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IMPLEMENTATION PROCEDURE OF CLINICAL PATHWAY ELECTIVE TYPE CESAREAN SURGERY WITH HEAVY COMPLICATIONS CASE STUDY OF

PLASENTA PREVIA DISEASES AND ITS EFFECT TOWARDS THE LENGTH OF STAY IN UNDATA HOSPITAL CENTRAL SULAWESI INDONESIA

SITTI RAHMAWATI

ALI GHUFRON MUKTI MOHAMMAD HAKIMI

INDRA BASTIAN RONNY RIVANI

Email siti131962@gmail.com

Associate Professor Department of Economics and Public Health Faculty Tadulako UniversitySpecialiston Economics of Health Professor of Department Medicine and Health FacultyUniversitasGadjahMada Yogyakarta Indonesia specialist on Health Finance Professor of Department Medicine and Health FacultyUniversitasGadjahMada Yogyakarta Indonesia specialist on GynecologyObstetrics Professor of Department Economics and Business FacultyUniversitasGadjahMadaYogyakarta specialist onAccounting Associate Professor of Public Health DepartmentUniversitas Indonesia

ABSTRACT The development of clinical pathway use in hospitals of Indonesia was begun with the policy of the Ministry of Health of the Republic of Indonesia in 2005 that requires every hospital to have clinical pathway. The hospitals that consist of medical, nursing, pharmaceutical personnel and other health personnel must have a clinical pathway in accordance with the conditions of the hospital. The objective of this research lies on the implementation procedure of clinical pathway that affects the quality of service in the hospital. The sample of research is pregnant woman experiencingprevia placenta disease, It uses qualitative analysis as analytical method. Desained and implemented a clinical pathway on our perinatal service for the diagnostic-related group’s DRG;s 370 cesarean section with complications plasenta previa. The results of the clinical pathway indicator have effect to decreasing the length of stay at 4-6 days and standard produceof patient treatment in good service based on standard operational procedure of hospital and efficiency of resource use without reducing the quality of the hospital and support the effectiveness of clinical service, medical audit and risk management. Conclusion: the application of clinical pathway can be used as one of risk assessment evaluation mechanism tools to detect active errors both system and also nearly occured errors in clinical risk management to improving patient security and safety. Keywords : Clinical pathway, cesarean surgery,previaplacenta, length of stay, hospital.

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. I. Introduction

In 1990, the UK National Health System was altered by focusing on patients which began by studying and developing the Clinical Pathway concept. This year, a team was sent to the United States to study on it. Subsequently in 1991-1992 the organization conducted trials in Northwest, London by making 12 examples of Clinical Pathway. The UK refers to this system under the name of Anticipated Recovery System. Later in 1994 the system developed into an Integrated Clinical Pathway. The system encourages and directs medical practitioners to provide the best service to patients. In that year it was inaugurated the National Pathway Association. Next, in 2002 a NELH pathway data base was used to share information and experiences on the use of ICP. The ICP project is launched all over the UK. In the similar year the International Web Portal covered specifically on the Integrated Clinical Pathway.Initially, the Implementation of Integrated Clinical Pathway is used in surgery process because it is easy in terms of standardization. However, now a days this system has developed and applied iofn all categories of diseases, and is widely used in various countries such as Germany. Urgency of the clinical pathway needs to be done with the following considerations that the clinical pathway can: 1) improve the quality of health services, 2) maximize clinical path of efficient resources, 3) guarantee a continuous service and 4) support a effective way on clinical care, medical audit and risk management.(Ramson B Scoot, 1996, 1998).Khawaja, Khasholian and Jurdi (2004) conducted a cesarean section study in Egypt. It is medically contributed to complications in pregnancy such as bleeding, sepsis, twin infants, distpcia, eclamsia, placenta previa, placental abruption, infant weight isgreater than 2500 gr and less than 2500 gr, while non-medical factors by social demographic factors.

