1. 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

2. Agenda 1 Welcome and introductions 2 DVT Risk Assessment 3 Measurement4
Transforming Care 5
Monthly Reporting 6
Web Page/Newsletter 7
LS3 8
Additional areas for intervention 9
Any other business

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

4. Measures

5. 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

6. 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.

7. 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

8. 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

9. 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)

10. 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.

11. 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.

12. 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)

13. 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.

14. DVT Risk Assessment
Comments/Questions?

15. 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

16. 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

17. 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

18. 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

19. Thank you! Any questions?
Cath Roberts -
Phil Banfield –
Vicki Evans -