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New pathway to prevent preterm births spreads across the region
Prevention of Preterm Birth Pathway initiative is supporting maternity care providers to identify patients at risk and use medical interventions to prevent preterm births.
Preterm birth is the leading cause of perinatal mortality and morbidity in Canada and worldwide. Babies born before 37 weeks of gestation are at increased risk of severe medical problems. Having a preterm baby is also stressful for parents; particularly those who live in smaller communities, and need to leave their supports, jobs, and other children to seek specialized neo-natal intensive care in bigger c
entres.
Dr Jennifer Kask, a family physician attached to the Campbell River Maternity Clinic, was aware of very high preterm birth rates in communities across Vancouver Island - as much as 25% in 2016/17, compared to 7.4% and 7.8% in BC and Canada respectively (2013).
With the support of Facility Engagement funding, Dr Kask collaborated with Dr Kirsten Duckitt, an obstetrical specialist, to engage family physicians, midwives, and allied health providers in discussions about identifying patients at risk and using evidence-based, effective interventions to prevent preterm births.
They noted that a simple vaginal progesterone intervention that helps at-risk patients extend their pregnancy to bring them closer to term, was used by obstetricians but not always by other providers or patients.
"We concluded there was a gap was in the knowledge of our colleagues and patients," she says.
"We knew a main risk factor for a mother having a preterm birth is having had a preterm birth previously," Dr Kask says. "So it was a matter of how we help to educate our colleagues and provide some resources to identify who is at risk, and how to help prevent recurrent preterm birth."
Those insights led to the development of a Preterm Birth Pathway with a package of resources including:
With provider adoption underway in communities around Campbell River, Dr Kask then accessed SSC Spreading Quality Improvement Initiative funding expand the work further, including to Port Alberni and Tofino, as well as the Cowichan Valley through direct work with the Cowichan Valley Tribe. Dr. Kask notes that preterm births disproportionally affect First Nations individuals.
Dr Kask and Duckitt expect to spread the work across Vancouver Island rural communities by end of 2023. Her hope then is to further spread it across all BC regions, where patients in smaller communities share the same experiences and risks, and can benefit from the pathway created.
“Spread would never have happened if people in other communities weren’t interested," she says. "It is the providers who have taken a moment to listen. They are the ones who are making spread happen.” - Dr Kask
Dr Kask says that one of the highlights of the project has been making specialized care more accessible to other providers.
“The neat part of it has really been the relationship and mentorship I’ve received from my colleague Dr Duckitt. She is an excellent educator, a wonderful OBGYN and was so willing to share her specialist knowledge.”
Through data collected in the maternity clinic, Dr Kask notes there has been real progress in preventing preterm births, both through measurement in her clinic showing a downward trend in pre-term births, and patient stories.
“When a patient delivers at term in their own community, and says, 'I am so grateful that I didn't have to go to an NICU this time.' it warms my heart. Particularly because it implies that they have a little person at home" - Dr Kask
"I recognize that we are not going to able to prevent all preterm births, but recognizing that preterm birth is the biggest cause of perinatal morbidity and mortality, aren't all of them worth trying to prevent?"
This project has been funded by the Specialist Services Committee Facility Engagement and Spreading Quality Improvement initiatives.
At Kootenay Lake Hospital (KLH) in Nelson, the MSA's Gender Equity Working Group is introducing strategies to shift to a more supportive, equitable environment for women in medicine, that is also more conducive to leadership. The group is also working with neighbouring hospitals to elevate and promote strategies at the regional level.
As the number of female physicians grows, more women have the opportunity to take on leadership positions and have a greater influence in health care decisions. However, female physicians in medicine experience gender equity challenges in both leadership and clinical opportunities.
Read about the KLH strategy here>
Left to right: Dr Heather Clark, Repirologist, Carmen McClymont, Senior Respiratory Therapist, Jodi Zimmer, Supervisor, Respiratory Ambulatory Programs - with the Ambius air filtration unit.
