•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• • • • HSIB HEALTHCARE SAFETY INVESTIGATION BRANCH Maternity Newsletter January 2023 Introduction from the senior team We are pleased to share this newsletter. This will be our last newsletter that comes to you from the Healthcare Safety Investigation Branch (HSIB), because from April 2023 the HSIB maternity programme will transform into the Maternity and Newborn Safety Investigations (MNSI) Special Health Authority. Your support has been fantastic. So many Trusts across England have shared their innovations and learning with us in response to the safety recommendations we make. The opportunities you have given us to share your learning, and demonstrate the continued work to improve maternity care, come at an important time. As you know the maternity system has received the publication of the East Kent report ‘Reading the signals’ which was led by Dr Bill Kirkup and the ongoing attention shows the pressures on the whole of the healthcare system. With this level of scrutiny indicating challenging stafng levels and low morale, the continued energy and passion to improve care is admirable. As we enter the New Year, we would like to thank the trusts and staf we work with who support us to continue our work and respond to the safety recommendations we make to improve care. Click here for contents page 1
• • • Contents Introduction from the senior team 1 Guidance for staf on escalation in the Midwife Led Unit 3 Increased Maternal Age Pathway 5 Recognising diabetic ketoacidosis 6 Improving the management and outcomes of post-partum haemorrhage (PPH) 7 Support for staf following a patient safety incident 9 Bereavement support after maternal death 10 Placenta retention and storage 11 Improving thromboprophylaxis at discharge 14
Click here 3 for contents page •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• • • • HSIB HEALTHCARE SAFETY INVESTIGATION BRANCH Maternity Newsletter Guidance for staf on escalation in the Midwife Led Unit An HSIB investigation learned that two clinicians were sharing the care of the mother during the latent phase of labour due to the workload on the midwifery led unit (MLU). Both were unable to spend any length of time with the mother to assess whether she was transitioning to the active frst stage of labour. So that we could make improvements, we reviewed the diferent categories of clinical care being provided on the MLU to ensure the stafng requirements were suitable to cover all aspects of the care being provided. After our review we designed a fow chart to be used when MLU is busy to escalate safety concerns and ensure that senior managers are aware that, due to activity, safety may be comprised. We launched the fow chart in September 2022 and all staf are now aware of who to contact at times when the MLU is busy, and care cannot be safely provided. We raised, via safety briefng for all MLU staf, the beneft of using concise and clear language when escalating concerns either with a patient or overall activity. We did not need to use the fow chart in the few weeks after it was launched but we have noticed (for example in a case discussion which involved a transfer from the MLU to Delivery Suite) the use of words/ language to make it very clear that a woman required transfer. For further information please contact: Lyndsay Durkin, MLU Manager [email protected] The Royal Wolverhampton NHS Trust
Click here for contents page r ( ) l ( ) l ( J l - r .... I 1 ... j - l r .... I I...__ .J - l - r ..... I 1 ... J - nHn ..4 I "'--- - • • • Escalation Process MLU at times of high activity The stafng model for MLU is 2 x midwives and 1 x maternity support worker – this is as agreed and recommended by Birthrate+ At times when the activity is high and potentially unsafe you must escalate When a woman in labour cannot have the required support and monitoring it is vital the Band 7 is aware. Inform the Band 7 Co-ordinator in frst instance Contact MLU staf via social media and groups and ask if anyone can support the unit Seek support from other areas; FAU, Maternity ward, request any support from including Specialist Midwives Add additional entry on Birthrate+ acuity tool which refects activity and any red fags Complete a Datix Document in maternity care records and apologise to the families on MLU Consider if Postnatal women could transfer to D10 Would any women not in established labour like to return home Consider if any women in labour should transfer to DS Discuss with Band 7 • Community midwives being requested • Informing matron (In hours) • Inform manager on call (out of hours) The Royal Wolverhampton NHS Trust 4
Click here 5 for contents page • • • Increased Maternal Age Pathway There was no clear pathway for increased maternal age that included discussions about the timing and mode of birth. - Maternal age was added to the IOL guideline as a risk factor. A care plan was added to the Maternity Information System (BadgerNet) for age greater than or equal to 40 at booking. This helped us to have a more streamlined approach to managing women with increased maternal age with clear guidance for staf and women. For further information please contact: Karen Grubb [email protected] Epsom & St. Helier University Hospitals NHS Trust
