Transforming Maternity Services Mini-Collaborative Learning Session 1 Friday 4th March 2011 Transforming Maternity Services Mini-Collaborative Learning Session 1 Cath Roberts Insert name of presentation on Master Slide

What are we trying to achieve? Reducing mortality and harm from venous thromboembolism in pregnancy and the postnatal period. OVERALL AIM: To improve experience and outcomes for mothers, babies and their families within Maternity Services Reduce mortality and harm by improving the recognition and response to the acutely deteriorating woman.

How do we plan to achieve this? Implementing a series of care bundles: Admission bundle Recognition bundle Response bundle Sepsis six bundle Patient involvement Clinical competence

Why bundles? What is a bundle? A small, straightforward set of evidence based practices – generally 3 to 6 – that, when performed collectively and reliably, have been proven to improve patient outcomes.

What does the evidence tell us? Admission Bundle Full set of observations on admission Booking BMI recorded Recorded DVT risk assessment Clear monitoring plan specifying the physiological observations and how often Communicate this with the clinical team

‘Acutely Ill’ Recognition Bundle What does the evidence tell us? ‘Acutely Ill’ Recognition Bundle Monitor observations at least 12 hourly as according to plan Record track and trigger risk assessment Consider severe sepsis if patient is ‘at risk’ Communicate this information with the clinical team using SBAR format/safety briefs/patient status board

Early Warning Systems - MEOWS

Guidance Number Recommendations NICE CG 62: Antenatal Care (2) There is no reference to recording physiological observations during pregnancy/admission to hospital/community. NICE CG 55: Intrapartum Care (3) Initial assessment: temperature (T), pulse (P), blood pressure (BP), Urinalysis 1st stage: 4hrly T & BP, hrly P 2nd stage: hourly BP & P, 4hrly T 3rd stage: colour, respirations & how woman feels NICE CG 13: Caesarean Section (4) ‘After recovery from anaesthesia, observations (respiratory rate, heart rate, blood pressure, pain and sedation) should be continued every half hour for 2 hours, and hourly thereafter provided that the observations are stable or satisfactory. If these observations are not stable, more frequent observations and medical review are recommended. Following intrathecal opioids, epideural opioids, and patient controlled analgesia with opioids, they recommend hourly resp rate, sedation and pain scores throughout treatment and at least 2 hours following discontinuation of treatment.’ No further reference. NICE CG 37: Postnatal Care (5) ‘At each postnatal contact, the healthcare professional should ask the woman about her health and wellbeing……………. Any symptoms reported by the woman or identified through clinical observations should be assessed.’ Signs and Symptoms table: ‘Fever, shivering, abdominal pain and/or offensive vaginal loss’ = infection In the absence of any signs and symptoms of genital tract sepsis, routine assessment of temperature is unnecessary. Temp should be taken and documented if infection is suspected. If >38– repeat in 4-6 hours. If temp remains >38 degrees centigrade on the second reading or there are other observable symptoms/measurable signs of sepsis, evaluate further (emergency action).

DVT Risk Assessment

Communication

What does the evidence tell us? Response Bundle Prescribe/administer appropriate thromboprophylaxis Inform appropriate staff using SBAR tool of any deterioration in observations Change frequency of observations Additional monitoring if appropriate Timely assessment and initiation of response Initiate Sepsis Six Bundle if appropriate

What does the evidence tell us? Sepsis Six Bundle Appropriate and timely treatment for severe sepsis within 1 hour of diagnosis Oxygen Blood Culture IV antibiotics Fluid Resuscitation Serum Lactate and Hb Hourly Urine Output Monitoring

Intervention Patient Involvement Good quality and consistent education play a vital role in helping women take responsibility for their own health including preventing illness.

Intervention Ensure competence in monitoring, measurement, interpretation and prompt response to the acutely deteriorating patient and prevention of DVT

How will we know that the change is an improvement? Measurement is a critical part of testing and implementing change. Measures tell a team whether the changes they are making actually lead to improvement.