Placenta previa can have serious adverse consequences for both mother and baby, including an increased risk of maternal and neonatal mortality (HM. Salihu, Li, DJ Rouse, GR Alexander, 2003), Fetal growth restriction and preterm delivery, antenatal and intrapartum hemorrhage, and women may require a blood transfusion or even emergency hysteretomy.In England, Cesarean Section constituted 25% of National Health Service (NHS) deliveries during 2010, and the rates have been rising for both primary and emergency. The risk of placenta previa in a preqnancy after CS delivery has been reported to be between 1,5 and 6 time higher than after a vaginal delivery. Among women in England cesarean section in the first delivery increased the risk of placenta previa in the subsequent delivery by 60%. There was no evidence that the effect of CS on placenta previa Rates varied among different group’s of women or by the time between two preqnancies. The risk of placenta previa in the second prenancy, advance maternal age and with birth intervals of less than one year or more than four years. (Yang Q,Wen SW, Philips K, Oppenheimer L, Black D, Walker MC, 2009).

The incidence of cesarean delivery and complications in labor is due to placenta previa where

the baby's birth canal is closed. The last few years of birth have increased from about 5.5 percent in 1970 to 22.7 percent in 1985 and 24 percent in 1988. This can be reported with a range of 10 percent to 40 percent of all deliveries. In 1988, as many as 20.2 percent of the 4 million births in the United States occurred through cesarean section (National Center of Health Statistics, (2008).Statistics 2008 suggested that it is fewer than one death from 2500 had undergone cesarean section, compared with 1 : 10,000 for a normal delivery. The United Kingdom's Health Service cited the risk of maternal mortality in cesarean section being three times the risk of death during normal maternal, and yet it is impossible to directly compare the normal maternal mortality rate with cesarean process due to surgical mothers are those at risk in pregnancy. The results of research conducted by Chang Gung at several hospitals in China found that 18 clinical pathways for urological procedures has been found from 1784 patients. It significantly

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reduced the length of stay (LOS) by 11 percent (from 5.5 days to 4.9 days), maintenance costs 12.9 percent, and average hospital costs decreased from 12 percent (Chang et al 2003). According to John (2003) the implementation of clinical pathways can save as much as US $ 5.2 billion over 6 years operating expenses in children's sections in San Diego United States hospitals. They reported it through implementing Clinical Pathway for standardized surgery may decrease Length of Stay from 6, 8 days to 4.2 days and can lower hospital costs by about 19 percent. One evidence of evidence-based clinical indicators of emergency obstetric rooms, incidence of near miss objectives is that each pregnancy is a desirable pregnancy and ends with a healthy mother and a healthy born baby (The maternal mortality rate, which is often used as an indicator of the quality of maternal health care, remains high at 390 / 100,000 of live births in 2000 (Rosmans Fillipi, C Gohou,V Goufodji, et al. 2005, UNDP, 2014), and by 2014 it decreases to 226 / 1000,000 of live births, The highest number among ASEAN countries. It can open wide opportunity for evidence based -medicine to participate in efforts to reduce internal mortality rate in Indonesia (Hakimi, 2000), maternal mortality fund in Central Sulawesi Province reaches 390 / 100,000 of live births is still above the national average. The aim of this researchis to know the procedure of arranging clinical pathway, and how long the length of stay in the hospital, and how much the cost of tariff per case in patient. MATERIAL AND METHODS In developing the clinical pathway, we reviewed the case mix index of the hospital from the previous year. .Diagnostic- Relation Group’s 370 (cesarean section with complications) was selected because of its relative frequency base on the number of discharges. To develop a clinical pathway for DRG 370.The goal of clinical pathway project research at Undata Hospital 2015 year as it related to obstetrics and gynecology. The sample of research is pregnant woman experiencing previa placenta disease, It uses qualitative analysis as analytical method. Desained and implemented a clinical pathway with Diagnostic information is coded using the International Classification of Diseases 10th revision (ICD 10) -codes that represented 50% to 70% of the cases in the DRG on our perinatal service for the diagnostic-related group’s DRG;s 370 cesarean section with complications plasenta previa. . Plasenta previa with DRG 370 complication type DRG’s O01B are classified as high complication with 14 MDC Major Diagnostic Clasification amounted to 23 MDC. Cases of placenta previa identified by the ICD 10 code O44. Financial data was the first organized to show the individual elements of cost by day,the financial records of each of the selected 15 patients in the DRG to casemix plasenta previa.Each format was organized vertically by natural class expense – laboratory, blood bank, physical and theraphy, supplies, pharmacy, radiology/ultrasound, and room and board. Finally a summary of financial data was tabulated. The first section of the summary proveded data for each day of the admission by natural class of expense the labels for the columns across the top were units per patient called for by the clinical pathway, units consumed per patients, unit variance per patient, and dollar variance patient.(Australian Refined Diagnosis Related Group’s (2006)Version 5.2.Definitions Volume one DRGs

