Thursday 24th November 2011 Transforming Maternity Services Mini Collaborative Learning Session 3 Cath Roberts 1

Process Measures How can you as organisations demonstrate that you are making the change?

Process Measures Admission bundle Full set of observations on admission Booking BMI recordedRecorded DVT risk assessment Clear monitoring plan specifying the physiological observations and how often according to local guidance Communicate this with the clinical team /whiteboard & safety brief % compliance admission bundle Denominator: Number of admissions/transfers in to the ward in that shift. Numerator: the number of women fully compliant within 2 hours of admission/transfer with the admissions bundle in one day.

Process Measures Acutely ill’ Recognition Bundle Monitor observations at least 12 hourly as according to plan /this may differ from one organisation to another depending on local guidance Record track and trigger risk assessment according to early warning system used plus trigger guidance (This can be displayed on the ‘status board’ as colour coded). Consider severe sepsis if patient is ‘at risk of sepsis’ As the woman may be ‘high risk’ due to eg pre-eclampsia etc…. do we need a separate question of ‘could this woman have sepsis?’ This may address this question ….. Communicate this information with the clinical team using SBAR format/safety briefs/white board % compliance with ‘Acutely ill’ recognition bundle Denominator: the number of women on the ward at the end of the shift. Numerator: the number of women on the ward (at the end of the shift) that are fully compliant with the acutely ill recognition bundle.

Process Measures Response Bundle (women at risk of sepsis only – DVT prophylaxis element has been removed) Inform appropriate staff using SBAR tool of any deterioration in observations filed in medical notes. Change frequency of observations Additional monitoring if appropriate Timely assessment and initiation of response Initiate Sepsis Six Bundle if appropriate % compliance with response bundle Denominator: all women, identified as being at low, medium or high risk of deterioration at the end of shift. Numerator: the number of women, identified as being at low, medium or high risk of deterioration fully compliant with the acutely ill response bundle at the end of shift.

Process Measures Denominator: number of women deemed at risk of DVT Response – DVT Prophylaxis Prescribe/administer appropriate thromboprophylaxis to those who need it Denominator: number of women deemed at risk of DVT Numerator: number of women who have been administered appropriate DVT prophylaxis (this needs to include mechanical) To be added to data collection tool.

Process Measures Sepsis Six Bundle Oxygen Blood culture Iv antibiotics Fluid resuscitation Serum lactate and Hb Hourly urine output monitoring % compliance with ‘sepsis six’ Denominator: all women identified as having sepsis requiring a response at end of shift. Numerator: the number of these women fully compliant within 1 hour with the ‘sepsis six’ .

Numbers of multidisciplinary reviews Process Measures Numbers of multidisciplinary reviews Regular and frequent multidisciplinary reviews of circumstances surrounding cases of deterioration & those diagnosed with VTE so that lessons can be learnt Multidisciplinary definition to be agreed locally - depending on the individual case but suggest - Obstetrician, Midwife, Obstetric Anaesthetist, Community midwife, risk Midwife. A count of the number of reviews undertaken per month. Definition of review to be determined locally. UKOSS link can identify those diagnosed with sepsis. DVT – linked to outcome measure?

% Clinicians that are trained Process Measures % Clinicians that are trained Multidisciplinary training in monitoring, measurement, interpretation and prompt response to the acutely ill & assessment and risks of DVT & appropriate prophylactic treatment including mechanical methods, pharmaceutical methods and early mobilisation Consider professional role (midwife, obstetrician, anaesthetist) and seniority (trainee, consultant) – Refer to Report ‘Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman’ and CMACE ‘Back to Basics). Appropriate to the level of care each clinician is providing (as a minimum). What is the most useful measure for this? What training is already being provided? Denominator: How many clinicians need to be trained Numerator: How many clinicians are trained

Outcome Measures As an organisation, how can you demonstrate that you have made a difference?

Existing Outcome Measures Monthly number of calls for a response to women who have been assessed as being of medium or high risk of acute deterioration. Number of women escalated to higher level of care

Every death = 9 severe maternal morbidity NUMBERS OF WOMEN ADMITTED TO LEVEL 2&3 INTENSIVE CARE DURING PREGNANCY & POSTNATAL PERIOD COMBINED – ALL WALES   2009 2010 level 2 73 77 level 3 41 34 ‘Providing equity of critical care and maternal care for the critically ill pregnant or recently pregnant woman’ Royal College of Anaesthetists 2011 Every death = 9 severe maternal morbidity Maternal death rate = 14/100,000 Critical care utilisation = 260/100,00 (difficult to ascertain and may be as high as 1200/100,000)

Outcome Measures Sepsis Mortality Rate VTE Mortality Rate VTE Incidence per month - proving to be a challenge! Currently testing the use of Radiology data List of all doppler scans, VTE and VQ scans (per month) Unable to ascertain positive/negative results Filters: female, under 50, no filter of referral Review of ‘scan notes’ of remainder to determine the ‘positives’ and those relating to pregnancy Certain degree of casenote review for quality control

UKOSS – Severe Maternal Sepsis “Aim is to estimate the incidence of severe maternal sepsis in the UK, to investigate and quantify the associated risk factors, causative organisms, management and outcomes and to explore whether any factors are associated with poor outcomes.” June 2011 – May 2013 Who is your lead – needs to link National Outcome Measure? Only as good as the data submitted!

Outcome Measures As an organisation, how can you demonstrate that you have made a difference?

Thank you If we can improve care for one woman, 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 every woman in Wales.

DVT Prophylaxis

Communication

Speaking the same language! Early warning system – a tool to aid the recognition and management of a deteriorating woman eg MEOWS Track and trigger describes how you use the tool Track – periodic observation of vital signs Trigger – pre-determined criteria ‘trigger’ the summoning for help – timely response, appropriate level of assistance WHAT TO DO AND WHEN TO DO IT!

Why stories? Help is available Inspiration Provide the why we do what we do! Provide the human element Learning Generating dialogue identifying needs creating improvements feedback outcomes Education Provides a focus on the patient not just the outcomes Stories from women Media Change a public mindset Endorse good work Draw attention to work Help is available

Additional Information

Web Page http://www.1000livesplus.wales.nhs.uk/maternity

Reporting Monthly catch-up calls (beg each month) Measures – to Cath (where do they go?) Measures/progress – display in local areas Local reporting to appropriate committees Nursing & Midwifery Metrics

Support Cath/Phil/Lisa Locally Executive lead – get them involved, visible support Local 1000 lives Plus Lead Local Improvement Lead RRAILS team

NLIAH - Learning Channel http://www.learningwales.tv/groups/discussion_topic/24/

Sharing your success Internally – on wards, comms leads, via reporting mechanisms Externally - NHS Awards Deadline - Friday 20th January 2012

Webex Dates Monday 9th January 2012 General Call 4-5pm Monday 23rd January 2012 Sepsis Call

Thank you If we can improve care for one woman, 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 every woman in Wales.

Online evaluation – link will be sent Thank you And finally………. Online evaluation – link will be sent But Before you go……… ‘Post it’ on flipchart What was good about the day and what was not so good? Any unanswered questions?