Authors (including presenting author) :
Lee YCC
Affiliation :
Department of Obstetrics & Gynaecology, United Christian Hospital
Introduction :
Breastmilk is the best nutrition for newborns (Centres for Disease Control and Prevention, 2021), and World Health Organization (WHO) recommended that all newborns should be exclusively breastfed for six months (WHO, 2022a). However, only 22.2% mothers in Hong Kong were able to accomplish exclusive breastfeeding for six months (Department of Health, 2022). One of the reasons that affect mother’s decision to breastfeed is hospital practices (Centers for Disease Control and Prevention, 2015), such as rooming-in (WHO, 2022b), which means mother stay with her infant 24 hours per day.
TCAB was a nation-wide programme aimed at improving in-patient care and hospital environment (Rutherford et al., 2004). However, there is no TCAB in midwifery practice could be found from the literature. Therefore, the aim of this project is to apply the concept of TCAB in midwifery practice, which will in turn improve the rooming-in rate.
Objectives :
In our ward, team-based approach was adopted to take care of mothers and babies by different midwives separately. Midwives in each shift were allocated as Team I, Team II, Nursery, and Runner.
However, in a recent Baby-Friendly accreditation audit, it was found that the rooming-in rate in our ward was only 60%, which was far below the standard of 80% as recommended by the WHO. The reason may possibly due to the fragmented care approach that mothers and babies were taking care by different midwives separately.
In order to improve the rooming-in rate, we proposed to adopt the model of TCAB, so that each midwife will take care of mothers and their babies at the same time. Therefore, we need to switch from team-based approach to TCAB approach. Under the TCAB approach, one midwife is responsible for 1 – 1.5 cubicles, meaning each midwife need to take care all mothers and babies together (or maximum nine mother-baby dyads). The roles of Nursery midwife and Runner midwife will be cancelled. Therefore, the working environment and workflow need to be re-designed.
There are two objectives for this project: apply the concept of TCAB in midwifery care, and increase the rate of rooming-in to more than 80%.
Methodology :
Plan-do-study-act methodology was used to carry out this project.
1. Plan
In order to develop a plan to carry out the changes, three meetings were held with team members, including Department Operating Manager (DOM), ward manager, advanced practiced nurses (APN), and registered midwives between October to December 2021 to discuss about the project objectives, proposed changes, potential risks, and resources required. Advice from other stakeholders were also sought, such as patient care assistants, obstetricians, and paediatricians.
2. Do
This project was originally planned to carry out on 7 February 2022 (after the Chinese New Year holiday), but delayed to 21 March 2022, due to the outbreak of the fifth wave of COVID-19 pandemic.
When the fifth wave of COVID-19 pandemic was nearly end, our ward was turned into a combined ward (antenatal and postnatal), and the job allocation of each midwife was rearranged.
Bed 1 to bed 20, bed 41, and bed 42 were reserved for antenatal patients and they were cared by antenatal midwives. Bed 21 to bed 40, bed 43, and bed 44 were reserved for postnatal patients and they were cared by postnatal midwives. Team I midwife is responsible for mother-baby dyads from bed 21 to bed 30, while team II midwife is responsible for those from bed 31 to bed 40, bed 43, and bed 44. Each midwife is responsible for 1.5 cubicles, means that in case of 100% occupancy, each midwife will be responsible for nine pairs of mother-baby dyads.
3. Study
After the implementation of TCAB in postnatal ward, it was found that mothers and babies were able to stay together 24 hours per day. Some adjustments on the workflow and environments were made. For example, an extra mini nurse station was set up in the corridor to enhance care of mothers and babies together. Moreover, patients’ medical record trolley was reorganized to improve work efficiency.
After another BFHI internal audit carried out in April 2022, it was found that rooming-in rate increased from 60% to 93%.
4.Act
By applying the principles of lean management (Institute for Healthcare Improvement, 2005), the calculation of patient numbers by Duty in-charge at the end of each shifts were abandoned. Based on the results from the study, we determined to continue to adopt the TCAB approach of midwifery care in postnatal ward.
Result & Outcome :
After implementation of this project, it was found that rooming-in rate was increased from 60% to 93%.
Colleagues were engaged in the early planning phase so that they could familiar with the project and understood its importance in increasing rooming-in rate.
The fifth wave of COVID-19 pandemic delayed our project. With DOM’s support, we resumed to carry out the project amidst the pandemic on 21st March, 2022.
The advantages of TCAB was well documented, however, no application of TCAB in midwifery practice can be found from the literature. By applying the concept of TCAB in midwifery practice using PDSA methodology, it was found that rooming-in rate was increased.