The theoretical framework is adapted from the King's conceptual framework and theory of goal attainment (Husting 1997, p 16-17). The concept of King's Theory was first published in 1971 where it discusses the focus of nurse knowledge, and develops basic knowledge of nursing. King's identifies the social concepts of the health system, namely the interpersonal relationship and the universally nursing discipline of nursing. Clinical pathways appear on the surface of nursing patients in hospitals. King's said that nursing is governed by the surroundings of people, between people and the social system. King's concepts include communication, interpersonal relationships, information, energy resources, social organization and status which later developed into a theory of achievement of the objectives of the results in 1981. The framework of King's theory system is based on the assumption that humans are the focus of the nursing department. The purpose of nursing is to include

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health; health promotion, health care, health restoration and attention to sick people, or accidents and critical care (King, 1992, Housing (1997).) King's theory says (1966) that the scope of nursing includes humans, families and communities as a framework Thought interpresional systems and social systems include human and environmental relationships such as physicians, pharmacists, nutritionists, nurses, health and health workers.(Khawaja,Kurshid,2006).

The objectives of Kings in the nursing sciences argue that there are four models of transactions in health services namely: a). Decision-making, b) .communication, c), interaction, d) transactions and critical thoughts. From these results producethree transaction model, that is 1) the theory of achieving the goal of results, 2) Integrated Clinical Pathway, 3) the theory of achievement of results. The research of Panela et al , 2005 found that the results of Clinical Pathway testing using King's theoretical concept of Clinical Pathway Implementation for patients can decrease the Length of Stay from 6.5 days to 5.7 days, and cost savings of US $ 3100 per patient. Ramson, B Scoot, 2003reported that the results of testing the use of Clinical Pathway using King's theory of Clinical Pathway for the treatment of asthma patients can reduce the use of beta-agonist drugs used for patients with asthma. Clinical pathway understanding according to Hunter (1997) is an integrated planning concept that summarizes every step taken by the patient, from patient entry to hospital into going home of patient based on standard medical care, nursing care standards, and evidence-based healthcare standards with measurable results. Blesser, et al (2004) That the schedule of medical and nursing procedures included in the diagnostic test, treatment and consultation designed with the efficiency and coordination of the hospital's clinical management program. Carolle (1997) and the European Pathway Association (2005) say the clinical pathway concept is a methodology of mutually beneficial decision making services for patient groups over a period of time, and a multidisciplinary plan in collaboration with a patient-centered team approach per day systematically by including outcome standards.

The nature of the clinical pathway is 1) prioritize the patient, 2). Systematic, consistent and sustainable service activities, 3). Provide continuous feedback and analysis of service flow, 4). Role-based, 5) competence and responsibility, and has a service process map, 6). Containing the yield standard, 7). Accommodate variations within certain limits, and be specific depending on the institution, 8) synergize between medical planning, 9). Nursing care, physical therapy, nutrition and mental health, by providing opportunities for teamwork, 10) this is a mandatory treatment plan, not a substitute for clinical decisions or substitutes for physician instruction (Scoot B Ramson (1998, 2003). The European Pathway Association explains that the characteristics of the Clinical Pathway is an evidence-based service, excellent service, and rewards for patients to reduce length of stay, (Mukti, 2000, 2001) improve service quality control and health care costs, documentation, monitoring, evaluation of service variations used in hospital.

