Audit of Caesarean Sections in a Tertiary Hospital

We aimed to evaluate the use of a peer review audit on the indication and decision for Caesarean sections at our hospital to ensure appropriate patient selection and audit clinical quality. Weekly anonymized audits were held for all Caesarean sections performed in the preceding week. Each reviewer gave a score of 1, 2 or 3 for each case based on whether they believed the decision for Caesarean section was appropriate, appropriate with areas for improvement, or inappropriate respectively. Mean scores were used for classification to one of four categories: Category A (score 1.0) implying unanimous agreement with management, B (1.1-1.9) suggesting minor reservations about management, C (2.0-2.4) suggesting significant reservations and D (2.5-3.0) suggesting serious issues with management. All indications for CS in our institution had a low mean score of <1.6. Among singleton pregnancies, there were more category A cases (72.0% versus 54.9%, p <0.001) but also more Category D cases (2.8% versus 0.9%, p <0.05) in the elective CS group than the emergency CS group. We conclude that the majority of reviewed cases had appropriate indications and acceptable management. Peer review audit sessions provide a platform for discussion, education, and identification of specific conditions where management can be improved. Zheng Yuan Ng*, Jarrod K Tan, Eng Loy Tan, Devendra Kanagalingam and Lay-Kok Tan Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore Introduction Caesarean Section (CS) is the most common surgery in women. CS rates in the United States rose from 22.9% in 2000 to 32.9% in 200 [1,2]. In England, CS rates increased from 21.5% in 20002001 to 24.8% in 2009-10 [3,4]. CS rates in Singapore are rising as well, with rates in Singapore General Hospital more than doubling from 14.0% between 1986 and 2000, to 28.3% between 2001 and 2012. Caesarean section can be associated with increased risk to both mother and fetus compared to vaginal delivery. These include higher infection rates, anaesthetic complications, lower breastfeeding initiation rates, increased length of hospital stay, and fetal complications such as an increased risk of respiratory morbidity including transient tachypnoea of the new-born, respiratory distress syndrome and persistent pulmonary hypertension, particularly if CS is performed less than 39-40 weeks of gestation [5-7]. There are also important long term consequences such as an increased likelihood of repeat CS for future deliveries, and uterine scarring, which can affect future fertility and increase the incidence of placenta creta and uterine rupture [6-9]. Obstetric decision making is often complex. Apart from the clinical scenario, patient wishes also influence the decision for Caesarean section, and the fear of medical litigation may influence the Obstetrician’s actions as well. Hospital or practice-based audits have been used as part of measures to address rising CS rates [10]. A small Scottish series on CS audit by peer review by Wareham et al found significant interauditor disagreement with regards to the indication and decision for CS [11]. They subsequently introduced structured diagnostic criteria for CS indications and have implemented on-going peer review by the on-call team of daily CS cases [11]. There is unfortunately a lack of contemporary literature analysing the role of peer review audit as a clinical quality and educational tool. With the variation and diversity in individual obstetricians’ practice as well as the intricacies of individual cases, there is a need for the peer review process to appraise the decision for Caesarean section. Our hospital introduced a peer review-based system of auditing Caesarean sections using weekly audit meetings and instituted a scoring system to reflect each reviewer’s opinion on every case performed. This was primarily intended to be a clinical quality control and education tool, rather than a direct attempt to reduce the Caesarean section rate, and the aim of this paper is to report our experience in using this system. Materials and Methods The study period was from Jan 2010 to June 2012. Weekly audits were held, each attended by Zheng Yuan Ng, et al., Clinics in Surgery General Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2017 | Volume 2 | Article 1628 2 at least 6 department Consultants and post-MRCOG (or equivalent) specialists. During each audit, all cases from the preceding week were anonymised and presented, using a fixed template (Appendix A). For every CS, each reviewer gave a score of 1 (CS entirely appropriate), 2 (some reservations over indication) or 3 (CS not indicated or management seriously flawed). The scores for each case were tallied and the mean score calculated at the end of each case, with a lower score suggestive of a more appropriate or less controversial decision for CS. An arithmetic mean of scores was used to determine the final mean score for each CS, to allow for analysis of appropriateness of each CS decision, and also for comparison of scores between indications. Four classification categories were assigned based on the mean score obtained: Category A for a mean score of 1.0 implying unanimous agreement with the decision for Caesarean section, Category B for a mean score of 1.1-1.9 suggesting management was considered mostly acceptable with minor reservations, category C for a mean score of 2.0-2.4 suggesting significant reservations over the indication and Category D for a mean score of 2.5-3.0 suggesting there were serious issues with the indication and management. Additionally, the composite of Categories A+B was designated “overall acceptable management” whereas the composite of Categories C+D was designated “unacceptable management” for outcome analysis. Score analysis was divided into singleton and multiple pregnancy subgroups, elective or emergency (including "Crash" CS, or immediate CS necessitating delivery within 30 minutes), and subdivided according to the main indications for the CS. The overall mean scores and the mean scores for the different indications for CS were also calculated. The main outcome measures of interest were the relative proportions of Category A and D between elective and emergency CS, as well as the relative proportions of “overall acceptable management” (composite of Categories A + B) and “unacceptable management” (composite of categories C + D) in the CS subgroups. Results There were a total of 1254 CS deliveries in our hospital during the study period and 3667 deliveries, giving a CS rate of 34.2%. Among the CS cases, audit scores were available for 956 out of 1254 (77.8%), including 886 singleton CS and 70 multiple pregnancy CS cases. The remaining cases had missing or incomplete audit scores and therefore excluded from the study. Within the study group, there were 356 Elective CS (37.3%) and 600 Emergency CS (62.7%) 52 emergency CS cases were Crash, or immediate CS (5.4% of total CS cases) (Table 1). Among singleton CS deliveries, there were significantly more Category A elective cases (72.0%, 231/321) than emergency CS (54.9%, 310/565), p <0.001 (Table 2). However, there were also significantly more Category D elective cases; 2.8% (9/321) of elective CS were Category D compared to 0.9% (5/565) of emergency CS (p <0.05). Both elective and emergency CS had similar rates of CS having “overall acceptable management” at 95.7% (307/321) and 96.8% (547/565) respectively (p = 0.367). There were no Category D cases within the Crash CS subgroup. For multiple pregnancies, 70.0% were category A and only 2.9% Cat D (Table 3). Dividing the singleton cases by indication, all CS subgroups had a mean score of less than 1.6. In the emergency CS group, “failed induction” (1.45) and “failed instrumental delivery” (1.43) had the highest scores, whereas for elective CS cases the highest scores were for “pregnancy-induced hypertension (PIH) or pre-eclampsia” (1.58) and "other indications" (1.43) (Table 4). The commonest indications for Elective CS were Emergency Elective Combined Score Category Crash Non-Crash Total emergency No. of cases No. of cases Acceptable management 1 A 31 (59.6%) 304 (55.5%) 335 (55.8%) 255 (71.6%) 590 (61.7%) 1.1-2.0 B 19 (36.5%) 226 (41.2%) 245 (40.8%) 85 (23.9%) 330 (34.5%) Unacceptable management 2.1-2.4 C 2 (3.8%) 12 (2.2%) 14 (2.3%) 6 (1.7%) 20 (2.1%) 2.5 -3 D 0 (0.0%) 6 (1.1%) 6 (1.0%) 10 (2.8%) 16 (1.7%) Total 52 548 600 356 956 Table 1: Audit scores Overall (Singleton + Multiple pregnancies).