Like many older hospitals, the Royal Jubilee Hospital (RJH) in Victoria has clinical spaces that began as patient rooms. The Pulmonary Function Testing (PFT) Lab is located in such a space. When COVID hit, the lab was challenged: how do you conduct PFT when patients can’t wear masks and the room is not properly ventilated?
During the first couple of months of COVID, the lab remained closed, except for emergencies. Then the Canadian Thoracic Society came out with regulations for the safe resumption of lung function testing.
To meet these regulations, PFT at RJH resumed on a limited basis. A room had to be closed down for three hours between each patient to ensure any airborne viruses had settled.
Dr Heather Clark, a respirologist and the medical director who oversees PFT knew they needed a better, long-term solution.
Facility Engagement funding
A Facility Engagement (FE) project looking at patients with long COVID symptoms accelerated a solution. Lung testing was part of this FE project. “In talking with a colleague who was requesting these tests and explaining our issue – he suggested I apply to FE for funding to help us," says Dr Clark.
Dr Clark successfully applied for FE project funding to improve the air exchange in the PFT lab, which consisted of three rooms. “Applying for funding turned out to be easy. Clara Rubincam, FE Project Manager was a great help," she notes. "Physicians are so busy – I’d like them to know it is easy to apply for the funding, and there is a lot of guidance and assistance available.”
Engaging stakeholders in solutions
Dr Clark began by gathering a group of relevant stakeholders, such as PFT lab supervisors, ambulatory care administrator, facility maintenance to participate in a number of Zoom meetings. The meetings helped solidify a solution, which initially would have involved renovating each of the three testing rooms over a period of three to four years.
Cross-site knowledge sharing
Dr Clark connected with a colleague at Providence Health Care and asked him what they were doing to address the aerosolization of viruses and air exchanges. It turns out they were looking at other technologies, such as air filtration.
“He connected me with the facility maintenance manager at Providence and their pulmonary diagnostics coordinator, and I introduced them to our facility maintenance person. The air filtration units became the right solution. Rather than air exchanges, they now have air filtration, filtering the air through HEPA and carbon filters to achieve the equivalent cleaning of the air."
Project support
Part of Dr Clark’s success was due to Charlotte Bowey, an Island Health administrative assistant who was working on her Master’s Degree in project management, who scheduled the meetings, attended and took notes. “She was crucial to my success," says Dr Clark. "She knew who I should involve. She also knew just when to send out meeting notes to keep everyone engaged.”
“I’m pleased we solved the problem and I wouldn’t be losing sleep at night. My patients are compromised, often they are on immuno-suppressors and I need these tests to know if the therapies are working and how to adjust them if they are not.”
Solutions save costs
One advantage to this project is having the Providence Health Care solution already evaluated and approved before an investment was made at RJH. In addition, the cost savings are quite significant. Initially, $100,000 was earmarked to renovate one room. In the end, the costs for the health authority for air filtration systems for all three rooms were about $45,000.
Dr Clark’s adds an observation about obtaining FE funding. “I didn’t understand that it could be applied to this project – I thought it would have to be more directly tied to patients. I think it’s important to let physicians know that it is not difficult and that people want you to succeed.”
For about 20 years, the Royal Columbian Hospital (RCH) was the unofficial referral centre to help treat Placenta Accreta Spectrum (PAS), a serious pregnancy condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.
During delivery, a PAS patient may experience an average blood loss of about two to three litres with a need for a transfusion of up to 4-1/2 units of packed cells. There’s an 85% chance of a hysterectomy and a 50% chance of urological injury to the ureter or bladder.
In 2020, Dr Sara Houlihan, an obstetrics and gynecology surgeon at RCH applied for funding from Facility Engagement (FE) to help establish RCH as the provincial PAS Clinic.
“There is extensive research supporting this excellence of care model to reduce serious complications and deaths.” - Dr Sara Houlihan
Multi-disciplinary engagement
Dr Houlihan engaged a small multi-disciplinary team to collaborate on overlapping processes such as ultrasounds, iron infusions, surgical interventions, and so on. “
There are so many wheels to put in motion when a patient gets referred to us,” says Dr Houlihan.