RESULT

Undata hospital is an urban reaching institution, which since 1972 has had four principal services, obstetrics and gynecology, pediatrics, surgery, and others. Seventy percent of its revenue is derived from the care of preqnant women, newborns and women, newborns, and women requiring gynecologic care. The goal of clinical pathway project research at Undata Hospital 2015 year as it related to obstetrics and gynecology was to reduce clinical practice variance for the diagnostic related group cesarean section with complications (DRG 370) and ultimately decrease length of stay and hospial costs associated with this DRG’s. The origin of the Clinical Pathway was permitted in 1990 in the United Kingdom of England and the United States. The development is very fast in several hospitals in the international world. The preparations of Integrated Clinical Pathway at Undata Hospital of Central Sulawesi Province can be done as follows:

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Establish a team of drafting of Integrated Clinical Pathway at Undata Hospital Identify "Key Player"

1. Form the preparation team of Integrated Clinical Pathway 2.Identify "Key Player" 3.Site visite 4. Study literature 5.Creating Focus Groups 6. Standard Clinical Standard, Standard Operating Procedure (SOP) 7. Conduct case bauram analysis (Case Mix) 8. Establish a process measurement system and outcome 9.Mendisain Integrated Clinical Pathway (ICP) 10. Basic Practice Guidelines and Development of Pathway Education Packages 11.Review Integrated Clinical Pathway, ICP 12.Process and measurement results.

CLINICAL PATHWAY IN INDONESIA AND ITS LEGALITY The development of Clinical Pathway in Indonesia hospitals was beglan with the policy of the Ministry of Health in 2005. This obligation requires each hospital to have a clinical pathway. Hospitals consisting of medical personnnel, nursing personnel, pharmaceutical personnel and other health workers mus have a Clinical Pathway with the condition of the hospital. Ministry of Health , 2005 Legality of Clinical Pathway in Indonesia is based on: 1. Law no. 23 of 1992 on health 2. Law no. 29 of 2004 on medical practice 3. Government Regulation no. 32 of 1996 on health personnel 4. Decree of the Minister of Health No. 1410 / Menkes / SK / X / 2003 on the determination of Hospital Information System Usage in Indonesia The fifth revision 5. Decree of the Minister of Health RI No. 159 b / Menkes / Per / II / 1988 about Hospital 6. Minister of Health Decree No. 436 of 1993 on the enactment of Hospital Service Standards and Medical Service Standards at the Hospital. 7. Decree of the Minister of Health No 920 / Menkes / Per / XII / 1986 concerning Private Service Efforts in the Medical Field 8. Decree of the Minister of Health RI No. 1333 / Menkes / SK / XII / 1999 on Hospital Service Standard 9. Decree of the Minister of Health RI No 496 / Menkes / SK / IV / 2005 on Guidelines for Medical Audit at the Hospital 10. Decree of the Minister of Health RI No. 631 / Menkes / SK IV / 2005 on internal regulations of medical staff.

The purpose of clinical patway is a).Fasilitate the implementation of clinical pathway guide-line and clinical audit in clinical practice, b). Improve communication and multidisciplinary planning, c).Reach or exceed exixting quality standards, d).Reducing unwanted variations in clinical practice, 5). Improve communication between clinicians and patients, 6). Increase patient satisfaction, 7). Identifying research and development issues, Clinical pathway concepts and stages based on ICD 10 and ICD 10 CM, MDC, Surgical/Other/Medical and Related Group Diagnosis (DRG’s, Casemix.

