evaluating the saving babies lives care bundle - impact and …€¦ · evaluating the saving...
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Evaluating the Saving Babies Lives Care Bundle -
Kate Widdows
Research Associate, University of Manchester
Impact and Outcomes in Early Adopters
National Maternity Ambition
“The ambition is to reduce the number of stillbirths, neonatal deaths, maternal deaths and brain injuries that occur during or soon after birth by 50% by 2030 and to keep on track we want to see these reduced by 20% by 2020”
Jeremy Hunt, Secretary of State
November 2015
Stillbirth rates in the UK
• 24th/49 listed HIC
• 19th/38 Europe
Lancet Stillbirth Series
19th January 2016, Lawn et al 2016
Annual rate of reduction
since 2000 only 1.4%
Variation in crude stillbirth rate by Trust and Health Board across the UK
Variation in stabilised and adjusted stillbirth rate by Trust and Health Board across the UK
Conceptual Model to Prevent Stillbirth
Heazell, Recent Advances in Obstetrics and Gynaecology, 2013
Key risk factors of relevance to the care bundle
Key findings from MBRRACE of relevance to the care bundle
Antenatal care
• In half of all antepartum, term, stillbirths there were critical gaps in care – elements of which may have made a difference to the outcome had they been managed differently
• This meant that women were managed as low risk when they were not
• Three critical areas with gaps in care
Suboptimal care in stillbirth in 2015 –MBRRACE-UK
Suboptimal care in stillbirth in 2015 –MBRRACE-UK
A significant proportion of term stillbirths are potentially avoidable by improving the
antenatal care in these critical areas
Saving Babies’ Lives – a care bundle to reduce stillbirth
Brings together four key elements of care that are recognised as evidence-based and/or practice:
1. Reducing smoking in pregnancy
2. Risk assessment and surveillance for fetal growth restriction
3. Raising awareness of reduced fetal movements
4. Effective fetal monitoring during labour
www.england.nhs.uk
Care Bundle Tracker Survey
Midlands and East:29 Responses
London:19 Responses
South:22 Responses
North:41 Responses
Who are the Early Adopters?
All of the early providers are implementing at least one element
96%100% 99%
95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Element 1 Element 2 Element 3 Element 4
Pe
rce
nt
of
Pro
vid
ers
www.england.nhs.uk 111 providers responded to the survey
Variation in elements fully implemented
48%
17%
41%
51%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Element 1 Element 2 Element 3 Element 4
Pe
rce
nt
of
Pro
vid
ers
www.england.nhs.uk
Adoption of element 2 and 3 are increasing
www.england.nhs.uk
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
1st Survey 2nd Survey 4th Survey 5th survey
Pe
rce
nt
of
Pro
vid
ers Element 1
Element 2
Element 3
Element 4
Regional variation in full implementation
www.england.nhs.uk
58%
37%
43%
78%
33%
42%
29%
44%
6%
16%
21%
11%
38%
21%
48%
56%
0% 20% 40% 60% 80% 100%
South
London
Midlands & East
North
Percent of Providers
Element 1
Element 2
Element 3
Element 4
Greater Manchester and East Cheshire
www.england.nhs.uk
Number of Responses = 8
Providers carrying out
improvement activities
National Benchmark
Providers at 100%
National Benchmark
Element 1: Smoking in pregnancy 100% 96% 50% 48%
Element 2: Detecting FGR 100% 100% 25% 17%
Element 3: Reduced fetal movement 100% 99% 50% 41%
Element 4: CTG monitoring 100% 95% 13% 51%
All elements 100% 92% 0% 3%
SPiRE: Saving Babies Lives Project Impact and Results Evaluation
• Commissioned by NHSE in May 2016
• Conducted by The University of Manchester
• Phase I: May-Jan 2017
• Phase II: Jan-Nov 2017
• Charity and professional bodies involvement
Northern England
• Gateshead Health NHS Trust• North Cumbria NHS Trust
Yorkshire & Humber• Barnsley Hospital NHS Trust• Doncaster Hospitals NHS Trust• York Teaching Hospital NHS Trust• The Mid Yorkshire Hospitals NHS Trust• Hull and East Yorkshire Hospital NHS Trust
• Taunton and Somerset NHS Trust• Royal Devon & Exeter NHS Trust• Plymouth Hospital NHS Trust• Royal United Hospitals Bath NHS Trust• North Bristol NHS Trust
East Midlands• Sherwood Forest Hospitals
NHS Trust
South West
West Midlands
• Birmingham NHS Trust
North West Coast• Liverpool Women’s NHS Trust• St Helens and Knowsley NHS Trust• Countess of Chester Hospital NHS Trust• University Hospitals of Morecambe Bay
NHS Trust
Greater Manchester and East Cheshire
• Central Manchester Foundation NHS Trust
NHS Trusts involved in the evaluation
Thames Valley• Oxford University Hospitals
NHS Trust
Outcomes
Leadership & governance
Health Economic analysis