Click here 6 for contents page mm King's College Hospililll _S,_....,.lt\oM Know the symptoms of Diabetic ketoacidosis (DKA) DKA Is a medical emergency with threat to life • Be aware of, recognise and treat DKA in a timely manner with IV insulin and saline (see Guidelines) DKA happens when the body cannot produce enough insulin and is more common with T1DM Blood Glucose >11 (in around 50% cases can be normal) Serum Bicarbonate <15 mmol/I Stomach pain and vomiting Blood ketones 3 mmol/1 or above If someone arrives by ambulance to the unit, Inform the obstetric team Immediately for review, holistic MDT assessment and a plan of care Check blood glucose (BG) and urinalysis on arrival with hospital meter (check blood ketones if T1DM) Needing to pee a lot (polyuria) Venous Blood Gas pH <7.3 Very thirsty (polyd1spIa) Blurred vision Passing out Distressed or confused Relevant gu,delones to review include the King's Diabetes ,n Pregnancy. NICE Diabetes ,n Pregnancy [NG3] and RCOG Pll • • • Recognising diabetic ketoacidosis This poster was produced to support staf in the rapid recognition of Diabetic Ketoacidosis (DKA) as an emergency that requires urgent medical attention. For further information please contact: Clare Cliford-Turner [email protected] King’s College Hospital NHS Foundation Trust
Click here 7 for contents page • • • Improving the management and outcomes of post-partum haemorrhage (PPH) HSIB investigation highlighted that the Trust should focus on ensuring that; • the massive obstetric haemorrhage process is based on principles that support staf to deliver the required care in a timely manner, with the process refected in staf training • escalation for an obstetric review occurs to ensure a holistic assessment is undertaken with a documented plan of care Our goal was to improve outcomes for service users, and to take a multidisciplinary team (MDT) approach to audit, education, and risk reviews. An obstetric consultant commenced a quality improvement (QI) project for ‘PPH prevention management’. Updates of the ongoing project are shared with staf. The actions we have taken include: 1. Undertaking a staf survey to assess the general understanding of the code red process and content of blood product ‘packs’ 2. Education for maternity staf on the back to basics, and the fundamentals of care for labour management in the 1st stage, 2nd stage and 3rd stage of labour 3. Circulating key messages to maternity staf about back to basics 4. A video demonstration of the code red process 5. Starting the process of implementing quarterly multidisciplinary simulation/drills training which incorporates learning from the fndings of the staf survey around PPH process 6. Undertaking audit e.g., an audit of compliance of escalation of blood-stained liquor to obstetricians 7. Making changes to guidelines Gloucestershire Hospitals NHS Foundation Trust
Click here 8 for contents page ............................................................... (: . JJ • • ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• • • • Trust PPH guideline changes: Recommendation for blood-stained liquor to prompt obstetric review and consideration of PPH bundle, if not already, as well as a BMI of <18 to be added to the criteria for PPH bundle. Staf should use ultrasound to guide the insertion of a uterine tamponade balloon. As a result of the survey, the PPH policy has also been updated to include a requirement to request ‘pack A’ once a code red has been called. We also designed a printed ‘code red’ board to include the patient weight and the estimated circulating blood volume in the management of a PPH, to avoid concentrating on the volume alone. A monthly MDT PPH risk meeting was started. All midwives and senior midwifery team, obstetricians, anaesthetists, blood transfusion staf and the patient safety team are invited to attend. Any learning identifed is communicated to the multidisciplinary teams. Data collection has shown signifcant improvement in PPH rates as a result of the PPH QI project. In the frst 6 months of 2022, the trust PPH rate >1500mls was below 4%. This remains an ongoing project, with a continuing MDT approach to the fundamentals of PPH prevention and management. For further information please contact: Ellie Coombs/ Lisa Baldwin [email protected] [email protected] Gloucestershire Hospitals NHS Foundation Trust
Click here 9 for contents page • • • Support for staf following a patient safety incident We reviewed HSIB’s national learning report ‘Support for staf following patient safety incidents’ and identifed that as a service we did not have specifc resources or any formal process of support for our staf or managers. There was no evidence when we had ofered staf support or directed them to resources. Our aim was to give managers the guidance and tools to understand the impact of the 2nd victim and to ensure that staf are given the vital support and care to undertake their roles safely, reduce sickness and stress. Our solution was to design the programme of support that we wanted to ofer and to document this in a guideline to support managers and leaders. This is so that they can support staf involved in and following patient safety incidents. The guideline includes templates we developed to guide managers and staf, to help to provide the emotional assistance required, and to signpost to other support mechanisms available within the Trust. The completed templates also provide evidence of discussions and support that has been ofered; enabling a more formal and structured process. As this is a new way of working with new documentation, we will be monitoring over the coming months, with staf, managers, and any HSIB feedback to fnd out if staf perceive they are having the support they require. For further information please contact: Caroline Cowman Deputy Head of Midwifery. [email protected] East Lancashire Hospitals NHS Trust
Click here for contents page 10 $ • • • II 1@ Bereavement support after maternal death Following a maternal death, we received feedback from the bereaved father that there was no specifc support for partners in this situation. This made us want to fnd some useful signposting that we could share with our bereavement team, the risk and governance team and the wider Local Maternity and Neonatal System (LMNS). We asked the LMNS for support, searched nationally available websites and liaised with HSIB to see what resources were available. We also spoke with some charitable organisations to see what they were able to ofer or if they had encountered similar situations previously. We were then able to design a leafet to be made available to the Trust. We also started to get it approved through our governance process so that it can be shared with the LMNS. We have demonstrated that we have listened and identifed a gap in our service. We have taken active steps to address this gap and now can provide a more holistic service to bereaved partners. We will share our learning more widely with the LMNS. For further information please contact: Marie Watkyns [email protected] Hampshire Hospitals NHS Foundation Trust
