapid response teams, and shorten the response time of other specialties by optimizing scheduling.
As a specialized hospital, Jiangxi Provincial Maternal and Child Health Hospital relies on subspecialty construction to solve problems. Since 2018, the hospital has successively opened a number of subspecialties such as fetal medicine, endocrine metabolism, preeclampsia, placental disease, prevention and treatment of preterm birth, and obstetric critical care, basically covering common pregnancy complications and complications. "For midwifery institutions at the city and county levels, it is difficult to further subdivide subspecialties. Therefore, as a provincial-level critical maternal treatment center, we provide remote technical support for lower-level medical institutions through the national 'women and children on the cloud' telemedicine platform. Last year, one-quarter of the critically ill pregnant women we helped with were guided remotely. Zeng Xiaoming, director of the obstetrics department of the hospital, said.
Zeng Xiaoming believes that cooperation between critical maternal treatment centers at the same level also needs to be strengthened, especially specialized hospitals and general hospitals should form horizontal linkage. "For example, we have established close contact with the Second Affiliated Hospital of Nanchang University, which is also a provincial-level critical maternal treatment center, so that in case of an emergency that is difficult to handle, the medical staff of the other party can arrive at the scene within 20 minutes." Zeng Xiaoming introduced.
The specialty strength of general hospitals is relatively balanced, while Xu Hongmei pays more attention to the "incidence of macrosomia". "Macrosomia is mainly caused by maternal overnutrition, diabetes, etc., and often requires cesarean section, which may endanger the health and life of pregnant women if not properly disposed of." Xu Hongmei told reporters that judging from the department's monthly report, this figure is 8%~9%, which is still far from the 7% requirement put forward in the 9th edition of "Obstetrics and Gynecology".
Ms. Xu's concerns are universal. Since 2016, the Beijing Municipal Health Department has implemented a city-wide campaign to improve pregnancy and childbirth nutrition and health care services, requiring midwifery institutions to set up pregnancy nutrition clinics. On this basis, Beijing Fengtai Hospital, as a district-level critical maternal treatment center, has a closer linkage with the community health service center.
"Nutritional intake during pregnancy is not just a problem for pregnant women, it needs to be mobilized by the whole family." Xu Hongmei introduced that Beijing Fengtai Hospital and the Community Health Service Center set up experiential classes in the community, requiring the "head chef" at home to be present to receive nutrition guidance during pregnancy, and strive to reduce the incidence of macrosomia to a reasonable level.
This closeness extends from the community to the home. "To ensure the safety of mothers and babies, it is necessary to strengthen the whole process management of high-risk pregnant women during pregnancy and reduce the occurrence of emergency first aid." Xu Hongmei said that after the number of mothers of the second and third children increased, the mothers of the children neglected perinatal health care because they were busy taking care of "Dabao". A high-risk pregnant woman who came to Beijing Fengtai Hospital for treatment had gestational hypertension and needed to be hospitalized, but the pregnant woman wanted to go home to adjust her blood pressure so that she could take care of "Dabao".
"Combined with the high-risk maternal follow-up system established in Beijing, we arranged for the pregnant woman to be seen in the obstetric outpatient clinic of the hospital, formulated an individualized treatment plan for her, and a fixed obstetrician was responsible for her perinatal care." At the same time, Xu Hongmei said, the hospital reported her situation to the District Obstetrics Quality and Safety Management Office, which coordinated with the community health service center to regularly monitor her blood pressure changes. When the blood pressure fluctuates abnormally, they will be transferred back to the hospital from home for treatment according to the situation, so as to implement "one case found, one case registered, one case reported, one case managed, and one case treated".
Scientific, objective and fair assessment
Extend the value of your application
According to the Plan, the provincial-level health administrative departments shall conduct a self-assessment of the provincial-level critical maternal treatment system, and the provincial-level and municipal-level critical maternal treatment system within their jurisdiction, and so on, up to the county level.
Zeng Xiaoming participated in the evaluation of the treatment system for critically ill pregnant women at the prefectural and municipal levels. He said that due to the decline in the birth rate, the probability of some midwifery institutions receiving critically ill pregnant women has decreased correspondingly, and young medical staff are inevitably unfamiliar with treatment techniques and procedures. To this end, the province plans to rely on the national "women and children on the cloud" telemedicine platform to carry out more targeted business training. "We have compiled the clinical cases into an obstetric critical care manual for the reference of subordinate midwifery institutions, and we will continue to update the case content in the future to enrich this reference book." Zeng Xiaoming said.
In order to make the evaluation results more recognized, Zhejiang Province handed over the evaluation work to the Zhejiang Provincial Materal, Child and Reproductive Health Center. "The center does not engage in specific medical work, and relatively speaking, the evaluation results given are more objective and fair; At the same time, they can give full play to their own expert resources and put forward professional suggestions on the scientific application of the evaluation results. Xu Ling, director of the Zhejiang Provincial Maternal and Child and Reproductive Health Center, said that the center is assisting the Zhejiang Provincial Health Commission in formulating more detailed index requirements according to the "Plan" and the actual situation of Zhejiang Province.
"There are different levels of critical maternal treatment centers, and the assessment focus is focused." Xu Ling said that for the provincial and municipal levels, the focus of the assessment is on the indicators related to the transfer of pregnant women from other hospitals, as well as the frequency of business guidance in the responsible area, and it is necessary to pay attention to whether its radiation effect is in place; For the county level, the assessment focuses on indicators related to the screening and assessment of maternal pregnancy risk, and it is necessary to pay attention to whether its basic role is in place because the accuracy of the assessment directly affects the follow-up treatment.
Of course, the evaluation is only a means, and the real purpose lies in the scientific application of the evaluation results.
In Xu Ling's view, the results of this assessment have multiple application values. First, it is convenient to dynamically adjust the setting of critical maternal treatment centers at all levels. On the one hand, more general hospitals with strong treatment capacity should be included, and their relevant specialties should be mobilized to improve the level of treatment for critically ill pregnant women in the jurisdiction; On the other hand, the treatment center with unsatisfactory assessment results is proposed to rectify the situation within a time limit. Second, it is convenient to have an overall judgment on the distribution of obstetric resources, and then narrow the differences between urban and rural areas and regions.
For midwifery facilities, this round of evaluation is also an effective feedback. Chai Yun said that because of the declining birth rate, the outside world may think that most obstetrics have become relatively "idle". After this round of evaluation, especially when the indicators such as "the ratio of physicians in the annual labor production" and "the proportion of midwives in the annual delivery volume" are collected and summarized, it will help the health administrative department to have a comprehensive understanding of the current situation of obstetrics, especially to grasp the differences between different levels of midwifery institutions, as the basis for planning obstetric staffing.
Text: Health Daily reporter Zhao Xingyue correspondent Xing Shiwei
Editor: Li Shiyao Proofreader: Yang Zhenyu Review: Guan Zhongyao Xu Bingnan
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