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Best practice №4

Create an antenatal checklist for care of women with OUD

by Elliott Main

Last updated March 14th, 2020

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Overview

Create a flow chart and/or checklist of care steps for antenatal care of women with Opioid Use Disorder (see example below and an additional example in the Resources section of this Best Practice).

Why we are recommending this best practice

A checklist will help providers remember the many steps involved in the antenatal care of women and families with OUD.  While these services and activities would normally be addressed over time, they may need to be compressed depending on when the woman presents for prenatal care. Referenced are examples from the Illinois Perinatal Quality Care Collaborative and the Northern New England Perinatal Quality Improvement Network.

Strategies for implementation

Collaborate with health care team members to adapt a written checklist that is specific for your unit.
ILPQC OUD Clinical Care Checklist (adapted for CA)

Deep dive

Checklists come in many forms:  some for use in emergencies, some for use prior to surgery, and some simply as reminders for the supermarket.  An antenatal checklist serves both as an ongoing set of reminders and as documentation of important tasks completed.  A checklist, such as the one above, is central to the care of a complex patient with many external consultations over a long period of time, and a pregnant woman with substance use disorder is one of the most challenging to care for.  A provider must navigate special laws and unfamiliar regulations, co-manage with other key providers, order different panels of blood tests, approach building communication and developing trust differently, and provide education on topics not usually covered in prenatal care. Examples of the latter include special plans for labor pain management, preparation for neonatal substance withdrawal, and most important of all, developing a Plan of Safe Care (POSC) for both the baby and mother.

The Prenatal Checklist provides the central direction for the team’s actions in antenatal care.  It belongs front and center in the prenatal record and should be reviewed at every visit by providers, staff, and the patient. This toolkit provides several examples. Through small tests of change, modifications can be made to the example checklists until it meets the needs of patients at the care site.  Follow up at the postpartum visit should include questions about what the patient thinks could be improved—no checklist is ever a final product! 

Resources

Elliott Main

MD, FACOG

Dr. Main is the Medical Director of the California Maternal Quality Care Collaborative (CMQCC) and has led multiple state and national quality improvement projects. He is also the Chair of the California Pregnancy-Associated Mortality Review Committee since its inception in 2006. For 14 years, he was the Chair of the OB/GYN Department at California Pacific Medical Center in San Francisco. He is currently clinical professor of Obstetrics and Gynecology at Stanford University. Dr. Main has been actively involved or chaired multiple national committees on maternal quality measurement. In addition, he helps direct a number of national quality initiatives with ACOG, the CDC and Maternal Child Health Bureau (HRSA) including the multi-state AIM project. In 2013, Dr. Main received the ACOG Distinguished Service Award for his work in quality improvement.