Shared learning database

Hampshire Hospitals NHS Foundation Trust (HHFT) and South Central Ambulance Service (SCAS)
Published date:
October 2014

Together the two organisations above have worked to develop a highly evaluated service; a maternity 24 hour labour triage line based for the first time nationally in an ambulance control centre. The development of this innovative service has led to a highly collaborative and mutually beneficial partnership demonstrating improvements in the quality and safety of maternity care and specifically:
- Improved support to women and their partners in early labour
- Improved satisfaction for mothers accessing the maternity service.

This example is in line with the NICE guideline CG190 intrapartum care, in particular recommendation 1.3.4, "Consider an early assessment of labour by telephone triage provided by a dedicated triage midwife for all women".

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

In January 2013 a review of the services for women in early labour at Hampshire Hospitals Foundation Trust was undertaken by a Trainee Consultant Midwife. The aim was to review the service, to assess consistency in advising and supporting women in early labour, to benchmark the service against national evidence and explore the need for a telephone triage line for women. The findings of the review were incredibly positive and concluded that the focus for key areas of improvement should be underpinned by 4 main themes;
- consistency in information giving with regard to birthplace choice and service provision;
- education of staff around decision making, clinical judgements and the latent phase of labour;
- education of women with regard to birthplace choice and the latent phase of labour
- communication with a particular focus on listening to the woman?s story.

This review highlighted that it would be appropriate to pilot the 6 month telephone triage service for early labour alongside further system wide changes including the development of a latent phase guideline based on the best available evidence, creating clear pathways and birthplace choice for women throughout the pregnancy and labour journey.

The service is based in the Emergency Operations Centre at South Central Ambulance Service (SCAS). The location of the service was chosen as a test site for the pilot, as it was a neutral, non-clinical environment which enabled access to information and telephone technology and gave immediate access to an ambulance in an emergency. Furthermore it facilitated the opportunity to explore the clinical support role of a midwife within the ambulance service, to share expertise and build infrastructure between the two partner organisations and to consider whether this model would be suitable for other clinical functions.

Reasons for implementing your project

The drivers for the service review were to align unscheduled care services across the Trust, promote normal birth by reducing unnecessary admissions to labour ward, a service wide commitment to increasing births at home and in the birth centre in support of the Trust philosophy of ensuring that services are to be local where possible and central where necessary.

The aforementioned review was also in response to a theme of complaints received by the trust in 2012, where 62% of the 48 complaints were with reference to ?poor staff attitude? towards women in triage settings.

The service review assessed the satisfaction level of women locally who were receiving advice and support in early labour from midwifery staff and a range of contact points across the service. The project sought to improve women?s experience, increase their confidence to manage the latent phase, reduce women on the acute sites not in established labour and increase access to community births by offering coordinated face to face assessments.

The team of 5.3 wte midwives working in the pilot service are experienced and are representative of midwives from across the service both from community and hospital sites. All have maintained a clinical role as well as working within the telephone triage service. Each were selected through a rigorous process and subsequently undertook an education and training programme underpinned by the themes and the key areas for service improvement identified in the review.

How did you implement the project

At each point of contact with the 24hour Labour Line service woman and partners have the opportunity to talk to an experienced midwife who will offer the same consistent approach to advice, support and information covering choice for face to face assessment and birthplace.

At each point of contact with the service the midwife documents the discussion, advice and support. This documentation is the start of the labour record. At the end of the discussion a decision is made with the woman and partner about the next step. If the woman remains at home then a decision is made about whether she would prefer to call back or whether she would prefer the Labour Line midwife to call her back. If a face to face assessment is required the Labour Line midwife will contact a midwife from one of the community teams or the clinical manager on one of the hospital sites to arrange a face to face assessment.

For each contact with the service an event is recorded in the Integrated Computer Aided Dispatch system within the ambulance service. This has facilitated audit.

Shared governance arrangements: a memorandum of mutual operational understanding was developed for the purpose of the pilot. Prior to the start of this work, SCAS nor any other ambulance service in the UK had piloted such a service. This gave us the opportunity to explore mutual benefits for example the clinical support role of the midwife within an ambulance service, any strategic and system wide benefits, building infrastructure between the two organisations and piloting a model for other clinical functions. The communications team at SCAS produced a promotional piece circulated to all staff about the joint venture. This explained that the service will give women in Hampshire access to a midwife twenty four hours per day during labour and that the staff at SCAS could also speak to a midwife for support, advice and guidance either within the Operation Centre or whilst out on the road. Convincing colleagues that midwives in a neutral site would be appropriate deployment of staff: this was achieved by agreeing a pilot and showcasing the service outcomes via evaluation.

Key findings

In the first 5 months of the 6 month pilot, the Labour Line service received 4450 telephone contacts from women and partners. This equates to an average contact rate of 30 per day.

When asked to comment on their experience via a service user survey, of the 52 comments received 44 were positive describing 'being impressed' and using words to describe their experience such as 'reassuring', 'excellent', 'efficient', 'friendly', 'calming', 'helpful' and used expressions like 'felt listened to', 'in control'.

When women and partners were surveyed as to whether their labour story was listened to 88% of the women and partners felt listened to and they cited many examples of how this made them feel 'supported' and 'at ease'.

When the women and partners were surveyed about whether they made the decision about what to do next, 58% of the women and partners said they made the decision fully, 34% of women and partners felt they partially made the decision and 8% of the women and partners felt it was the midwife's decision.

89% of the women surveyed said they would recommend the service. Overall the community birth rate at Hampshire Hospitals NHS Foundation Trust for 2013 ? 2014 was 5.8%, a significant increase of 1.2% from the previous year which was 4.59%.

Prior to the pilot a review of all unattended births (BBA's) at Hampshire Hospitals NHS Foundation Trust between January 2013 and June 2013 was undertaken. There were forty in total and it was noted that several of the unattended births were due to poor triaging technique, two of which cases culminated in formal complaints. Throughout the year and more significantly since the start of the Labour Line service pilot there has been a decreasing trend seen in the number of unattended births.

The findings of the service evaluation of the 24hour Labour Line service pilot have been incredibly positive. The most remarkable improvement was in the average rating of experience of 8.38, a significant increase from 6.63 (Based on a scoring system of 1 = not happy and 10 = very happy).

Key learning points

In addition to the positive feedback received from women, having a midwife based in the ambulance service has improved safety and the avoidance of unattended births. Timely attendance of midwives and attendance of ambulance crews when clinically appropriate has been facilitated by having a midwife based within the ambulance call center.

The evaluation provides evidence that having a midwife based in the ambulance service has improved safety and through the provision of advice and support has meant that a number of ambulances could be stood down having a positive impact on the availability of ambulances for emergency situations.

This model has transferability not only to other maternity services but also transfer to other to other clinical specialties. We are currently embarking on a Hampshire wide approach to telephone triage with two of our partner organizations setting up a service for 18,000 women across the patch. In addition to this SCAS are planning to set up a model for the psychiatry service based on the model for the 24hour Labour line.

Contact details

Tony Peters and Janice Mackenzie
Head of Emergency Operation Centre (SCAS) and Clinical Manager (HHFT)
Hampshire Hospitals NHS Foundation Trust (HHFT) and South Central Ambulance Service (SCAS)

Is the example industry-sponsored in any way?