Clinic and website
The multi-disciplinary PAS Clinic is now officially open, along with a PAS Clinic website, which is available to both care providers and the public. The website educates about the condition and provides referral forms to access services.
"We have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care."
Timely detection and risk factors
Timely management of this condition is imperative. The condition is often first detected on an ultrasound, usually at 22 or 28 weeks. Dr Houlihan notes, “it is a devastating condition that can have major ramifications for patients and the quality of their lives.”
If a radiologist suspects there is an abnormal placenta during a routine ultrasound – they suggest a referral and evaluation to the primary care physician, who can then refer the patient to the PAS clinic.
There are also risk factors that can pre-dispose a patient to have PAS, such as prior C-sections (the more C-sections, the greater the risk), placenta privia (placenta overlying the cervix) and any previous uterine surgery.
These pre-existing conditions can trigger a referral, which is why the PAS Clinic is working to raise awareness about these risk factors with care providers.
Why Royal Columbian?
Dr Houlihan talks about why RCH is uniquely qualified. “To be a centre of excellence you must have obstetrics ultrasound technicians who has experience in PAS, you need a capacity to do MRIs and radiologists who have experience in PAS, a level three maternity and nursery, ICU, obstetrical anesthesiologists, transfusion medicine and specialized surgical teams," she notes.
"Our biggest ace are our maternal fetal medicine sonographers. They are the ones who do the ultrasound, determine risk levels and triage for appropriate care."
“We are consultants on this issue – so the primary care provider continues the prenatal care – we stratify the patients’ risk with imaging, optimize patients with referrals to specialists and sub-specialists, and for high risk patients, we perform their surgery at RCH.”
Awareness and education
Education is important – so Dr Houlihan and her team are spreading the word about the PAS Clinic and its resources through discussions with the Obstetrical Societies in BC. For family physicians, plans are in the works to do in person education sessions. In addition, all the information has been uploaded to Pathways, which includes referral forms and patient handouts.
Progress and looking ahead
The long-term goal for the PAS Clinic is to navigate PAS patients through every step of their journey, including comprehensive after care that would address both the physical and psychological impacts of this condition.
Asked what she is most proud of, Dr Houlihan said, “I’m happy about the gains we have made in patients’ outcomes – we know we have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care.
"We all want to provide excellence in maternity care and everything we have been doing has made a positive difference.”
Prince George Medical Staff Physician Association, University Hospital of Northern BC
In 2021, the EQUIP Health Care research project conducted in three BC emergency departments including in Prince George, shared findings on health inequity issues that affect Indigenous people and others seeking care. It shone a light on opportunities for change in emergency departments, often the first point of entry for many people accessing medical care and inpatient treatments, and when patients are at their most vulnerable.
The University Hospital of Northern BC (UHNBC) in Prince George is in a unique position to help create long-term and sustainable approaches to address these issues. It is the largest teaching hospital in Northern BC for health care providers of the future, and is located in the region with the highest Indigenous population in the province.
At the same time, the work of the Prince George Medical Staff Physician Association (PGMSPA) is a collaborative and integral part of helping to build toward equitable and culturally safe care.
A foundation for change was established in 2018 when Dr Terri Aldred[1] pioneered the PGMSPA’s Cultural Safety and Humility work (currently led by Dr Todd Alec). In 2019, ER physician Dr Christina Boucher began to lead the cultural safety and humility work in the Emergency Department (ED). Dr Boucher is a non-Indigenous person who seeks to be an ally and advocate for issues of inequity in health care delivery concerning Indigenous people.
With PGMSPA Facility Engagement funding to cover physician time, she took several steps to get started. She first spoke with Dr Aldred about her vision. “Dr Aldred told me about her group, the identified need for physician peer support in the ED. This foundational work helped guide me in developing my ED work.”