How will we know that the change is an improvement? Compliance with Admissions Bundle Compliance with Recognition Bundle Outcome Measures Number of calls for response to women at medium and high risk Number of women escalated to higher level of care Sepsis mortality rate Incidence of VTE VTE Mortality Rate Compliance with Response Bundle Compliance with Sepsis Six Bundle Pt surveys Number of reviews/ % staff trained. Process Measures Outcome Measures

Additional interventions Community DVT Risk Assessment Antenatal booking appointment (or first contact) Recognition and response of acutely ill women within community setting (at each contact) / midwife led units General practice Out of hours provision

How to Guide…..

Thank you. Any questions? If we can improve care for one patient, then we can do it for ten. If we can do it for ten, then we can do it for a 100. If we can do it for a 100, we can do it for a 1000 And if we can do it for a 1000, we can do it for everyone in Wales.

The Tools What tool do you use/when? Do you have associated guidance? How effective is it? How do you know?

Admission Bundle Full set of observations on admission Where to start? Admission Bundle Full set of observations on admission Booking BMI recorded Recorded DVT risk assessment Clear monitoring plan specifying the physiological observations and how often Communicate this with the clinical team

Where to start? Admission Bundle What proportion of the women admitted to your clinical area have a: full set of observations on admission? plan for the frequency of observations? plan which has been communicated to all clinical staff? How many have a DVT risk assessment recorded on admission? Do all women have a recorded booking BMI within their hand held notes?

Methodology - IHI Model for improvement The Model for Improvement is a simple yet powerful tool for accelerating improvement. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement

PDSA Cycle 1. Plan..what needs to be done and how 2. Do..what you have planned to do 3. Study..the outcomes – expected and unexpected, of the test 4. Act..on the results and modify and improve. Act Plan Do Study Very Small Scale Test

We’ve all done at least one PDSA…. Act Plan Study Do

Why bother testing? Less time, money and risk involved. The process is a powerful tool for learning. Much is learned from ideas that don’t work as from those that do. It is safer and less disruptive for patients and staff. Where people have been involved in testing and developing ideas there is often less resistance on implementation.

The principles of PDSAs Breaks down change into manageable, bite-sized time-limited chunks Not audits – snap shots in time A PDSA cannot be too small!!!!!! It can be too big Small changes can be tested without causing upheaval to the whole system Tell others what you are doing If it doesn’t work, try something different based on your learning Document what did/didn’t work 28

Developing the first test of change 1. Plan..what needs to be done and how. 2. Do..what you have planned to do 3. Study..the outcomes – expected and unexpected, of the test 4. Act..on the results and modify and improve.

Intervention Patient Involvement Good quality and consistent education play a vital role in helping women take responsibility for their own health including preventing illness.

Intervention Ensure competence in monitoring, measurement, interpretation and prompt response to the acutely deteriorating patient and prevention of DVT

Identifying Leadership and Choosing Your Team Who do we need to engage? How will you share your learning? Obstetricians Midwives Obstetric anaesthetists Consultant Midwives Practice Development/Risk Midwives Student Midwives Obstetric trainees Transforming Care link Midwife Community Midwives Improvement/measures lead Transforming Care Facilitator Local clinical lead for general VTE Collaborative Local clinical lead for general RRAILs Collaborative Senior Leadership Roles Front Line Teams Day-to-Day Leadership

THIS IS YOUR COLLABORATIVE Expectations FROM US TO YOU Ongoing support…… email, phone, site visits, WebEx calls, future learning sessions Support a communication network Assist development of community interventions FROM YOU TO US Communication between team members within health board Contribute to learning events Networking Sharing your learning THIS IS YOUR COLLABORATIVE

Dates for your diaries… Webex Calls all 4-5pm Thurs 14th April 2011 Thurs 14th July 2011 Learning Sessions (LS): Full days in Cardiff LS1- Friday 4th March 2011 LS2 – Tuesday 7th June 2011 LS3 – Tuesday 6th Sept 2011

Thank you! Any questions? And finally…….. Cath Roberts - Maternity.collaborative@wales.nhs.uk Phil Banfield – philip.banfield@wales.nhs.uk Vicki Evans - Victoria.Evans2@wales.nhs.uk

Lone Nut – How to start a movement…. http://www. youtube. com/watch