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Clinical pathway study with a case of cesarean section on Plaventa previa disease complication was performed at Undata Hospital Central Sulawesi Province Indoensia. Study cases of or cesarean section, Placenta or cesarean section. Previa with elektive type of complication have abnormal maternal types or cesarean section. Plasenta previa with DRG 370 complication type DRG’s O01B are classified as high complication with 14 MDC Major Diagnostic Clasification amounted to 23 MDC the classification of DRG’s Plasenta Previa with average cost per DRG’s is approximately IDR 2,231,578 or US$ 165 for a total paid US$ 2475.The cost accounting (decision support) system, which allows us to understand and control our cost and cost saving and improve the hospitals. (Bastian, I 2008).

Enforcement of diagnoses in Diagnosis Related Group’s (DRG’s) group with severe high complications in cases of cesarean section has plasenta previa type disease as much as 15 patients .Treatment of patients performed on day1 is patient recording, anamnesa and vital sign check by nurse. Then for obstetrical examination, laboratory examination, and complication of placenta which is present in cesarean surgery. Type of maternal caesarean section with elective average age of patient are between 30-38 years with minimum age on 29 years. Clinical Pathway is influenced by the age type, therapeutic process, diagnosis and complications of placenta previa that is suffered by the patients at the time of delivery. The procedure of making a clinical pathway format with DRG’s O01B diagnosis group with the following utilizations.

PROCEDURE OF CLINICAL PATHWAY FOR CESAREAN SECTION AND COMPLICATIONS PLACENTA PREVIA AT HOSPITAL UNDATA INDONESIA. Clinical pathway procedure with Diagnostic DRG’s O01B (Commonwealth Department of Health Australia, 2005, 2006) Cesarean maternal (DRG 370) in cases of placenta previa.

A). F1 = Procedure for enrolling the patient to the hospital B). F2 = Diagnostic procedures and laboratory procedures C) F3 = Preparation procedures for surgery D). F4 = Surgical Procedure E). F5 = Patient care / post operation F) F6 = administration procedure of returning patient F1. Procedures for enrolling patients to the hospital. All patients with cesarean section having diagnosis of DRG's O01B at Undata Hospital, Central Sulawesi Provinceon the first day are required to register through obsgin polyclinic in the administration section which includes: registration activities for officers consisting of giving identity form to patient, receiving identity form back to record medical records, enter patient data into computer, check medical record file, go to polyclinic and enter patient data to computer and receive administration fee (resource person of administration). F2. Diagnostic procedures and laboratory procedures. The diagnosis of DRG's O01B was carried out on the 1st day including: patient registration, anamnesis, and vital sign examination by the nurse. Examination of obsgyn and anamnesis includes physical examination of general condition examination and obstetric gynecology examination. Results from the laboratory found that there is pententa previa in these patients so it is necessary to take action by obsgyn for direct surgery. (Nurse, obstetrician and obstetrician).