Dr Boucher reviewed the EQUIP research project to better understand specific health equity issues in the ED. She also gained insights from In Plain Sight "Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care" that reported on issues of inequitable health care access and outcomes endured by Indigenous peoples in BC in health care settings.
Dr Boucher then connected to work being done in Northern Health to incorporate into planning, including initiatives and resources offered by Northern Health’s Indigenous Health team to support learning and self-reflective practice among all physicians and employees.
In order to foster and sustain change, full representation of all vested voices was needed to source and articulate issues and work together on solutions.Dr Boucher assembled a collaborative, diverse working group (see below) representative of virtually all interdisciplinary positions working in the ED.
Most importantly, the group needed to include Indigenous community members who rely on the ED and have lived experience as Indigenous people, whose participation required having trusted voices from the Indigenous community engaged in the work.
Through Dr Montana Halliday, Dr Boucher reached out to Lucy Duncan, an Elder working at the Central Interior Native Health Society and a well-known member of the Indigenous Prince George community. Lucy has also contributed to the EQUIP Health Care work, which seeks to ensure health equity within BC’s health care system.
Lucy joined the working group as an Elder and also spread the word to Indigenous community members to add their voices, particularly patients who experienced care in the hospital ED.
WORKING GROUP
"I was excited to join and expand on the work I’ve been doing with other health providers. It’s important to understand historical racism and its impact, if we want to build a better health care system that serves everyone.
...It is important to have Elders from the community with lived experiences as part of the group," she notes. "It is through their participation that open communication can happen about what Indigenous people want to experience in the ED and what barriers they have faced.” - Lucy Duncan
The group agreed to meet monthly, and to start their work by creating an authentic foundation for change through relationship building and storytelling. The meetings place an emphasis on connection before content. Meetings start with introductions and check-ins, followed by open space for Elders and Indigenous community members to talk and share.
She emphasizes the importance of truth-telling to build understanding and support for action to address Indigenous-specific inequities in care. “The challenge is to be sure you are working on the real issues that will make culturally significant change – so it’s important to verify with the community."
"I have learned this year from the Elders on our group that relationships and trust are foundational, and are the most important activity when coming together as a group." - Dr Christina Boucher
Between meetings, Dr Boucher spends a lot of time checking in with each working group member about thoughts and feelings that have come up in the meetings. She notes that each person reacts differently, as personal, emotional stories are shared.
In her experience, she finds that talking about cultural safety and cultural humility can be challenging on a social and emotional level. It is a personal journey that takes time, and trust, and cannot be rushed."
It takes time to work through emotional contexts in order to even feel safe with one another, let alone to talk about all the details and processes involved in making the environment safe for all.
From there, the group can start to formulate action items that have arisen from the discussions.
"I see the activities of the working group prompting people in our department to engage in the self-reflective process of developing cultural humility.
Space and time are needed to build trust, create understanding, and shift beliefs to create sustainable change.“ - Dr Christina Boucher
The First Nations Health Authority's "Creating a Climate for Change" describes cultural humility as "a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience."
Dr Boucher uses this sentiment to approach thinking about practical steps to take as a health care provider: “As a non-Indigenous person, I try to approach the world with an open curiosity. I hope to be an ally and advocate for the Indigenous people who are my patients, and my patients’ family members."
"I hope to continue working on identifying my personal biases and the systemic barriers that contribute to the inequity of care the Indigenous people have historically received, to make some positive improvements.”
Asked how this work could be expanded to other communities, Lucy Duncan says,“we need to build credibility with other communities by initiating the working group’s recommendations, such as an Indigenous Patient Liaison working in the ED, and showing the positive changes happening in Prince George.”
She hopes to one day see a health care system that puts aside personal biases, and provides care in a safe environment that includes dignity and respect.
"It is only through acknowledging our past can we move forward to a better future." - Lucy Duncan
Discussions have led to the following action items:
Plans to redesign the ED space to be more inviting to the Indigenous community, for example working with a local artist to create drums and relevant artwork.
Advocating with Northern Health for an ED-specific Indigenous Patient Liaison position who would assist indigenous patients to navigate through the ED and access care.
