Shared learning database

 
Organisation:
Guy’s & St Thomas’ NHS Foundation Trust
Published date:
December 2016

This project established a specialist antenatal clinic, which takes a multi-disciplinary team approach to the care and management of women with chronic hypertension in pregnancy.

The project is based on NICE guideline CG107 (Hypertension in pregnancy: diagnosis and management) and QS35 (Hypertension in pregnancy). Recommendations 1.2.3, 1.2.4 and 1.2.5 from the guidance have been implemented as part of the project, as have quality statements 1, 3, 7 from QS35.

Contributors to the example were:  Funmi Buraimoh, QIPS Coordinator, Mary Stewart, Consultant Midwife and Christina Farrow, QIPS Manager.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

Aim:

To improve the care, management and outcomes for women with chronic hypertension in pregnancy and for their babies

Objectives:

  • gain an accurate understanding of how many pregnant women referred to Guy’s and St Thomas’ Trust (GSTT) for maternity care have chronic hypertension
  • ensure that all pregnant women booked at GSTT with chronic hypertension are referred to the hypertension in pregnancy (HiP) clinic
  • ensure that all referred women are seen within two weeks of referral
  • ensure that all women under the care of the HiP clinic go no longer than 4 weeks between monitoring of blood pressure
  • improve communication with women about planned mode and timing of birth
  • ensure that an obstetric consultant reviews the care plan, even if the woman is seen by a trainee
  • ensure out-of-hours contact numbers are included in patient information leaflets, so that women do not wait to seek help
  • ensure that community midwives and general practitioners have improved access to information about hypertension in pregnancy and when to refer women
  • ensure that care is given in adherence to NICE guideline 107 and Quality Standard 35
  • ensure that local guidelines are followed by making them accessible to all staff within the hospital and in the community
  • ensure that women themselves are well informed and are provided with support, treatment and information during and after pregnancy (Quality Statement 1 & 7 of NICE QS35).

Reasons for implementing your project

In May 2015 a new clinic was started to support women with chronic hypertension in pregnancy (HiP). The clinic was set up in response to a local audit which revealed poor outcomes for women with chronic hypertension in pregnancy (especially non-white women) and, a serious incident report into an individual case in which a baby was stillborn.

A Patient and Public Involvement (PPI) research group was set up which identified the following issues as important to the women:

  • there is a knowledge gap about hypertension in pregnancy between specialists and midwives/GPs
  • having a dedicated clinic can make a positive difference
  • communication between primary and secondary care needs to be improved
  • empowering women to understand their condition helps them to make informed decisions and be involved in their care
  • advice about healthy living after pregnancy would be welcomed

I always felt like I was an active participant of my care – part of the solution to my illness”

 

GSTT current birth rate and attendance at HiP clinic between May 2015 and May 2016

 

  • The total deliveries for GSTT during the year were 6989
  • More than 300 women were in attendance at the HiP clinic.
  • 151 women attended for Chronic Hypertension/Renal Disease while others attended for different reasons.        
  • 126 women attending the HiP clinic have delivered; 129 babies have been delivered.
  • 25 women attending the HiP clinic had not delivered their babies.

Demographic mix of women attending the HiP clinic between May 2015 and May 2016:

Ethnic Background

Number of Women

Percentage %

GSTT Comparison %

White

50

39.68

57.75

Black

62

49.21

26.02

Asian

12

9.52

11.94

 


How did you implement the project

A project team was set up comprising two consultant obstetricians, a consultant midwife, a specialist pharmacist in obstetrics and women’s health, a clinical research fellow and a clinical fellow, specialist IT midwives, members of the trust quality improvement and patient safety (QIPS) team. The project team established a robust parallel evaluation of many aspects of the care pathway. This has included (amongst other items) referral pathways, medication regimes, antenatal and postnatal management, information for dissemination to primary care and other health care professionals, evaluation of outcomes through various methodologies and patient feedback. The changes that were made include:

  • the project team produced a referral pathway to ensure that all women with hypertension were brought under the care of the clinic – we did this by mapping the current process, working out what worked and didn’t and then mapping an ideal referral pathway. We assessed who the key stakeholders were to ensure the pathway was followed (the women, the Antenatal Day Unit, the GPs, the community and hospital midwives, etc. We looked at the incidences where women did not attend follow up and created a DNA pathway to flag these women.
  • the project team produced a guideline for initial blood pressure medication management – the obstetric consultants, an obstetric trainee and the specialist women’s pharmacists worked with the QIP team to develop the guideline
  • a clear guide for up-titration of medication was developed – a sub group was formed with a specialist obstetrician trainee, and obstetric consultant and the specialist women’s pharmacist to look at this issue. A draft guideline was brought to the wider team and issue discussed and resolved if needed. The QIPS manager worked with the communication team to ensure the guideline was made available on the internet and intranet
  • the project team created a clear pathway for antenatal and postnatal care that can be used as quick guide reference points for staff within primary or secondary care
  • a patient information leaflet for women with hypertension in pregnancy was developed – the consultant midwife and an obstetric trainee were responsible for adapting a leaflet which was in use at a partner hospital. A patient public involvement (PPI) focus group was completed prior to this so that we knew what issue were important to the women themselves. The process involved revising the information and adding guidance. The communication team advice to use existing information saved a lot of time. The leaflets were regularly disseminated by email to the wider group for comments and corrections. This was a valuable use of staff time so that meetings could be used for sign off or discussion rather than corrections.
  • an advice leaflet for women who have experienced hypertension in pregnancy, which covers long term risk and advice on how to stay healthy was developed by the project team.
  • an electronic discharge letter to go to the woman, their community midwife and their GP to guide their continuing care was developed – the team worked closely with IT to develop this leaflet. The EDL was shown to GP collagues and midwives to ensure that the information they need to care for these women was included. The production process was relatively straightforward.
  • the existing guidelines of care was reviewed and updated – a sub group was et up to assess the existing guideline. Our pathways and protocols were added as addendums during this process to ensure they were available to hospital staff.
  • the IT Midwives adapted and improved the existing IT to ensure that clinical outcomes could be captured and audited – the IT midwives were involved from the start of the project and were able to adapt and change what was needed. The IT and clinical understanding was vital to know what could/should be captured.
  • the QIPS team surveyed the HiP clinic users on two occasions to see what they wanted from the service – we went to the clinic to distribute the survey and respond to any questions or suggestions the women had regarding the service

