Transforming Maternity Services Mini-Collaborative Thursday 14th July 2011 Transforming Maternity Services Mini-Collaborative Call Facilitator : Cath Roberts Insert name of presentation on Master Slide

Agenda 1 Welcome and introductions 2 DVT Risk Assessment 3 Measurement 4 Transforming Care 5 Monthly Reporting 6 Web Page/Newsletter 7 LS3 8 Additional areas for intervention 9 Any other business

Introductions Cath Roberts - Programme Manager Phil Banfield Consultant Obstetrician & Faculty Lead Jan Davies Director 1000 Lives plus Vicki Evans Programme Support

Measures

DVT Risk assessment - Standards ALL women should be assessed at their first antenatal visit (The first VTE assessment and any further management should have been initiated by 12 weeks). ALL women should be assessed at their first antenatal visit An assessment should be undertaken at each antenatal admission A postnatal assessment should be undertaken

Deep Vein Thrombosis Risk Assessment Booking (ideally before 12 weeks of pregnancy) All women to be reviewed at their midwifery booking appointment and referred for obstetric led antenatal care if Indications to consider antenatal thromboprophylaxis are present. Medical staff to assess ALL women receiving obstetric led antenatal care at their first hospital clinic visit. Indications to consider antenatal thromboprophylaxis (continue during any AN hospital admission)  Tick if present Previous DVT/PE Refer to haematology clinic Antithrombin deficiency Systemic lupus erythematosis Sickle cell disease Antiphospholipid syndrome Myeloproliferative disorder BMI ≥45kg/m2 Consider referral to anaesthetist as per local guidance Assessed by Date / Signature Referred to (if appropriate): Date: Please refer to local guidance re referral timeframes and follow-up.

Risk factors for VTE at antenatal admission that would usually lead to LMWH during the admission and while any condition is on-going Hyperemesis Dehydration with dry tongue / poor urine output Sepsis Immobility – >3 days bed rest Significant medical co-morbidity (such as heart disease, metabolic, endocrine or respiratory pathologies, acute infectious diseases or inflammatory conditions) Varicose veins with phlebitis Active cancer / cancer treatment Ongoing antenatal thromboprophylaxis High BMI

Risk factors for VTE postnatally that would usually lead to thromboprophylaxis - TEDS & Clexane for 5 days. PPH >1500ml Red blood cell transfusion or transfusion of coagulation factors Caesarean section (elective or emergency) Still-birth Sepsis Complex vaginal delivery (Thromboprophylaxis should be considered) High BMI

BMI 52% of women in Wales are overweight or obese (Statswales 2009) The risk of VTE is associated with high BMI, but there are often confounding features (such as immobility, dehydration, sepsis or operative delivery)

BMI All women with a BMI of 45kg/m2 should be given LMWH as agreed in local guidelines. The woman needs referral to a high risk obstetric and obstetric anaesthetic clinic, but with the timing agreed locally. Initiation of thromboprophylaxis can be in secondary or primary care.

BMI – ANTENATAL ADMISSION For MLC the cut-off BMI = 35kg/m2 Antenatal admission to an ‘obstetric’ bed is NOT equivalent to admission to a MLC ‘bed’? Treatment only during the hospital episode unless additional risk factors are identified or delivery and postnatal assessment occur.

BMI – POSTNATAL RISK ASSESSMENT Cut-off BMI postnatally is completely arbitrary Many high risk women already identified Largest group numerically - c/section In the absence of compelling evidence, a suggestion is a cut off of 40kg/m2 (Technically, clinicians can choose a lower BMI on an individual / local basis)

Caveats It must be clear that the increased risk of VTE in pregnancy is not being ignored, but managed or mitigated. At every visit, women should be asked if they are well or if they have any shortness of breath, chest pain or lower limb / groin tenderness that may be a symptom of concurrent VTE.

DVT Risk Assessment Comments/Questions?

Monthly Progress Reports Score Explanation Evidence required Expected Period of time for completion Exemplar total time in months from start of programme No activity – no contact from Organisation   1 Organisation programme lead and team identified by Local Health Board or Trust and confirmed with 1000 Lives Plus Programme Manager Names and contact details supplied to programme manager. Monthly PM report table 1 populated. Within 1 month of the time organisation is notified of the programme 2 Local team has met and agreed terms of reference and action plan. Programme Manager is in receipt of TOR and action plan. This confirms that the programme is now offically up and running in the Health Board or Trust Within 1 month after Level 1 is complete 3 Local implementation and data collection strategy agreed and conforms to the 7 steps of measurement. Programme manager has received a document or documents that outline the implementation and data collection strategies. Within 1 month after the programme level data requirements are agreed by the 1000 Lives Plus programme team 4 Data collection has commenced and programme data tool populated with baseline data for relevant areas. Testing is underway in the pilot area / population. Programme manager has received a copy of the programme data tool that contains some data for all relevant measures. This may be supplemented by written material highlighting actions undertaken or lessons learnt. No longer than 1 month after strategies agreed

Learning Sessions Learn from faculty and colleagues Gather new knowledge on the subject matter and process improvement Share experiences and build collaboration on improvement plans

Additional Focus Areas Community interventions Outcome measure – VTE incidence Information for women Stories/journeys Womens experiences/satisfaction Webpage General Practice, Obs day Units, D/S, Obs Triage Units, NHS Direct, Out of Hours, A&E Education Community interventions Outcome measure – VTE incidence Information for women Stories/journeys Womens experiences/satisfaction Webpage General Practice, Obs day Units, D/S, Obs Triage Units, NHS Direct, Out of Hours, A&E

Dates for your diaries… Webex Call all 4-5pm Thursday 24th August 2011 (Community interventions) Learning Sessions (LS): Full days in Cardiff LS3 – Tuesday 6th Sept 2011

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