A proposal for cultural safety training for the security company working in the ED.
Using video monitors in the ED to display information about community resources and supports.
Sharing culturally significant learnings from the monthly meetings with ED doctors and nurses, as well as community urgent care clinics and physicians in other Northern Health hospitals and communities.
[1] Dr Terri-Leigh Aldred is the Medical Director for Primary Care for the First Nations Health Authority. She is leading community-based First Nations Primary Care Initiatives (FNPCI), as well as the First Nations Virtual Doctor of the Day (VDOD) and First Nations Virtual Substance Use and Psychiatry Services (VSUPS) to engage medical affairs matters related to our programs.
This work has been supported with funding from the Specialist Services Committee Facility Engagement Initiative, one of four joint initiatives of Doctors of BC and the Government of BC.
At Northern Haida Gwaii Hospital in Masset, the introduction of locally-prepared and sourced traditional Haida foods to the hospital menu connected happy and grateful patients to their culture. In addition to increased patient satisfaction, the improvements in food quality also reduced costs by 20%.
In 2018, the Medical Staff Association and registered dietitian Tessie Harris embarked on a Facility Engagement project to restore on-site hospital food preparation, with a plan to integrate local and traditional foods.Haida Gwaii is home to the territory of the Haida Nation, where wild and traditional foods are abundant and an important part of the culture.
Prior to this project, the hospital had been serving retherm meals made elsewhere, delivered in individual portion sizes, and reheated for patients. There were patient complaints and low food satisfaction in surveys.
Although a small hospital serving 8 or 9 patients and residents, some big steps were needed to prepare meals on site.
To start, Tessie Harris liaised with Northern Health’s regional diet office in Prince George to align and coordinate the food service transition with Northern Health guidelines and processes. The site adopted the regional menu while incorporating traditional foods to reflect the needs and wishes of patients and respect local culture.
Staff then started cooking one meal a week on site, increasing the frequency over time. By the end of one year, they were cooking all of the patient meals in the Northern Haida Gwaii Hospital and Health Centre kitchen.
Traditional Haida foods were incorporated into the menu. Wild berries and greens were locally sourced. Arrangements were made with fishers in the area to catch salmon and halibut to be processed by local plants. They wanted support the hospital and patients, who were often their friends, family or neighbours.
Patients were happy and grateful. They commented about how much the food connected them to their families, culture and memories. They started eating more, and the amount of food returned to kitchen decreased.
Notably, while increasing the quality of the food – but without increasing staff levels – the site saw an approximately 20% reduction in food costs.
The success of the food service transition project has helped to influence a broader effort that continues in Haida Gwaii to integrate local and traditional foods into other areas of the community, and build capacity for a local, sustainable food system.
In our small rural hospital, improving quality of food served by resuming in-house cooking has had noticeably improved staff and patient morale. We are serving food that we want to eat!”
— Dr Caroline Walker, MSA President & Chief of Staff, Northern Haida Gwaii Hospital
Dietitians at the hospital continue to work with the community and Northern Health to increase the amount of local and traditional foods offered, an effort that reflects the greater focus within health care to provide patient-centered and culturally safe care.
"Patients light up when you serve food that reflects their culture. Nutrition is a big part of it, but the emotional, cultural and spiritual health and feeling of being connected is also making a difference.”
— Tessie Harris, Project Lead
Three pediatric physicians at the BC Children’s Hospital have a long-term vision to create a BC Pediatric Quality Improvement Practitioners (BCPQIP) Network. It brings physicians who have an interest in QI together on a regular basis to network with QI colleagues, share knowledge, receive guidance/advise and help further spread QI work.
Drs Tiffany Wong, Mia Remington and Sandesh Shivananda have all participated in QI in various ways, including through SSC’s Physician Quality Improvement (PQI) program.
