North East North Cumbria Health Safety Collaborative Learning

North East North Cumbria Health Safety Collaborative Learning

North East North Cumbria Health Safety Collaborative Learning System 2 December 2019 North East and North Cumbria #MatNeoNENC #PReCePTNENC Welcome and introduction Julia Wood North East and North Cumbria

Overview of MatNeo SIP Patient Safety Programmes in Obstetrics Mr Kim Hinshaw CTG What we know CTG- Whats next? System-level project updates Regional SCORE Update Wrap up Maternity and Neonatal Safety Improvement Programme (previously Maternal and Neonatal Health Safety Collaborative) National Patient Safety Collaborative rebranded to become the National Patient Safety Improvement Programme

All the workstreams which sit under this were also rebranded, including this programme Maternity and Neonatal Safety Improvement Programme (previously Maternal and Neonatal Health Safety Collaborative) To support improvement in the quality and safety of maternity and neonatal units across England AIMS: Contribute to the national ambition of reducing the rates of maternal and neonatal deaths, stillbirths and brain injuries that occur during or soon after birth by 20% by 2020 To improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England Two approaches, working together

Trust Improvement Trusts identify areas of focus which meet their needs (in line with National Driver Diagram) Learning Systems System improvement across North East and North Cumbria Evolve over time Building on the great work currently going on in the region Trust Improvement: Who is involved? Wave 1 (from Apr 17) North Tees & Hartlepool NHSFT

- 44 organisations Wave 2 (from Apr 18) Wave 3 (from Apr 19) County Durham and Darlington NHSFT North Cumbria University Hospitals NHS Trust South Tees NHS FT South Tyneside and Sunderland NHSFT Gateshead

FT The Newcastle Upon Tyne Hospitals Usually shareHealth TrustNHS Improvements: FT Only just over two months since the lastNHS event Healthcare NHS FT projects Lots toNorthumbria cover regarding system-level 43 organisations 46 organisations Everyone is involved in the Learning Systems

PReCePT Prevention of Cerebral Palsy in PreTerm Labour CTG Cardiotocography Transitional Care Date for your diary 3rd March Patient Safety Programmes in Obstetrics Mr Kim Hinshaw Director of Research, Consultant Obstetrician & Gynaecologist South Tyneside & Sunderland NHS Foundation Trust

North East and North Cumbria See Kim Hinshaws slides in the available pdf CTG What We Know Dr Stephen Sturgiss North East and North Cumbria Physiological CTG interpretation: what do we know Where did we get to at the end of the last meeting Enthusiasm to propose region-wide adoption of physiological interpretation Acknowledgement that such a decision needs wide-ranging agreement Critical to that decision will be a bringing together of evidence Facilitate decision-making within each provider unit, or at a bespoke meeting Also assess training and competency assessments

Physiological CTG interpretation: what we know What have we done since the last meeting Contacted clinical experts & leaders (directly or indirectly) Available literature Tele-conferences with: East of England Oxford Northern Physiological CTG interpretation CTG features baseline heart rate Normal baseline Value between 110-160 bpm Tachycardia Baseline > 160 bpm for 10+ mins

Bradycardia Baseline < 110 bpm for 10+ mins Values of of 90-110 can occur in a normal fetus, especially in a postdate pregnancy Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiological CTG interpretation CTG features - Baseline variability (BLV) Normal: Reduced BLV: Bandwidth amplitude 525 bpm

< 5 for 50+ mins or 3+ mins during decels Increased BLV (saltatory): 25+ for 30+ mins Sinusoidal: Regular, smooth, undulating signal at 5-15 bpm + no accels Pseudosinusoidal: Resembles sinusoidal + more jagged pattern

Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiological CTG interpretation CTG features Decelerations (15+ bpm for 15+ secs) Early decelerations: Gradual (ie onset to nadir > 30 secs) + coincide with contractions Do not indicate hypoxia Variable decelerations: V-shaped, with rapid drop (< 30 secs to nadir) + rapid recovery Late decelerations

Gradual onset + return, + increased or reduced variability within decel Prolonged deceleration Decels for 3+ mins Rarely indicate hypoxia, unless evolve to U-shape + (60s criteria), or reduced / increased variability during decel Indicative of hypoxiaemia Likely to indicate hypoxiaemia Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiology of hypoxia in labour

