PENGGUNAAN ALAT UKUR KUALITAS RUJUKAN OBSTETRI SOSIAL SEBAGAI ALAT BANTU PEMBUATAN REKOMENDASI PADA FORUM AUDIT MATERNAL PERINATAL

EUGENIUS PHYOWAI G, Prof. dr. Moh. Hakimi, PhD., Sp.OG (K).; Prof. dr. Ova Emilia, M.Med.Ed., Ph.D., SpOG(K).;

2017 | Disertasi | S3 Ilmu Kedokteran

Latar Belakang: Evaluasi kualitas rujukan obstetri merupakan salah satu cara dalam menurunkan angka kematian ibu. Faktor penting yang berperan dalam menentukan kualitas rujukan seperti tenaga, SOP, transportasi, komunikasi, dan jarak perlu menjadi perhatian bagi para pemangku kepentingan dalam kesehatan ibu dan anak. Dengan mengevaluasi kualitas rujukan dapat diketahui faktor-faktor apa yang belum berjalan optimal dapat menjadi pertimbangan dalam forum audit maternal perinatal. Tujuan: Penelitian ini bertujuan untuk menganalisis dan memformulasikan suatu alat ukur yang dapat menilai kualitas rujukan sebagai alat bantu pembuatan rekomendasi pada forum audit maternal dan perinatal. Metode: Penelitian ini bersifat kuantitatif-kualitatif (mixed-method) dengan desain studi kohort prospektif yang dilakukan di RSUP Dr. Sardjito pada bulan Januari-Desember 2016. Alat ukur dibuat melalui beberapa tahapan yaitu persiapan rancangan alat ukur (Fase 1), perbaikan alat ukur (Fase 2), penyempurnaan dan uji awal alat ukur (Fase 3), dan uji coba alat ukur dan rencana tindak lanjut (Fase 4).Uji validitas, sensitivitas dan spesifisitas dilakukan terlebih dahulu pada alat ukur tersebut. Pengambilan sampel dilakukan secara berurutan dari pasien rujukan obstetri yang masuk IGD RSUP Dr. Sardjito. Analisis bivariat yang digunakan adalah Chi-Square, sedangkan analisis multivariat yang digunakan menggunakan uji regresi logistik. Angka kemaknaan yang diterima adalah p < 0,05. Hasil: Uji validitas logis didapatkan 93,3% (p=0,001) ahli setuju penggunaan alat ukur kualitas rujukan tersebut. Untuk uji sensitivitas 66,7% dan uji spesifisitas 84,1% (OR: 10,6 CI 95%: 4,43-25,34). Hasil uji coba alat ukur kualitas rujukan pada 120 subjek, yang terdiri dari 72 (60%) pasien dikategorikan kualitas rujukan baik dan 48 (40%) pasien kualitas rujukan buruk. Hasil analisis bivariat didapatkan pengaruh kualitas rujukan erhadap kejadian asfiksia neonatorum (RR = 0,34; 95% CI = 0,15-0,80; p = 0,01) dan perawatan NICU (RR = 0,26; 95% CI = 0,12-0,57; p = 0,001). Hasil analisis multivariat didapatkan kualitas rujukan (RR = 2,74; 95% CI = 1,16-6,46; p = 0,02) dan umur kehamilan (RR = 0,36; 95% CI = 0,15-0,86; p = 0,02) mempunyai pengaruh yang besar terhadap kejadian asfiksia. Sedangkan umur ibu, berat bayi baru lahir dan status paritas tidak memiliki pengaruh bermakna terhadap kejadian asfiksia neonatorum. Kesimpulan: Alat ukur kualitas rujukan obstetri sosial telah mampu menilai kualitas rujukan obstetri dan perinatal yang ada di RSUP Dr. Sardjito sebagai rumah sakit tersier rujukan tertinggi yang ada di Provinsi D.I. Yogyakarta dan mampu dijadikan pertimbangan sebagai alat bantu pembuatan rekomendasi pada forum audit maternal dan perinatal.

Background: Evaluation for referral system of maternal health is a method to decrease maternal mortality rate. The important factors affecting the quality of referral system are staff, protocols, transportation, communication, and geographical access/distance that need to be concerned from the stakeholders which involved in the program of maternal and child health. By evaluating the quality of referrals it can be found which factors that have not work optimally and could be considered for maternity and perinatal audit. Objective: The study aimed to analyze and formulate an evaluation toolkit that can assess the quality of referrals as an instrument for making recommendations for maternal and perinatal audit forum. Method: This study was qualitative-quantitative (mixed-method) with prospective cohort design which undertaken at Dr. Sardjito General Hospital, Yogyakarta within January until December 2016. The evaluation instrument was developed through several phases, preparation phase to design the evaluation instrument (Phase 1), the evaluation instrument improvement (Phase 2), refining and initial testing of the evaluation instrument (Phase 3), testing of the evaluation instrument and follow-up plan (Phase 4).Validity, sensitivity, and specificity test were carried out first on the evaluation instrument. Sample were obtained in consecutive patients from obstetric referral at Emergency Department of Dr. Sardjito General Hospital. Chi-Square was used as bivariate analysis, and logistic regression was used as multivariable analysis. Statistical analysis was significance if p < 0.05. Result: Logical validity test was obtained 93.3% (p=0.001) expert agreed to use social obstetrics evaluation toolkit. For sensitivity and specificity test were 66,7% and 84.1% concecutively (OR: 10,6 CI 95%: 4,43-25,34). The results of obstetrics evaluation toolkit trial on 120 subjects, consisting of 72 (60%) of patients were categorized as good quality referrals and 48 (40%) patients as poor quality referrals. The result of bivariate analysis showed that the influence of the reference quality on the incidence of asphyxia neonatorum (RR=0,34; 95%CI=0,15-0,80; p=0,01) and NICU admission (RR=0,26; 95%CI=0,12-0,57; p=0,001). The result of multivariable analysis showed the quality of referrals (RR = 2,74; 95% CI = 1,16-6,46; p = 0,02) and gestational age (RR = 0,36; 95% CI = 0,15-0,86; p = 0,02) had an influence on the incidence of asphyxia. While the age of maternal, birthweight and parital status have no significant effect on the incidence of asphyxia neonatorum. Conclusion: The evaluation toolkit has been able to assess the quality of maternal and perinatal referrals in Dr. Sardjito General Hospital as the highest tertiary referral hospital and be able to be considered as a tool for making recommendations in the maternity and perinatal audit forum.

Kata Kunci : angka kematian ibu, audit maternal perinatal, kualitas rujukan, maternal mortality ratio,maternal perinatal audit, referral quality