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F3. Preparation procedure for surgery in cesarean delivery in placenta previa cases. Enforcement of the diagnosis in DRG's group O01B is a complication of the discharge of the baby from her mother's womb so it is necessary in cesarean section. The type of elective maternal is cesarean surgery which is planned by the doctor for surgery after a vital sign examination by the nurse and anamnesis include physical examination and general condition examination, and obstetric examination by obstetrician and gynecologist. Preoperative preparation is the same as other obstetrics such as shaving operation area and klisma. Then a visit is performed during the patient waiting process for the surgery, and the laboratory examination is not performed twice, unless the patient has bleeding or anemia. If this happens, hematological examination, drug administration, and pre medication are performed. Preparation of preoperative operations is usually done in the ward and is not held in the laboratory examination room. Examination is only done for emergency only. For patients of placentaprevia, it is recommended for hemoglobin check and give antibiotic with cefotaxim 2 ampoule / 2 gr. (Resource of obstetrics and gynecologist) F4. Cesarean Section Surgical Procedure. For surgery stage, an interviewed is performed with an anesthesiologist such as the following information :esthesia to be done. “ In patients with caesarean section surgery is usually sufficient with regional anesthesia, exept in the cse of spinal blockonly. Unless the patient’s condition does not allo anesthesia to be done. For an Sthesia drugs used marcain drugs, then added drugs such as analgesic antibiotics when area of operation is widespread, doctors accompanies by anesthesiologistrs, pediatricians, and nurses are ready in the operating room “ (Recource Obstetrics and Gynecolist). F5. Patient Care and Post Surgery and its Utilization. Nursing care is performed by nurses. The nurse's job is to handle patients from the central surgery room to treatment room. Next, take the patient from the treatment room and observe the bleeding, administer the medicine according to the physician's instructions, observe patient support, pain in the patient, provide food according to diet, assist patient mobilization and provide support and motivation to the patient. Next, drugs are given including: infusion liquid with IV dextrose 5% Or 500 ml, 500 ml of lactate. Antiobiotics are given by 1x 24 hours after surgery on day 1 including: sharo 75 mg, 0.2 mg systosynon, tracrium 1 ampoule, trasmadol 1 ampoule, injected with transamine per 8 hours for 2 days (6 ampoules) with a content of 5 miles. It functions to stop bleeding. Injections are given consisting of: 1 ml per 8 hour dose ulcumate for 2 days of 1 ml, cefotaxim per 12 hours for 2 days (4 vial) 1 g of contents, motrodinazole per 8 hours for 2 days (6 bottles) of 50 ml, Transamin per 8 hours for 3 days (60 ampules) 5 ml of oxytocin 1 ampoule per kolf given each liquid / day and 25 ml aquadest, vitamin C for 1 tablet, ketoralak 6 ampoule (8 hours / 1 ampoule, cefotaxin 25 ml , Oxytoxone 6 ampoules, amoxilin 500 ml / tablet (3x1) 12 tablets, brought mefenamic acid dose 250-800 mg (3x1) as much as 12 tablets to be used at home. The doctor whose specialist on obstetrics and gynecologists visits to patientsdaily in the Maternal and Child Health room. Postoperative activities at the hospital were conducted in three rooms: recovery room, inpatient room and ICU room for one patient with a predominant diagnosis of placenta previa. Activities in the recovery room include the doctor's check-up and the carer's care.

F6. Administration Procedure for Returning Patient. The procedure for returning patient administration is done by all patients suffering from placenta

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previa disease. If the patient's life is allowed by the doctor to go home. The doctor's job is to make a recipe to be used at home. Doctors give drugs such as amoxilin 500 mg consumed 3 x 1 (10 tablets), mefenamic acid 500 mg 3x1 (10 tablets), biosambe 1x1 tablet (10 tablets). Patients are expected to control every 3 days in obsgin polyclinics to replace bandages and aff heathering. Equipment used is tweezers, scissors, and medical materials used are gauze, betadine, alcohol, hypaviks. If the patient dies, the doctor's job is to make a medical resume, recapitulate the use of drugs and equipment, make a certificate of death and handover to the family. COST ANALYSIS AND LENGTH OF STAY AT HOSPITAL The process of surgery, the stages of F1-F6 operation procedure are determined by the cost of treatment activity of hospital resource usage through procedural clinical pathway Standard Operational Procedure (SOP)hospital. Length of Stay (LOS) of inpatients, before clinical pathway process the patients are treated in hospital as much as 7-10 days, however after a clinical pathway process, they areaverage length of stay treated for 4-6 days. The cost incurred by the patient during the hospital is relatively expensive costing to US $592, but after the implementation of clinical pathway the amount of cost expended by the patient is cheaper with as much as IDR 2,231,578 or US $ 165per patient. Total of 15 patient compilation of maternal in placenta previa pay US $ 2475. Clinical pathway for caesarean surgery for maternal complication of placenta previa is shown on table 1 below:

Tabel 1 .Procedure Chart Version of a Clinical Pathway Elective type for Cesarean Surgery with Complication (DRG 370) Cases of Risk of Placentaprevia

ACTIVITY

UTILITY

NOTE day day Day day day

1 2 3 4 CONTINUE

I REGISTRATION 1 Note patient identity √ 2 Prepare a status √ 3 Check the completeness of status √ 4 Giving status and continuous card √