Acute hypoxia Prolonged decel 5+ min (or 3+ min if reduced BLV) Causes Accidents cord prolapse, abruption, uterine rupture Iatrogenic maternal hypotension, uterine hyperstimulation Management 3-minute rule (unless preceded by reduced BLV) 3+ min raise emergency alarm 3-6 diagnosis 6-9 prepare for delivery 9-12 aim for delivery by 12-15 mins Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiology of hypoxia in labour Subacute hypoxia

Fetus spends majority of time in decels Invariably caused by hyperstimulation Management in 1st stage Stop / reduce uterotonics Avoid supine position Start IV fluids Consider tocolytics Expedite delivery if persists Management in 2nd stage Stop pushing Expedite delivery if no recovery in 10 mins

Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiology of hypoxia in labour Gradually evolving hypoxia (stages 1-4) Most common form of hypoxia in labour Stages 1-4 represent evidence of stress + fetal compensation Stage 1 - hypoxic stress - decels Stage 2 - loss of accels - lack of cycling

Stage 3 - exaggerated response to hypoxia - decels wider and deeper Stage 4 - redistribution to vital organs - facilitated by catecholamines - rise in baseline FHR Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiology of hypoxia in labour Gradually evolving hypoxia stages 5 & 6 (fetal decompensation) Stages 4 (&5) may be reversible

Stage 5 further redistribution vasoconstriction affects brain reduced BLV Stage 6 terminal heart failure unstable / progressive decline in BLR step ladder pattern to death Management improve fetal conditions with first signs of redistribution (stage 4) Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiology of hypoxia in labour Chronic hypoxia Antenatal type of hypoxia Presents as BLR at upper

end of normal, with reduced BLV + often shallow decels Indicates a fetus with reduced reserve Low threshold for surgical intervention Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiological interpretation of CTGs Management of suspected fetal hypoxia Hypoxia Features Gradually Evolving hypoxia

Management Compensated Rise in the baseline (with normal variability and stable baseline) preceded by decelerations and loss of accelerations Decompensated Reduced or increased variability Unstable/ progressive decline in the baseline (step ladder pattern to death)

Likely to respond to conservative interventions (see below) Regular review every 30-60 minutes to assess for signs of further hypoxic change, and that the intervention resulted in an improvement. Other causes such as reduced placental reserve MUST be considered and addressed accordingly Needs urgent intervention to reverse the hypoxic insult (remove PG pessary, stop oxytocin, tocolysis) Expedite delivery if no improvement seen Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al Physiological interpretation of CTGs Management of suspected fetal hypoxia

Hypoxia Features Management Subacute hypoxia More time spent during decelerations than at the baseline First stage May be associated with saltatory pattern (increased variability)

Remove prostaglandins/stop oxytocin infusion If no improvement, needs urgent tocolysis If still no evidence of improvement within 10-15 minutes, review situation and expedite delivery Second stage Stop maternal active pushing during contractions until improvement is noted. If no improvement is noted, consider tocolysis if delivery is not imminent or expedite delivery by operative vaginal delivery Intrapartum Fetal Monitoring Guideline February 2018. Chandraharan et al

Physiological CTG interpretation: Significance of baseline FHR after onset of decelerations Without tachycardia (n=81) With tachycardia (N=262) Z P-value Gestational age (weeks) 40.4 40.3

-0.868 .386 Birthweight (g) 3371 3427 1.157 .247 1 min Apgar 8.82 +/- 1.0 7.96 +/- 1.78

-4.816 0.000 5 min Apgar 9.79 +/- 0.47 9.34 +/- 1.04 -4.03 0.000 Umbilical arterial pH 7.25 +/- 0.05 7.20 +/- 0.1

-3.38 0.001 <7 0 13 (5%) 2.927 0.087 >7 81 249 (95%)

Jia et al (2019) J Maternal-Fetal & Neonatal Medicine Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies Primary objective Examine whether an interpretation of CTGs using types of intrapartum hypoxia correlates with the nature of hypoxic injuries Retrospective study of 52,187 births at St Georges (2006-17) 16 babies with postnatal diagnosis of HIE AAP criteria from 2003 used to diagnose occurrence of acute hypoxic event CTG traces classified independently by 2 assessors (SSY/EC) Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies

