Shared learning database

Type and Title of Submission


NICE training improves outcomes: making the right way the easiest way


A strategy to implement NICE guidance, assess and monitor outcomes: from safe design to safe practice and beyond, through interprofessional training. D Siassakos, Clinical Lecturer (Hon) in Medical Education and Research Specialist Registrar Obstetrics; T Sibanda, Research SpR Obstetrics; C Winter, Practice Development Midwife; T Draycott, Consultant Obstetrician



Does the submission relate to the general implementation of all NICE guidance?


Does the submission relate to the implementation of a specific piece of NICE guidance?


Full title of NICE guidance:

CG55 - Intrapartum care: management and delivery of care to women in labour

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?


Description of submission


- To determine whether the introduction of multi-professional training in electronic fetal monitoring (EFM) interpretation and the use of a structured proforma in line with the NICE Guideline recommendations, were associated with a reduction in perinatal asphyxia and neonatal hypoxic-ischaemic encephalopathy (HIE) - To develop and test a cumulative sum (CUSUM) based surveillance system, using routinely collected data, that could provide serial monitoring of one of the recommended outcome measures of fetal hypoxia; low Apgar score (5 minute Apgar score <=6)


1. To reduce the number of term infants who need resuscitation at birth, as indicated by a 5-minute Apgar score of <=6, the incidence of moderate or severe HIE, a predictor of neurological damage, in term, liveborn infants 2. To detect increased rates for low Apgar scores in term infants of 50% or more above the baseline reference rate 3. To address any deterioration with root cause analysis, implement solutions for problems identified, and identify improvements once corrective action has been taken


In the 7th Confidential Enquiry into Stillbirth and Disability in Infancy >75% of cases had evidence of poor care. The most frequent criticism related to failures in the interpretation of electronic fetal monitoring (EFM). Delays in recognising the signs of suspected fetal compromise and/or acting upon them, may mean that infants require prolonged resuscitation at birth and could develop HIE, leading to an increased risk of subsequent cerebral palsy and long-term neurological impairment. Claims for cerebral palsy arising from negligent intrapartum care are the highest contributors to the annual NHS litigation bill. In view of this identified safety problem, we acknowledged the NICE guideline for Electronic Fetal Monitoring (EFM) which recommends that Trusts should ensure that all maternity staff receive annual training in EFM, and that outcome measures of fetal hypoxia, such as 5-minute Apgar scores, should be monitored. Therefore, we introduced an 'in-house' multi-professional training course for EFM interpretation and mandated annual attendance by all maternity staff. Moreover, we developed a structured proforma as a sticker (Appendix) to append in the maternity notes, to facilitate standard reporting and prompt management of EFM. We evaluated the effect by comparing results before and after the intervention and demonstrated significant improvements. We were not content with identifying a one-off improvement; the lack of systems for monitoring quality in healthcare has been repeatedly highlighted. Hence, we developed a cumulative sum (CUSUM) surveillance system that could rapidly detect periods of deteriorating standards using readily available, routinely collected, electronic patient data. Finally, we have continually updated our training material in line with further national recommendations, including a revised CTG proforma (Appendix) that conforms to the latest NICE Guideline, CG55: Intrapartum care.


1. Participation in our training course has ranged from 98% to 100%, at minimal cost (<20 per participant). Term infants born with 5-minute Apgar scores of <=6 decreased from 86.6 to 44.6 per 10,000 births (P < 0.001). Those infants with HIE decreased from 27.3 to 13.6 per 10,000 births (P = 0.032). Term antepartum and intrapartum stillbirth rates remained unchanged, at about 15 and 4 per 10,000 births, respectively 2. The improvements were sustained over time (low Apgar rate of 0.44% from 2001 to 2004), until 2005 when the CUSUM system detected periods of increased rates of low Apgar scores, at 0.67%, which was higher than the baseline reference. Overall, there were 27 cases of low Apgar scores observed during this particular year, which was 10 more than would have been expected 3. Root cause analysis identified deficiencies in CTG education which were subsequently addressed by targeted training. This corrective action was followed by a prompt improvement (rate 0.34% after intervention) to rates even lower than the baseline.

Results and evaluation

- We organised multi-professional bi-monthly case reviews to monitor compliance, continue professional development and facilitate further improvement - We published our initial evaluation results in BJOG (Draycott, 2006) and pilot monitoring outcomes in BMC Medical Research Methodology (Sibanda, 2007) - We have initiated continuous prospective monitoring of outcomes and aim to publish our results so far in one of the two journals above (Sibanda, 2008) - References: 1. Maternal and Child Health Research Consortium. CESDI 7th Annual Report-CTG Education Survey. HMSO. London, 2000:53-64. 2. National Institute for Health and Clinical Excellence. Electronic Fetal Monitoring: Evidence-based Clinical Guideline Number 8. NICE Evidence-based Clinical Guideline, 2001. 3. National Collaborating Centre for Women's and Children's Health. Intrapartum Care: care of healthy women and their babies during childbirth. NICE Clinical Guideline 55. London: NCC-WC; 2007 4. Draycott T, Sibanda T, Owen L, Akande V, Winter C, Reading S, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG: An International Journal of Obstetrics and Gynaecology 2006;113(2):177-182. 5. Sibanda T, Sibanda N. The CUSUM chart method as a tool for continuous monitoring of clinical outcomes using routinely collected data. BMC Med Res Methodol 2007;7:46. 6. Pratt S, Mann S, Salisbury M, Greenberg P, Marcus R, Stabile B, et al. Impact of CRM-based Team Training on Obstetric Outcomes and Clinicians' Patient Safety Attitudes. JQPS 2007;33(12):720-725.

Key learning points

The introduction of a multi-professional training course, with particular reference to EFM interpretation, was associated with a significant and sustained reduction in low Apgar scores (relative risk 0.51), HIE (relative risk 0.50) and moderate/severe HIE (relative risk 0.53) in term infants. Our lessons were: - Successful implementation of national guidelines requires local solutions. - Using structured proformas is an effective way of reducing disparity in clinical interpretation and improving documentation: Make the right way the easiest way. - Include multi-professional groups in developing and running courses. It is important for all those working 'on the shop floor' to be directly involved in training. This ensures training is relevant to all staff, and professional groups learn from differing experiences. - Reduce costs and improve access by providing training 'in-house'. This develops a team of 'in-house experts', provides long-term sustainability, and again provides local solutions to national problems. - Ensure changes are supported by management. - Make training fun. This encourages staff to attend. - Monitor clinical results. The improvement in neonatal outcomes after the implementation of the CTG proforma and EFM training is the best incentive to continue with training. - CUSUM charts are sensitive and may be particularly suitable for recognition of small changes from baseline, but the choice of target outcomes is important. - Regardless of which measures are chosen, and whether case-mix adjustments are made or not, the usefulness of CUSUM charts is limited if alarms are not followed by corrective action. - Root cause analysis is a risk management tool that can inform the development of such corrective actions and stimulate reflective practice for clinicians. The benefits are not only clinical. Improvement in quality indicators has led to reduced litigation and lower insurance premiums in a USA maternity unit (Pratt, 2007).

This submission won the 2008 Shared Learning Award.

View the supporting material

Contact Details

Name:Dimitrios Siassakos
Job Title:Clinical Lecturer
Organisation:North Bristol NHS Trust
Address:Southmead Hospital
Postcode:BS10 5NB
Phone:0117 9595176


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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.