$ Click here for contents page 11 • • • II )]jJ Placenta retention and storage A theme coming through from our investigations was an inconsistency in following the guideline for placental histology for babies born in poor condition. Further to this our histology guideline did not capture the cohort of babies who were born in good condition but experienced ‘sudden unexpected postnatal collapse’, where the placenta may have already been frozen or disposed of after 24 hours. The quality improvement we were seeking was • For staf to follow the guideline for placental histology, i.e., 100% of placentas that ft the criteria to be sent for histology • Extended placental storage to facilitate keeping placentas for longer without freezing them and before disposal. Working collaboratively with our histopathology colleagues, a multidisciplinary team of midwives and obstetricians developed a new standard operating procedure (SOP): ‘Placenta retention and identifcation of placentas that need to be sent for histopathological examination’. This works in line with our ‘Placenta examination after birth - practice guideline’ that was also updated to refect the new processes. ALL placentas will now be retained for 48 hours. We also: • Purchased upgraded clinical fridges for storage of placenta • Put a wireless monitoring and alert system in place to ensure fridge temperature is maintained • Bought in anatomical waste bags for storage of placenta which can be clearly labelled • Purchased recycling bins for transporting placentas in community Royal Berkshire NHS Foundation Trust
~T 0 0 0 Aug 2022_ Please reod SOP fOt' ful"ther infotn"IOtion. Does THE PLACENTA NEED TO GO TO HISTOLOGY? • ADMISSION TO NEONATAL UNIT FROM BIRTH • PREMATURITY 32+0-36+& WEEKS • FETAL DISTRESS • ADMISSION TO NEONATAL UNIT WITHIN FIRST 48 HOURS OF LIFE • MATERNAL TEMP> 38 • UNDER THE 10"' CENTILE/IUGR • BABY LOSS - NEONATAL DEATH, STIUISIRTH. LATE MISCARRIAGE • MULTIPLE PREGNANCY • PLACENTA ABRUPTION • TWO VES.SELS • PLACENTAL ABNORMAUTY - SHAPE • ADHERANT PLACENTA • FETAL ABNORMALITY • FETAL HYDROPS • MATERIAL GESTATIONAL DIABETES • MATERNAL GROUP B STREP •PRE-ECLAMPSIA/ MATERNAL HYPERTENSION • MATERNAL COAGULOPAT'HY • RUPTURE OF MEMBRANES > 36 HOURS • • • Infographics have been produced to raise awareness with staf of updated policy and new SOP: Royal Berkshire NHS Foundation Trust Click here for contents page 12
Click here 13 for contents page • • • Dissemination and communication of the new pathways to staf is continuous through safety huddles; closed Facebook groups; handovers; team meetings etc. We recognise the inconsistency of sending placentas can be down to many things at the time. We have therefore also engaged our neonatal colleagues to support us in emergency situations to ensure the placentas are sent. The new processes were due to go live week commencing 26th September 2022. This was delayed due to a problem with the installation of the fridges. Once started we intend to undertake audits on the placental histology pathway to ensure those placentas that meet the criteria are sent. We anticipate that the benefts will be: • Those placentas that meet the criteria are sent • Improved information for women and their families who have babies where placental histology is available. This will be challenging to measure objectively but we know that availability of placental histology can add to reviews such as perinatal mortality review tool (PMRT) For further information please contact: Sharon Andrews [email protected] Royal Berkshire NHS Foundation Trust
Click here 14 for contents page • • • Improving thromboprophylaxis at discharge HSIB investigation highlighted that there should be a review of the venous thromboembolism (VTE) risk score as well as the VTE risk level, to ensure that the correct duration of postnatal thromboprophylaxis is prescribed. At the time of the investigation, when mothers were discharged requiring a full course of post-natal thromboprophylaxis and the full course was not available, they were given clear instructions of the need to collect to take out (TTO) medication the next day. Our goal was to ensure all women who require thromboprophylaxis receive the correct medication at discharge or are aware of the need to collect this the next day. We developed a new individualised form specifc to maternity for TTO prescriptions based on risk factors to determine dosage, and duration. We now have prepacked medication (prepack) in use on the ward to ensure women are given TTOs at the point of discharge. This means that all women requiring TTO Enoxaparin are given a prepack supply at the point of discharge as it is a stock item on the ward and doesn’t involve waiting delivery from pharmacy. For those women requiring a supply of six weeks the woman is encouraged to remain an inpatient until the TTOs are received on the ward. On the rare occasion that the woman is transferred home before her 6-week TTO supply is available a record is kept in a book and the ward coordinator will make contact the next day to remind her that her TTOs require collection. Pharmacy have been asked to provide audit data as an assurance that all TTOs have been collected. For further information please contact: Tracy Muir, Ward D10 Manager [email protected] The Royal Wolverhampton NHS Trust
Click here 15 for contents page WWW.HSIB.ORG.UK @hsib_org 01.23.V1