52,187 births between 2006 and 2017 16 cases of HIE (0.3 / 1000) (cf ) Condition HIE Year 2012 2013 2014 2015 No.of cases 1674

1674 1824 1742 Rate / 1000 LBs 2.4 2.5 2.8 2.6 Number of term cases 1409

1401 1480 1417 Number of term births 640787 612816 607972 609076 Rate term cases 2.2

2.2 2.4 2.3 Gale et al 2017 ArchDis Child Fetal Neonatal Ed Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies 52,187 births between 2006 and 2017 16 cases of HIE (0.3 / 1000) (cf national of 1.4-1.8 / 1000) Other quoted outcomes Intrapartum emergency CS: 8.1% Emergency CS for failed instrumental: 0.3-0.5%

Intrapartum stillbirths: None in 7+ yrs Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies Our study has shown that, whilst our rate of HIE based on Sarnat Criteria is 0.8/1000, our actual rate of neurological damage based on neonatal MRI scan is much lower (16/52,187 births or 0.3/1000). Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies Inter-observer agreement: 81%

Typical reported rates: 30% (Rhose et al, 2014. Reif et al, 2016. Hruban et al, 2016) Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Types of intrapartum hypoxia on the CTG: do they have any relationship with the type of brain injury in the MRI scan in term babies Hypoxia No. of babies MRI findings Subacute

3 Normal (1), Unavailable (2) Evolving 4 Normal (1). Abnormalities in thalami (1), diffuse cortical injury (2) Combined acute + subacute 2 Abnormal myelination in ares supplied by posterior circulation (1), Unavailable (1) Combined evolving + acute

2 Abnormal myelination in areas supplied by post circulation + very severe HIE (1), Unavailable (1) Evolving + subacute 2 Normal (1), Severe atrophy of cerebral hemisphere in watershed areas None 3 Post cerebral infarct (1), Metabolic pathology (1) Yatham+ J Obstet Gynecol https://doi.org/10.1080/01443615.2019.1652576 Improvements in Intrapartum Caesarean Sections, FBS Rates & HIE Rates

120 after Physiology-based CTG Masterclasses 100 80 60 40 20 0 % Reduction in FBS % Reduction in Intrapartum C Sections Physiologic interpretation of CTGs

Case study from Lewisham & Greenwich NHS Trust Sign up to Safety team introduced physiologic interpretation Staff attended CTG masterclass Weekly CTG meetings, induction program and mandatory training Appointment of B7 midwives 32% reduction in number of babies admitted to NICU with HIE Reduction in babies transferred out for cooling (Only a couple of FBSs) Evaluating the value of intrapartum FBS to predict adverse neonatal outcomes: A UK multicentre observational study Outcome Test threshold Sensitivity

Specificity Positive predictive value Negative predictive value Area under the curve (95%CI, p value) Neonatal acidaemia Suboptimal pH 22 87.3

4.9 97.4 0.59 (0.51-0.68, 0.31) Abnormal pH 7.3 94.6 3.9 97.2 Suboptimal pH 14.5

87.5 23.4 79.6 Abnormal pH 8.8 95.5 33.8 79.9 Suboptimal pH 20.3

87.4 7.6 95.6 Abnormal pH 7.2 94.7 6.5 95.2 Suboptimal pH 20.3

78.5 13.3 92.1 Abnormal pH 9.3 94.7 14.3 91.8 Apgar < 7 at 1 min Apgar < 7 at 5 mins

NICU admission 0.55 (0.51-0.59, 0.004) 0.55 (0.48-0.62, 0.13) 0.58 (0.52-0.53, 0.0002) Wattar et al 2019 Eur J Obstet Reprod Biology Physiological interpretation of CTGs What do we know? Some evidence of reduction in HIE Underlying principles not rebutted by neuro-anatomic evidence No evidence of increase in interventions (and potentially a reduction) Recent evidence in relation to merit of FBS is equivocal Very strong case for formal evaluation

Enthusiasm ++++ CTG Whats next Facilitated by Dr Stephen Sturgiss and Julia Wood CTG Whats next?: Part 1 Group Work Focus on three areas, identified through the table discussions at the LLS in September: Training and competence assessments (tables 1 and 2) Ensuring staff implementation (tables 3 and 4) Resistance to change how to overcome it (tables 5 and 6) Two tables focus on each area If you want to move tables, please move now Use of the Kipling Questions: Barriers What: What are the potential barriers?