Resources & training
Patient & staff views
Key themes of the evaluation
Element 1. Reducing smoking in pregnancy
Intervention
1. Carbon Monoxide (CO) testing of all pregnant women at antenatal booking appointment
2. Referral to a stop smoking service/specialist, based on an opt out system
National figures Element 1
95% 96% 97% 96%
40%
49%44%
48%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st Survey 2nd Survey 4th Survey 5th Survey
Pe
rce
nt
of
Pro
vid
ers Carrying out
improvement activities
Carrying outelement at100%
www.england.nhs.uk
Intervention
1. Use of the algorithm and risk assessment tool
2. Estimated fetal weight (derived from serial ultrasound) on growth chart (high-risk)
3. Symphysis fundal height plotted on growth chart (low-risk)
4. Ongoing audit of Small for Gestational Age (SGA) babies
5. Ongoing audit of missed SGA babies
Evaluating Element 2. Fetal growth
National figures for Element 2
81%
92%96%
100%
8% 9%
21%17%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st Survey 2nd Survey 4th Survey 5th Survey
Pe
rce
nt
of
Pro
vid
ers
Carrying outimprovement activities
Carrying outelement at100%
More Trusts are using GAP
GAP, Perinatal Institute
www.perinatal.org.uk
SGA detection has increased
SaBiNE, June 2015-Sep 2016 – pilot of the ‘Fetal Growth’ element
www.perinatal.org.uk
Reductions in Stillbirths following GAP
Evaluating Element 3. Reduced Fetal Movements (RFM)
Intervention
1. Information and advice leaflet on RFM to be provided to all pregnant women by the 24th week of pregnancy and RFM discussed at every subsequent contact.
2. Use provided checklist to manage care of pregnant women who report reduced fetal movement, in line with RCOG Green-top Guideline 57.
National Figures for Element 3
73%
89%93%
99%
22% 19%24%
41%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1st Survey 2nd Survey 4th Survey 5th Survey
Pe
rce
nt
of
Pro
vid
ers Carrying out
improvement activities
Carrying outelement at100%
• 87% of providers are giving the leaflet to all women• 50% of providers are using the checklist to manage women with RFM
www.england.nhs.uk
Evaluating Element 4. Effective fetal monitoring during labour
Intervention
1. All staff who care for women in labour are required to undertake an annual training and competency assessment on cardiotocograph (CTG) interpretation and use of auscultation.
2. Buddy system in place for review of CTG interpretation, with aprotocol for escalation if concerns are raised. All staff to betrained in the review system and escalation protocol.
National Figures for Element 4
96% 97% 98% 95%
55%49%
43%51%
0%
20%
40%
60%
80%
100%
1st Survey 2nd Survey 4th Survey 5th Survey
Pe
rce
nt
of
Pro
vid
ers Carrying out
improvement activities
Carrying outelement at100%
• Clinical guidelines vary greatly in quality between Trusts
• How do the guidelines align with current implementation?
• AGREE II Tool to assess quality in six domains
1. Scope and purpose
2. Stakeholder involvement
3. Rigour of Development
4. Clarity of presentation
5. Applicability
6. Editorial Independence
Antenatal care guideline appraisal
Jokhan S, Whitworth MK, Jones F, Saunders A, Heazell AE. Evaluation of the quality of guidelines for the management of reduced fetal movements in UK maternity units. BMC pregnancy and childbirth 2015;15:54.
Leadership, Governance, Resources & training
• What are the key drivers of cost for implementation
• What is the cost of each stillbirth potentially avoided as a results of the care bundle
• Unit Level Resource questionnaire (Clinical director, HoM)
• ONS data will be used to capture nationwide costs
How did you feel about
being offered a carbon
monoxide breath test?
Were you given this Reduced
Fetal Movements leaflet
(produced by Tommy’s/NHS
England) about your baby’s
movements?
What made you decide to
monitor your baby’s
movements during this
pregnancy?
Which ONE way would you
prefer to be given
information about baby’s
movements?
Questionnaire for Mothers
Do you feel
competent in CTG
interpretation?
Does your work area have
enough CO monitors to
ensure all women are
offered the breath test?
How regularly do
you refer to clinical
guidelines to inform
your practice?
How do you perceive
the demand on the
ultrasound scanning
at your hospital?
How do you feel
about a buddying
system for the
review of CTG
interpretation?
Questionnaire for Healthcare professionals
Key Outputs and Next Steps
• Best-practice pathway, based on evidence
• Identifying facilitators for implementation
• Set standards for clinical guidelines
• Encourage Trusts to collecting quality data
• Encourage Trusts to measure and report progress
