1. Insert name of presentation on Master Slide Transforming Maternity Services Mini-Collaborative Introductory WebEx Call Monday 9 th January 2012 Call Facilitator : Cath Roberts

2. Agenda 1Welcome and introductions 2Thromboprophylaxis 3Transforming Care 4Newsletter 5Measures 6Recognition & response to the acutely ill woman 7AOB

3. Thromboprophylaxis Any issues? Booking Risk Assessment

4. Transforming Care There was a recent meeting in Cardiff, attended by Health Board Transforming Care (TC) Facilitators and your nominated Maternity TC Leads. This meeting was well attended and proved to be extremely useful in clarifying aspects of both programmes. It is important that we aim to link these two programmes as much as possible. The following documents were agreed for circulation to the group for information: Copies of Staff /Patient satisfaction surveys used in your HB for Transforming Care/Maternity Services Photos showing the layout of PSAG / White boards used in Maternity to gather/display data. Once received these will be circulated along with some brief notes on the actions/decisions agreed and the activity follow sheets modified for Maternity by Cardiff and the Vale. A follow up date for a WebEx Call in February will be circulated shortly. Should you have any questions or queries regarding the above then please contact Lisa Henry (lisa.henry@wales.nhs.uk) or Cath Roberts.lisa.henry@wales.nhs.uk

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

7. Process Measures 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 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.

8. 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). Could this woman have sepsis? 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.

9. 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.

10. Process Measures 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) Has been added to data collection tool & circulated.

11. 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’.

12. 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? Process Measures

13. % 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 Process Measures

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

15. 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

16. NUMBERS OF WOMEN ADMITTED TO LEVEL 2&3 INTENSIVE CARE DURING PREGNANCY & POSTNATAL PERIOD COMBINED – ALL WALES 20092010 level 27377 level 34134 ‘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)

17. 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

18. 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!

19. Monthly Progress Reports ScoreExplanationEvidence required Expected Period of time for completion Exemplar total time in months from start of programme 0 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 1 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 2 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 3 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 4

20. AOB? Dates for your diaries… Webex Calls all 4-5pm Focus on Acute deterioration – Obs early warning system and sepsis MONDAY 23 RD JANUARY 2012 Learning Session (LS): Full day in Cardiff To be arranged

21. Thank you! Any questions? Cath Roberts - Maternity.collaborative@wales.nhs.ukMaternity.collaborative@wales.nhs.uk Phil Banfield – philip.banfield@wales.nhs.ukphilip.banfield@wales.nhs.uk Vicki Evans-Park – victoria.evans-park@wales.nhs.ukvictoria.evans-park@wales.nhs.uk