Where: Where will be the barrier/s? (so in which part of the process/system)? Who: Who may be the barrier? When: At which point in the process/system will the potential barrier/s become evident? I keep six honest serving men (They taught me all I knew); Their names are What and Why and When And How and Where and Who Why: Why is each barrier a problem? How: How will we know that the potential barrier has become a problem? 20 minutes Use of the Kipling Questions:

Overcoming Barriers What/Where/Why: You have this information from the previous group work How: How should each barrier be tackled When: When is the best time to tackle each barrier? Who: Who is best placed to tackle the each barrier? (individual/staff group/organisation) 20 minutes Refreshment Break #MatNeoNENC #PReCePTNENC North East and North Cumbria CTG - Whats next?: Part 2

Feedback from each table (20 minutes in total) System-level Projects System-level Projects Updates Dr Sundeep Harigopal Martyn Boyd Karen Hooper North East and North Cumbria TC at the RVI Dr Sundeep Harigopal Dec 2019

Location Predominantly on one of two PNW Nursery nurse focus and TC nursing base Overflow capacity possible on other PNW No theoretical cot limit to TC number on any day How Mother with baby always (Dad alone tricky) PNW run jointly by midwives and TC with nursery nurses Baby care delivered by all of TC, nursery nurses and midwives Oversight by consultant Daily ward round on TC (M-F) w/e trouble shooting When 24/7 and 365 on level of mother with baby and care delivery unchanged Deliverers of care do change

TC M-F 07:30 15:30, junior docs OOH W/e some TC, more junior docs off NICU Consultant availability always dedicated M-F, shared with NICU, transport OOH What i.v antibiotics NG feeds Heated cots Phototherapy NAS management Fresh off NICU (big babies and graduating older prems both accepted back)

other (occasional stoma, complex baby etc) NIPE for TC babies, and some failsafe for NIPE TC team also do BCGs (but not viewed as TC activity) Recording/reporting TC coded by coders for financial purposes We think by specific activity not as TC E.g phototherapy, i.vs etc No current record in badger for TC babies ?we might start How much April 356 days May -369 June 345 Challenges

Staffing differences MF vs w/e etc Returning babies to normal care once in TC Space Stopping silo working PReCePT (prevention of cerebral palsy in preterm labour) Update 2 December 2019 Exceptions September/October September-19 1 BBA, 1 admitted with SROM, labour to delivery time of 17 minutes, 1 CI due to abruption October-19 1 class 1 for bradycardia (GA), 1 BBA, 1 CI due to placenta previa with large bleed

November 2019 13 eligible women 4 did not receive 2 imminent delivery 69% compliance National breaking news! We have 100% badgernet permissions given Despite not hitting our 85% target nationally this quarter, there is still lots to celebrate. Nationally, we are 80.6% towards our patient benefit count target. Therefore, we look like we will achieve our NHS England target by the end of the financial year. This really is something to celebrate as a network well done to all! Specific congratulations to North East North Cumbria. Despite only achieving 74.5% in Q2, you have achieved 124% of your patient benefit count target meaning you have made massive improvements against your 2017 baseline. Did not Eligible get

Month mothers MgSO4 Oct-18 18 Nov-18 21 Dec-18 12 Jan-19 11 Feb-19 14 Mar-19 15 Apr-19 22 May-19 14 Jun-19 20

Jul-19 12 Aug-19 18 Sep-19 13 Oct-19 17 Compliance* if exclude Wrong Compliance reasonable exceptions data input 2 89% 100% 2 4 81% 81% 5

1 92% 100% 3 5 55% 91% 2 4 71% 86% 0 3 80% 100% 0 1 95% 100% 0

3 79% 93% 0 6 70% 100% 1 4 67% 100% 1 2 89% 100% 1 3 77% 100% 0

3 82% 100% 1 Since October 2018 (when the project really started) we have had 207 eligible mothers (ie. Mothers that have delivered 1 or more babies below 30 weeks gestation), of these 41 did not receive MgSO4, meaning that the remaining 166 did (an average compliance over the 12 months of 80.2%). The number needed to treat to prevent 1 case of CP is 37 therefore, potentially 4.5 cases of CP have been prevented in the past 12 months. Lifetime cost of 1 case of CP is approximately 800,000 therefore potential savings of 3.6 million from just this 1 year. 35 of the 41 that didnt get it, we believe were reasonable clinical exceptions such as

