Women’s health team of the year
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h2030 (Published 30 April 2015) Cite this as: BMJ 2015;350:h2030- Nigel Hawkes, freelance journalist, London, UK
Improving induction of labour
Induction
of labour is increasingly common, says Sabrina O’Dwyer, a specialty
registrar at Barts Health NHS Trust, but is “infamous” for being poorly
managed, to the irritation of women and at the risk of increasing the
caesarean section rate. “We have an ageing maternal population, more
medical problems, more fertility treatments, more diabetes in pregnancy,
and all lead to a higher induction of labour rate,” she says. “But it
is elective work, it doesn’t take priority, and it can be neglected a
bit. It features a lot in complaint letters.”
A study
launched at Whipps Cross Hospital in north London, part of the Barts
trust, found inconsistent and outdated guidelines, poor patient
information, a lack of coordination, and no feedback to staff.
“Caesarean rates were high—we were an outlier,” she says.
One
big change was to implement outpatient induction of labour in low risk
women, using Propess, a single administration prostaglandin that works
over 24 hours. Strong conditions were enforced, such as insisting that
women had access to a phone, good English, and the competence to remove
the pessary as instructed. An induction of labour suite with a dedicated
midwife was also introduced, and the programme involved effective and
continued engagement of all the staff involved.
The
results show a reduction in active labour from the time of admission,
and a fall in the caesarean section rate from 30% to 20%, as well as
improved patient satisfaction scores. “There was a big culture change,”
O’Dwyer says. “We have to prioritise women’s expectations and outcomes.
The idea that they could wait for ever needed to change. The challenge
now is to sustain the improvements.”
Training for cultural change
Cultural
change through human factors training was the key to reducing
postpartum haemorrhage at Peterborough City Hospital. “In 2012 in our
hospital it was very high,” says Manjula Samyraju, consultant and
intrapartum care lead at the trust. “We tried very hard in 2013 to
reduce it and had some success in reducing cases of massive blood loss
(more than two litres) but had little effect on less severe blood loss
which ought to have been avoidable.”
With the support of
Maggie Boyall, practice development midwife at the trust, and others,
she decided that training in the human factors that often underlie poor
performance might help. A survey in September 2013 showed a defensive
culture in the maternity staff, with more than half of responders saying
they would not raise their concerns for fear of ruffling other people’s
feathers.
With the aid of the University of
Hertfordshire and support from the trust board, mandatory training days
were used for human factors training. “It’s non-clinical,” she explains.
“It’s about why do we make mistakes, how can we help each other and
manage risks better. It’s not about systems but about how individuals
can change them. At the end of the day it’s about how we come to work.”
Achieving
change was difficult, but worthwhile. Blood transfusions in the
postnatal ward were cut by 30%. Postpartum haemorrhage was no longer the
top risk. A new staff survey showed that 85% now felt able to express
their views and concerns. “Oher departments are showing an interest and
may take up the same training themselves,” Samyraju says.
Essential obstetric training
In
low and middle income countries with weak healthcare systems, services
in obstetrics and care of the newborn struggle. This is the problem
addressed by the “Making it Happen” programme from the Liverpool School
of Tropical Medicine, which mobilises 300 UK based volunteers to deliver
short courses of training in 11 countries across sub-Saharan Africa and
South Asia, funded by the UK Department for International Development
(DFID).
“We go out initially to start training and build
up capacity, and then we play a quality assurance role,” says Charles
Ameh, deputy head of the Centre for Maternal and Newborn Health at the
school. “Most of our volunteers work full time in the NHS and take
unpaid leave to carry out the training, so we make sure they are away
for a maximum of two weeks at a time.” Sustaining the improvements
achieved is very important so the team has set up and furnished more
than 200 skills rooms in countries where they have been active to scale
up training packages to regional and national levels. Outcomes show a
mean reduction in maternal deaths of 50% and a 15% reduction in
stillbirths.
“We’ve trained over 12 000 healthcare
workers so far in phase 2 of the project and our target is 17 000,” Ameh
says. “Clearly there’s a high need for this kind of training. Even
within the countries we already work in there’s room to expand—in Kenya,
for example, we’ve only worked in three out of eight provinces and will
be expanding, and other countries such as Ethiopia, Namibia, Sudan, and
Uganda have also asked us to come.” That will depend on the
availability of additional funding from DFID.
Diabetes preconception website
“Women
with diabetes need to plan for pregnancy, but it’s not happening,” says
Valerie Holmes, senior lecturer at Queen’s University Belfast. “If they
have poor glycaemic control, they risk congenital malformations and
miscarriage, so it’s important to plan.” Changes such as the increasing
prevalence of type 2 diabetes at younger ages, and the movement of care
from secondary to primary care mean that the conversations aren’t
happening, and awareness of the risks is low.
She
applied for a grant from Diabetes UK to develop a DVD, which was
distributed to almost 5000 women with diabetes in Northern Ireland, and
subsequently converted into a website with the backing of Public Health
Agency Northern Ireland. Entitled “Women with Diabetes,” the subtitle on
the opening page is “Things you need to know, but maybe don’t.”
Results
showed that women were significantly more likely to have had their
blood glucose recorded in the six months before conception and to have
planned to take folic acid supplements. The team has also targeted
health professionals. Holmes says the responses from both groups have
been strongly positive, stressing that the DVD filled an educational
void.
To get the message out wider the team has focused
on social media such as Twitter, a good tool for reaching this
particular group. “Doctors find it hard to have the right conversations
with women at the right time because they need to mention it before they
are pregnant or maybe even planning a pregnancy. So we try to get
information packs to GP surgeries and to pharmacies where women will see
them.”
Day case breast cancer surgery
How
long do breast cancer patients need to stay in hospital after surgery?
At Wrightington Wigan and Leigh NHS Foundation Trust in 2010 it was
between two and three days. But consultant breast and oncoplastic
surgeon Amar Deshpande believed that for straightforward cases without
reconstruction length of stay could be greatly reduced.
“It
is not medically necessary to stay for two to three nights but the
culture had grown up that people have to stay in,” he says. “Once we got
everyone together to discuss it, it wasn’t difficult to persuade them
that it would be beneficial to reduce it. Initially we were looking to
send them home the next day, and then we moved to the same day. Patients
weren’t hard to persuade once we had been able to reassure them that
they would get good support from community nurses and that if they
needed it help would be at hand or only a phone call away.”
Enlisting
the support and enthusiasm of community nurses was the key. “When they
realised how important it was, they got involved. In addition, because
we hold clinics every week day, if patients do need to be looked at they
can be brought to the hospital.”
Now breast cancer
surgery is done as a day case procedure for 85% of patients, and length
of stay has fallen from an average of 2.7 days to 0.8 days in 2012 and
0.6 in 2014. “We found no evidence of harm. Patients have heard of it by
word of mouth and now expect to be home the same day—and it reduces
their risk of deep vein thrombosis and hospital acquired infection.” As
well as saving the NHS money through reduced bed days, the trust earns
more through the best practice tariff designed to encourage day case
surgery.
Notes
Cite this as: BMJ 2015;350:h2030
Footnotes
- The BMJ Awards are sponsored by MDDUS. The awards ceremony takes place on 6 May at the Park Plaza, Westminster Bridge, London. To find out more go to http://thebmjawards.bmj.com.
