Advanced Specialist Audit and Research Midwife GROW Lead Midwife - PowerPoint PPT Presentation

Donna Southam Advanced Specialist Audit and Research Midwife GROW Lead Midwife Basildon and Thurrock Hospital

Fetal growth restriction is associated with stillbirth, neonatal death and perinatal morbidity. Confidential Enquiries have demonstrated that most stillbirths due to fetal growth restriction are associated with suboptimal care and are potentially avoidable The charts are used to plot both fundal height measurements obtained during clinical examination and estimated fetal weight following an ultrasound examination. They are customised to each individual taking into account the height, weight, and ethnicity of the woman.

‘ ’Change is hard at first, messy in the middle and gorgeous at the end’’ Robin Sharma ‘ ’Education is the most powerful weapon which you can use to change the world’’ Nelson Mandela

Practise Development GROW Lead Midwife Midwife GROW Lead Consultant Head of Midwifery/ The Midwifery GROWTEAM Managers Lead Ultrasonographer IT/ Information Governance Consultant Neonatologist

Retrospective Audit was undertaken at BTUH 2011 5 years stillbirth >50% may have been preventable if a GROW chart was used Retrospective Baseline Audit of 554 cases Live births and Stillbirths. Input dates: April 2014 SGA (birth weight below 10th customised centile) 17% prior to implementing GROW SGA is now 35-40% 2016 on par with GAP Do you monitor yours? Where do you present your data?

GAP User average Retrospective Audit 2014 demonstrated 33% referral rate 2016

2016

Challenges and Opportunities Initially increase in more fetal abnormalities being detected from serial scans Increase in detection in breech in 3 rd trimester leading to increase in hip scans Babies born under the 10 th centile on the GROW chart having BMs Risk Assessing Antenatally Risk Assessing Intrapartum Increase in IOL (Big babies) Increase in Ultrasound scans Beta Blockers being taken for another reason not hypertension All smokers – Saving Babies Lives NHS England

Increase in incidents in undetected IUGR Neighbouring Trusts pulling the GROW program

3 rd trimester scanning- Professor Jason Gardosi There is little evidence that a routine scan improves detection of SGA. We have recently looked at the sensitivity at 34-36 weeks in detecting SGA at birth and found it to range between 19 and 36 %. This is illustrated in the attached abstract (accepted for BMFMS 2016). We looked at the LAST scan done, regardless of indication. The performance was poor despite the relatively high rate of SGA in this population (high because they represented mothers who had one or more indication for a growth scan, since it was not offered routinely). We think this poor sensitivity is due to: 1. One-off scans being a spot check only, and cannot provide info on the trajectory of growth; 2. Most FGR is late onset, so may not have been manifest at the time of the scan. Most SGA in fact occurs at term. The SGA detection rate is probably even lower in the general, unselected population. And as concerns outcome, the Cochrane Review states unequivocally that ‘There is no evidence that routine ultrasound in late pregnancy improves perinatal outcome’. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001451.pub4/full The President of the RCOG stated in 2016 the RCOG does not support a third trimester scan to be used for the detection of SGA

Quality Improvement projects/ Audits A continuous audit (incidents) of babies born under the 10th centile highlighted many cases where not managed following the guideline. Therefore weekly teaching sessions on learning lessons and a proforma was developed as a safety net to identify early on the in the pregnancy if the woman was low or high risk. To date the monthly review of all incidents of babies born under the 10 th centile demonstrates the GROW programme was followed 90-100% Regular Audits to review the use of GROW Charts. QI – Inappropriate scans started 2015. Through education we reduced inappropriate scans. There is no point monitoring unless you plan to ACT!

GAP has been taken up by 120 NHS Trusts to date, and has led to the recent drop in stillbirth rates in England to lowest ever levels, representing 500 fewer deaths each year. Queens Enterprise Award for Innovation

BTUH Stillbirth rate has gone from 4.2 per 1000 in 2014/15 to 3.4 per 1000 in 2015/ 2016. 5 4 3 2 1 0 2014/15 2015/16

In October 2016 Mr Ikomi and Donna Southam won the Health Education England Awards for the Innovation in Patient in Patient Care for the Growth Assessment Protocol.

Gestational Diabetes Gestational diabetes mellitus affects around 12% of women in the UK. A woman can develop GDM for various reasons, including obesity, ethnicity and advanced maternal age. NICE guidelines (2015), women with a positive oral glucose tolerance test (OGTT) result should be seen within a week, which is a challenge. Last year, over 400 women were recorded on our diabetes database, outstripping clinic capacity.

A Solution We had identified issues in this area, and in 2014, we began the general ownership of diabetes (GooD) care pathway. This shared-care framework features a service hub of midwife-led diabetes telephone clinics (teleclinics), enabling safe transfer of certain aspects of care to standard antenatal clinics. The teleclinics are scheduled phone calls to patients, so we can discuss all aspects of their condition, avoiding the need for them to physically attend. We run three or four scheduled sessions a week and feedback has been positive. One woman said: ‘Before the teleclinics, I was there so often I said I might as well move in... It really helped, especially as I had to do the school run.’ We then launched educating gestational diabetic group sessions (EGGS), held weekly and for up to 10 women. Each session runs from 9am to 11am. We explain GDM, the dietician gives a detailed talk on healthy eating, and an interactive session looks at food labelling and low GI foods.

Women learn how to monitor blood glucose, then leave with a monitor, a diary to record readings, and leaflets. Feedback has been positive. One woman said: ‘This group has helped me so much, I was fearful and unsure of what to eat, also what it would be like having to test my blood sugars. Yet in this relaxed environment, I felt confident to ask questions, am less fearful and like the group support. In summary, we have improved operational efficiency and sustainability through partnership, as shown by 60% fewer overbooked specialist clinics since 2013, no diabetes-related perinatal deaths since November 2014 and a 40% reduction in macrasomic babies. User satisfaction has improved and staff confidence has grown, despite a further increase in our caseload of 17%.

Live birth rate for GDM 102 100 100 98 97.3 96 94 92.6 92 90 88 2014 2015 2016

Newly Diagnosed Diabetics seen within 7 days - NICE Additional clinics added Issues with Pathology first in delays Pathology by diabetic team Commencement of EGGS on March 2016 in reporting abnormal GTT results. moved to off Meeting with Consultant Biochemist site facility. 2nd November to resolve delays Change in reporting GTT results

Following the implementation of the Midwife tele-clinics as a solution to over booked specialised clinics a cost analysis was undertaken to review the cost of running another clinic to delay with capacity would cost £54165.6. The tele- clinic costs 3108 per year.