the baby was born too quickly or before arrival at the hospital, or there were genuine clinical contraindications or decision not to administer. This means that in the past 12 months, only 6 women that were eligible potentially could have been given MgSO4 prior to delivery, and these 6 women all delivered before May 2019 since June 2019 we have 100% compliance if we exclude the reasonable exceptions. In addition, 97% of identified staff in all of our acute maternity units have received training in PReCePT, we have had 4 learning events for staff with opportunity for regional updates, units have made their own sustainability plans for continuing training & we have made several PReCePT films & heard from patient voices about the impact on their journey. Regional SCORE Update Tony Roberts SCORE Survey detail The SCORE Survey is made up of 86 questions, split into 15 sections Culture

Learning environment Local leadership Teamwork Safety climate Resilience Burnout climate Personal burnout Work/Life balance

Workload strain Emotional thriving Emotional recovery Engagement Growth opportunities Job certainty Intentions to leave Decision making Advancement The national picture Number of organisations and sites who took part in the SCORE Survey:

Number of staff responses to the SCORE Survey: The national picture Document: Measuring safety culture in maternal and neonatal services: using safety culture insight to support quality improvement NHSI published this document in March 2019. This document includes insights from wave 1 & 2 sites only. This is because wave 3 sites were still undertaking their SCORE survey at the time of its publication. Copy available today if you want to look at it speak to Julia Key findings from the National Report How culture is perceived varies widely in maternal and neonatal work settings and roles Leadership is key to improving culture Leaders need to understand the culture of their organisation to be effective in facilitating improvement

Culture will only improve if everyone supports the changes required When quality improvement is linked to improvements in safety culture, both the quality of care and the culture improves Antenatal staff have the most consistently positive perception of culture Neonatal unit staff perception is positive of their ability to improve but with a more negative view of leadership Midwifery managers have a more positive view of culture than midwives who are not managers Midwives who are band 6 and below have among the lowest perception of safety culture but a more positive perception of team work There are high rates of personal burnout within all staff groups 70% of midwives band 7 or above say they find it easy to speak up 65% of all respondents believe that there are communication breakdowns within the work setting Conclusions from the National Report There is significant variation in the way that staff perceive culture Improvements in culture are linked to improvements in safety, quality and the experience of care Through the process of quality improvement the quality of care improves as does the

culture within the team It is much harder to improve culture in isolation Where a units culture is positive and supportive, women, families and babies will experience the highest quality and safest care Everyone must contribute to changing culture where this is required Modelling and supporting positive behaviours and challenging poor behaviours creates a healthy, supportive and just culture in the work place The regional picture Trusts in the North East and North Cumbia region who have undertaken the SCORE Survey and received their findings:

1994 County Durham and Darlington NHS FT (July 2018) members of staff Gateshead Health NHS FT (July 2018) have completed the Newcastle Hospitals NHS FT (April 2019) survey in the North East and North North Cumbria University Hospitals NHS FT (April 2019) Cumbria region North Tees & Hartlepool NHS FT (April 2018) Northumbria Healthcare NHS FT (July 2018) South Tees NHS FT (July 2018) South Tyneside and Sunderland NHS FT - Sunderland only (April 2019) Event on 18th November to discuss the findings and next steps

The regional picture.continued High level anonymous regional overview report developed based on domains High level regional analysis of how staff groups have responded High level regional analysis based on domains, similar to regional overview report, but data represented in a different way and includes how staff groups have responded for individual Trusts Detailed regional analysis based on the 86 questions and includes how staff groups have responded for individual Trusts The regional picture key findings The regional picture key findings

The regional picture key findings Trusts No outliers Domains As can be seen from the previous 2 slides there are some positives Areas where regionally we would like to focus are: Work/Life Balance and Burnout Team work Leadership Safety Staff groups Those who scored most positively are:

Junior Dr Anaesthetic Manager Midwifery Consultant Anaesthetic Those who scored most negatively are: Administrative/Secretarial Midwife band 6 or below Sonographers Other SCORE work Discussions ongoing with the national team to see if as a region we can help with national SCORE analysis Watch this space! Wrap Up Julia Wood North East and North Cumbria

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