II DIAGNOSE ENFORCEMENT √ 1 Patient notification 1 2 Anamnesy and vital sign examination by nurses 1 3 Obsgyne examination Anamnesy 1 Physical examination General check up 1 Obstetric examination 1 4 Consultation with specialist doctor Internal disease Heart Lung Child 5 Supporting examination Laboratory Complete blood 1 Blood sugar 1 Ureum 1 Creatinin 1 Clotting Time 1 Bleeding Time 1

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SGOT 1 SGPT 1 Blood type 1 USD examination 1 CTG 1 6 Diagnosa enforcement Complication disease Bleeding Infection Others III PRE SURGERY 1 Doctor visit Anamnesy 1 Physical examination General check up 1 Vital sign examination 1 Obstetric examination 1 2 Consultation with specialist doctor Anasthetic 1 3 Nursing care Officer as follows: Measuring the patient vital’s sign 1 Room service Patient fasting 1 Room service Give medicine according to prescription 1 Room service Infusion installation 1 Room service Shave surgery area 1 Room service Catheter installation 1 Room service Assess patient’s comfort level 1 Room service Giving support and motivation 1 Room service Preparing blood for transfusions 1

4 Giving medicine *based on patient condition

Antibiotics Cefotaxim 2-12 g/hr/3-6 dose

Antibiotic injection Ceftriaxon 1-2 g/hr/1-2 dose

Cefriaxon/Gentamycin/cefotaxim 1 Gentamycin 2-4x1-2 mg/kg BB

IVFD Dextrose 5% √ Ringer Lactat √ IV Surgery 1 Anasthesia Anesthesia SPINAL Marcain 1 &ORRegival 1 &ORMiloz 1 &OR Fantanyl 1 &OR Recofol 1 &OR Katalar 1 Analgetic Morphine 1 8-10 mg &OR Remopain 1 &OR Pethidine 1 Antiemetic Metoclopramid 1 3x5-10 mg/day Uterotonica Syntosinon 1 Methergin 1 0,2 mg/day IVFD

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Dextrose 5% √ Ringer Lactat √ Asering √ 2 Surgery Surgery procedure The patient is supine in anesthesia √ A danantiseptic areas of surgery √ Regional surgery incision √

Remove the baby and placenta from uterus √

Baby cleansing √ Threat bleeding complication √ Blood transfusion √ Additional infusion √ Checking completeness alkes √ Sewing wound surgery √ 3 Consultation If complication found Pediatrician 1 Other specialist (if required) 1 4 Nursing care *officer as follows: Sterilize instruments and linen 1 Nurse is OK Call the patient from the room 1 Nurse is OK Receive patients who will be operated on 1 Nurse is OK Check the completeness of the status 1 Nurse is OK Clothes surgery on the patient 1 Nurse is OK Preparing medification and alkes 1 Nurse is OK Prepare the surgery room 1 Nurse is OK Put the patient on the operating table 1 Nurse is OK Assist the anesthesiologist to prepare anesthesia medications 1 Anesthetic officer Organizing instruments 1 Nurse is OK Assisting surgery in the room 1 Nurse is OK Transfer the patient to the recovery room 1 Nurse is OK Make an observation in the recovery room 1 Nurse is OK Tell the nurse to take the patient 1 Nurse is OK Washing alkes 1 Nurse is OK V POST- SURGERY 1 Doctor visit Anesthesia doctor 1 Obgyn doctor 1 1 Other specialist doctor 1 If required only 2 Supporting examination Laboratory Complete blood Blood sugar 1 3 Nursing care Submit patient form OK to recovery room 1 Take the patient from the recovery room 1 Observing vital sign 3 6 3 3 Observing bleeding 6 3 3 Give medicine according to prescription 3 6 3 3 Observe the pain in the patient 3 6 3 3 Provide diet food 3 3 3 3 Helps mobilize patients 3 3 Provide support and motivation to the patient 3 3 3 3 Add compres 1 3 If required only 4 Giving medicine IVFD