Although there was a lot of QI work being done in the hospital – much of it was siloed. “We came together in a very organic way,” Dr Wong says. “Mia and I met through PQI and we met Sandesh through his work with the Hudson scholarship program, which is a program that allows junior physician scholars to focus on quality improvement one day a week over a two-year period.”
. . 
Left to right: Drs Tiffany Wong, Mia Remington and Sandesh Shivananda
Drs Wong, Remington and Shivananda acting as co-chairs began to build the network with funding from SSC’s Facility Engagement Initiative and Health System Redesign. They reached out to Quality Leads within each hospital division, physicians who have participated in PQI, Hudson scholars and others who expressed an interest in QI. Dr Remington notes, “We conducted a needs assessment survey before our first meeting because we didn’t believe the three of us should be setting the direction – it’s a shared experience.”
The survey responses helped to guide their first meeting in October 2020. There were about 27 physicians who all weighed ideas, expressed opinions and helped set priorities. Of course, all of this work was happening at the height of the pandemic, so Zoom meetings were core to furthering the development of the network.
Learnings from the survey and first meeting found that physicians wanted regular quarterly 90-minute meetings to share and receive feedback from QI colleagues on their projects, hear from QI experts and create partnerships for the spread of QI work across hospital programs. Physicians also wanted to foster engagement with the Health Authority (HA) Leaders and create a QI centre of excellence with ongoing operational funding. The co-chairs then prioritized their next steps.
The initial intention was to have the FE funding pay for speakers and some meetings held in a semi-formal atmosphere for face-to-face and network opportunities – but pandemic restrictions eliminated this approach. Two of the co-chairs went to the Institute for Healthcare Improvement (IHI) Annual conference in 2020 and identified some outside speakers, who they invited to present to the BCPQIP network. There have now been regular quarterly meetings held all through 2021 on Zoom with full attendance.
Dr Claire Seaton joined the network and says, “working in QI lends itself to collaboration, learning from others’ successes and failures, and getting feedback. The network gives us a space to do this, and has supported our efforts to be recognized for our work. I’m grateful to be a part of it.”
“We had a couple of HA Leaders invited to our meetings including Dr Felicia Lang, who is a Quality Lead within the health authority," Dr Remington notes. "She spoke to our group around quality structures – so it was a good opportunity to get to know each other.”
The next meeting is in April and for the first time it is planned to be a face-to-face dinner meeting with the goal of setting their direction for the coming year. Health Authority Lead Dr Derek Human is scheduled to share his experiences in QI, and also help members identify HA quality improvement initiatives that could be of interest to them.
“We don’t pay anyone to come to our events and they still come. I think they see value in being connected with like-minded colleagues,” he observes. “I think that is really powerful and valuable in itself.”
The co-chairs agree that to be successful you need to really use your network, identify champions, and make meetings valuable so people want to attend.
Dr Shivananda notes, “We started this journey by nurturing connections and relationships between members. One of the challenges faced by our physician leaders is maintaining enthusiasm in driving change. Validation and appreciation of their efforts by peers helps everyone be resilient and remain engaged.”
Since the network has been established there have been a number of diverse QI projects presented and discussed, including a multi-disciplinary approach to asthma education, prescription medication equity and a parenteral nutrition program.
In addition, Dr Wong worked with the Faculty of Medicine DARPT committee to develop a promotions package where a doctor could be promoted based on QI work from Clinical Instructor right up to Full Professor.
“We developed a package with the DARPT committee and presented it to the pediatrics department,” she said. “They liked it so much they brought it to the Faculty of Medicine. After some revisions, it has been formally accepted. I’m very proud that health quality improvement, systems innovation and patient safety work is now formally recognized as important academic work.”
QI work will continue to be integral to delivering quality patient care and the BCPQIP Network is laying the groundwork for sustainable QI improvements in BC. Dr Shivananda is optimistic about the future. “We hope to strengthen the infrastructure for spread and scalability of innovative practices across the campus and beyond."
This work has been supported with funding from the Specialist Services Committee Facility Engagement Initiative and Health System Redesign. Both are joint initiatives of Doctors of BC and the Government of BC.