Shared learning database

 
Organisation:
St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust
Published date:
March 2017

Implementation of routine high throughput non-invasive prenatal testing (NIPT) for fetal RHD genotype at the University Hospitals Bristol resulted following a successful pilot run by a consultant in fetal medicine and midwifery matron. The postpartum pathway has remained unchanged and cord blood continues to be checked for all babies born to a mother who is rhesus D-negative.

Offering NIPT for all pregnant women who are Rhesus D negative is in line with NICE DG25 recommendation (1.1) and will help reduce unnecessary use of the blood product anti-D immunoglobulin. This case study has been adapted from the ‘Adoption support for high-throughput non-invasive prenatal testing for fetal RHD genotype: insights from the NHS’ and reflects the service at the time of resource publication (February 2017)

Guidance the shared learning relates to:
Category
Does the submission relate to a general implementation of all NICE guidance?
No
Does the submission relate to a specific implementation of a specific piece of NICE guidance?
Yes
Full title of NICE guidance:
-

Submission

Aims & Objectives

Aim:

  • To target routine antenatal anti-D prophylaxis for women who are Rhesus D negative, instead of treatment with anti D for all pregnant women who are rhesus D negative.

Objectives:

  • prevent unnecessary administration of blood products (anti D immunoglobulin) and their associated risk
  • avoid unnecessary painful injections for women where the NIPT for fetal RHD genotype is negative
  • reduce the number of antenatal anti-D prophylactic clinic appointments needed, and the amount of anti-D immunoglobulin used
  • increase availability of anti-D immunoglobulin for use following potential sensitising events (PSEs) in pregnancy where the NIPT result for fetal RHD genotype is positive
  • reduce the anxiety associated with potential sensitising events for D-negative women where the NIPT result for fetal RHD genotype is negative
  • provide information to allow D-negative women to make an informed decision about whether to have treatment with anti-D immunoglobulin.

Context

University Hospitals Bristol NHS Foundation Trust consists of 9 sites providing services to the people of central, south Bristol and the north of North Somerset, serving a population of approximately 350,000 people. Community midwives providing care in Bristol may be employed by either University Hospital Bristol (UHB) or North Bristol NHS Trust (NBT). Women can book for delivery at either trust. The maternity midwives are based either in the community or hospital setting. There are 5500 babies delivered annually at University Hospital Bristol.


Methods

High throughput NIPT for fetal RHD genotype was implemented initially on a pilot basis in 2 locations within the UHB trust from April 2013 (Soothill et al 2014)1 . On completion of the initial pilot, agreement was gained to extend the pilot for 1 year to all the women attending community services for antenatal care under UHB. This extended pilot offered an opportunity to gather patient and midwife feedback and helped to gain clinical acceptance for use in routine clinical practice. Cost savings were demonstrated which helped to secure support from senior managers.

Senior staff provided 30 minute training sessions in the community to optimise attendance. These included an update on Rhesus D and presentation and feedback on new local guidelines.

A local clinical guideline was developed which includes a care pathway and the RAADP algorithm. It contains two main routes in the patient pathway; women who 1) accept and 2) decline the FFDNA test.

A paper test request form is used due to the limitations of the current IT system. The test is done by community based midwives when the women attends for her 16 week antenatal appointment.

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[1] PW Soothill, K Finning, T Latham, T Wreford-Bush, J Ford, G Daniels (2014) Use of cffDNA to avoid administration of anti-D to pregnant women when the fetus is RhD-negative: implementation in the NHS DOI: 10.1111/1471-0528.13055 www.bjog.org 21 August 2014

 


Results and evaluation

Results from the initial pilot are reported the the Soothill et al (2015)1 paper ‘Use of cffDNA to avoid administration of anti-D to pregnant women when the fetus is RhD-negative: implementation in the NHS’.

This prospective observational study included 2 other hospitals as well as University Hospital Bristol (UHB). Samples from the UHB totalled 197 out of the total 529.

Overall the results across all three sites showed that implementation of this test reduced anti D use by 29% which equated to 35% of Rhesus D Negative women not receiving anti-D injection in their pregnancy unnecessarily.

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[1] PW Soothill, K Finning, T Latham, T Wreford-Bush, J Ford, G Daniels (2014) Use of cffDNA to avoid administration of anti-D to pregnant women when the fetus is RhD-negative: implementation in the NHS DOI: 10.1111/1471-0528.13055 www.bjog.org 21 August 2014


Key learning points

  • Targeting RAADP may be a significant change in practice and initially user confidence may be low. Strong leadership, good communication and implementing as a pilot helps to improve clinician confidence.
  • Consider local arrangements of maternity services, and appointment uptake rates by pregnant women, to help target point the implementation point in the pathway.
  • Clarify who has the responsibility for checking and acting on the ffDNA result.
  • Consider providing information in other forms such as a maternity app.

Contact details

Name:
Jenny Ford
Job:
Midwifery Matron
Organisation:
St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust
Street Address:
Southwell Street
Town:
Bristol
County:
Postcode:
BS2 8EG
Phone:
0
Email:
Jenny.Ford@UHBristol.nhs.uk
Website:

Category(s) that most closely reflect the nature of the submission:
Primary care
Is the submission industry-sponsored in any way?
No