Improving obstetrical care by multidisciplinary team training for patient referral situations. The LOCOMOTIVE Study: Local Obstetrical Collaboration Multidisciplinary On-site Team-training effectIVEness Study

The obstetrical care system in the Netherlands is performing suboptimal. Building on the same level of scientific knowledge, other Western-European countries have lower perinatal mortality rates. The Netherlands has a unique obstetrical care system based on the premise that pregnancy, childbirth and the postnatal period are physiological processes. Obstetrical care is provided by different groups of professionals working in three echelons: primary, secondary, and tertiary obstetrical care. Improving interprofessional collaboration and communication is indispensable when trying to lower perinatal morbidity and mortality within the Dutch obstetrical care system. The objective of this research project is to improve perinatal outcomes by improving the quality of the referral process as well as the collaboration between professionals involved in the chain of obstetrical care. More specifically, a multidisciplinary team training aimed at the implementation of structured referral procedures will be developed and tested. The research questions that will be addressed are: What is the effect of a multidisciplinary team training aimed at implementing structured referrals during pregnancy and labour… …on perinatal morbidity and mortality? …on the perceived quality and safety of obstetrical care by pregnant women and obstetrical professionals? …on the completeness and accuracy of information transfer during patient referral? …on the variation in decision making process of obstetrical care professionals? The project focuses on all antenatal and perinatal unplanned referrals by primary care midwives to clinical care in a secondary or tertiary hospital after 22 weeks gestation and up until 2 hours postpartum. In this population both emergency referrals and less acute situations occur. From the 10 Local Obstetrical Collaboratives (LOC), i.e. a hospital and the primary care midwifery practices that are their preferred referrers, in the regional obstetric network of the VU University Medical Center, 5 LOCs will be randomly selected to participate in the study intervention. The intervention is a stepwise implementation programme of the SBAR tool for structured obstetrical referrals, using a multifaceted implementation strategy. A crucial part of the implementation strategy is a multidisciplinary team training based on crew resource management principles. The first phases of the intervention, including the multidisciplinary team training take about 5 months after which implementation is maintained during 19 months. The research design is a longitudinal multicentre one, using continuous measurements of the primary outcomes and pre- and post-intervention measurements for other outcome measurements. The effects of the multidisciplinary team training will impact the organisation of obstetrical care at different levels. Therefore, Kirkpatrick’s framework was adopted to measure outcomes at the level of the participants in the intervention, changes in attitudes, knowledge, and skills, changes in behaviour, and changes in patient outcomes and organisational practice. This has led to the following set of outcome measurements: - Satisfaction questionnaire for participants after 2nd multidisciplinary team training - Safety Attitude Questionnaire for Labour and Delivery - Interprofessional Collaboration Measurement Scale - Completeness and accuracy of SBAR tool - Monitor of telephone conversations to study communication during referrals - Vignettes about decision making during labour - Mixed-method study on patient satisfaction after an intrapartum referral. - Comparison of PRN data on morbidity and mortality pre- and post-intervention Triangulation of qualitative and quantitative measurements will enable a thorough analysis of the effects of the intervention. The start of the study is June 2012, the first multidisciplinary team training sessions for LOCs can be held in January 2013, the follow-up period will extend until December 2015. Together, the aims of this research proposal address aspects of the three main themes of the regional perinatal network that includes the VU University Medical Center: improving collaboration within local obstetrical collaborations, strengthening the (pro)active participation of pregnant women, and improving referral procedures in obstetrical care transitions between echelons. Moreover, this research will provide better evidence of the impact of practice-based interprofessional collaboration interventions on professional practice and healthcare outcomes in obstetrics.