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Ringer Lactat √ √ Dextrose 5% √ MgSO4 √ Antibiotic Antibiotic Injection Cefotaxim/Gentamycyn/Cefriaxon 1 1x24 hours after surgery Oral Antibiotic

Amoxyclav 3 3

250-800 mg A/125 mg KV/eating(9taking home)

OR Cefixime 2 2 200-400 mg/day, dose 1-2 (6 taking home)

OR Metronidazol 3 3 3x500 mg/day(9taking home)

OR Ciprofloxacin 2 2 2x250-750 mg/day (taking home 6)

OR Clindamicin 4 4 150-300 mg/six hour (12 taking home)

Analgetic OralAnalgetic

Mefanamate acid 3 3 250-800 mg/eating (taking home 4)

AnalgeticSuppositoria Caltrofene 3 Ulterotonic

Methyl Ergometrin 3 3 0,2 mg/eating (4 taking home)

Vitamin Hematinic 3 3 4 taking home 5 Diet food ML 1 MB 1 3 3 6 Replace verban 1 VI PATIENT ADMINISTRATION FOR GOING HOME 1 Life Doctor license Make a recipe for going home √ Make a medical resume before the patient goes home √ Make a recapitulation of drug and appliance use √ Return any unused remnants to pharmacies √ Check the proof of payment √ 2 Died Create a medical resume √ Recognize the use of drugs and tools √ Make a certificate of death √ Handover with the family √

Case of placenta previa were identified by the ICD 10 code O44 was related to the level of other risk factors, such as whether the effect of CS on the pacenta previa risk differed between younger and older women.

DISCUSSION

Implementation of Clinical Pathway of cesarean with placenta previa cases in hospital and length of stay (LOS) has proved to decrease length of stay (LOS) 4-6 day of patient's of hospitalization and may decrease hospital cost. In addition, it can improve clinical quality and increase quality of hospital services. The implementation of clinical pathway caesarean has an effect to the quality of service and cost efficiency in the hospital. Clinical pathway caesarean can be used as a basic example for clinical

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pathway with the type of coronary heart disease and can serve as the basis for calculating the cost of treatment in hospital resource management. ACKNOWLEDGEMENTS

We would like to thank Alexander Von Humboldt Foundation Germany-Indonesia for the Nature Research the Complexity and Collective Phenomenon in Emergent Societies, which has facilitated the Humboldt Call. REFERENCE

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KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI UNIVERSITAS TADULAKO

Kampus Bumi Tadulako Tondo Palu - Sulawesi Tengah 94111 JI. Soekarno Hatta Km. 9 Telp : (0451) 422611 – 422355 Fax: (0451) 422844

email: untad@untad.ac.id

SURAT IZIN

Nomor: 5167/UN.28/KP/2017

Yang bertanda tangan dibawah ini : Nama : Prof Dr.Ir Muhammad Basir , SE.,M.Si NIP : 19610202 198903 1 001 Jabatan : Rektor Universitas Tadulako Dengan ini memberikan izin kepada : Nama : Dr.Sitti Rahmawati,SE.,M.Si NIP : 196209131990012001 Pangkat/Gol : Pembina Tkt I , IV/b Unit Kerja : Fakultas Ekonomi Universitas Tadulako Untuk mengikuti dan menjadi pembicara pada konferensi International (as presenter) Oral Presentation dengan judul “Implementation Procedure of Clinical Pathway Elective Type Cesarean Surgery With Heavy Complication Case Study of Plasenta Previa Diseases And Its Effect Towards The Length of Stay in Undata Hospital Central Sulawesi Indonesia” Pada tanggal 24-26 th Juli Tahun 2017 di Ancol Putri Duyung Jakarta. Demikian surat ini dibuat digunakan sebagaimana mestinya. Palu, 5 Juli 2017 Tembusan: 1. Dekan Fakultas Ekonomi Untad 2. Ketua Jurusan Ekonomi Pembangunan