1. 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

2. 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.

3. 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

4. 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.

5. 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

6. ‘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

7. Early Warning Systems - MEOWS

8. 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).

9. DVT Risk Assessment

10. Communication

11. 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

12. 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

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

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

15. 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.

16. 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

17. 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

18. How to Guide…..

19. 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.

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

21. 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

22. 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?

24. 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

25. 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

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

27. 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.

28. 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

29. 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.

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

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

32. 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

33. THIS IS YOUR COLLABORATIVE
Expectations
FROM US TO YOU
Ongoing support……
, 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

34. 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

35. Thank you! Any questions? And finally……..
Cath Roberts -
Phil Banfield –
Vicki Evans -

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