An initial scoping exercise was invaluable to map the current structures, processes and outcomes. The exercise involved all the team contributing in a two hour session. The structures needed included assessing both the material resources (such as the setting, the facilities available, the funding) and the human resources needed to staff and support the hypertension in pregnancy clinic (including the skills and experience needed for the clinic).


Key findings

The overall satisfaction with the Hypertension in Pregnancy clinic was high (72% very satisfied, 16% fairly satisfied). Women who had previous antenatal experience rated the HiP clinic as better than their previous experience (72%).

Evaluation of clinical outcomes:

The clinical outcomes achieved were in line with the expectations for the service. This has led to a robust parallel evaluation of many aspects of the pathway. This has included (amongst other items) referral pathways, medication regimes, antenatal and postnatal management, information for dissemination to primary care and other health care professionals, evaluation of outcomes through various methodologies, patient feedback and much more. It also resulted in a much quicker and smoother establishment of a new service for women with chronic hypertension in pregnancy.

Comparison of GSTT maternal outcomes including mode of delivery and timing of birth between May 2015 & May 2016 following the inception of HiP Clinic

Mode of Delivery

Number of Women

Percentage (%)

GSTT Comparison (%)

SVD

47

37.30

54.29

Instrumental

6

4.76

13.93

ELLSCS

21

16.67

11.82

EMLSCS

43

34.13

19.96

EM Classical C Section

1

0.79

 

Timing of birth

Age at Delivery

Number of Women

Percentage %

GSTT Comparison

<25

3

2.38

9.39

25-29

17

13.49

19.56

30-34

34

26.98

33.43

35-39

41

32.54

28.45

40-44

23

18.25

8.27

45-49

3

2.38

0.83

>=50

3

2.38

0.17

Perinatal outcomes including birth weight, gestation at delivery, live birth/ stillbirth and neonatal admissions:

Birthweight Centile

Number of Babies

Percentage %

0-3rd

4

3.10

3-5th

3

2.33

5-10th

10

7.75

10-25th

26

20.16

25-50th

32

24.81

50-75th

19

14.73

75-90th

15

11.63

90-95th

9

6.98

95-97th

1

0.78

>97th

3

2.33

 

Gestation at Delivery

Number of Women

Percentage %

<34 weeks

12

9.52

34 to 36+6 weeks

20

15.87

37 to 37+6 weeks

24

19.05

38 to 38+6 weeks

30

23.81

39 to 39+6 weeks

25

19.84

40 to 40+6 weeks

8

6.35

>41 weeks

2

1.59

 

Birth Outcome

Number of Babies

Percentage %

Live

125

96.90

Stillbirth

2

1.55

Non-Registerable

2

1.55

 

Admission to Neonatal Unit

Number of Babies

Percentage %

Yes

29

23.2

No

96

76.8

 A further audit is also planned in order to measure:

  • the proportion of women seen in clinic within the one or two week aim
  • the proportion of women prescribed aspirin (or rationale given if aspirin not prescribed) for pre-eclampsia prophylaxis (NICE QS35, statement 2)
  • the proportion of women for whom an appropriate blood pressure target is set
  • the proportion of women admitted to hospital during their pregnancy
  • whether the timing and mode of delivery plans are made according to the pathway
  • the proportion of women lost to follow up / effectiveness of the DNA pathway
  • the satisfaction with the clinic care, involvement in decisions about timing of birth and mode of delivery; information provision at both antenatal and postnatal wards.

 


Key learning points

The key to the success of this project has been the collaboration between and commitment from all the members of the project team. Most members of the team self-selected to be part of this group and already had an interest in improving care for this group of women.

Regular meetings, especially in the early stages of the project, helped to ensure that the project developed to time, and that aims and objectives were met. Having both clinicians and non-clinicians in the project group was useful as it ensured that the language used in the guidance, the information leaflets and on the webpage was kept less medical and more user friendly rather than being overly technical.

Ambitious aims were set to drive progress. Actions were distributed evenly with staff expertise determining who worked on which element of the project. Often the actions were split amongst small sub groups of two or three people in the team. This division of labour meant that no one felt overwhelmed with their actions and the supportiveness of the team allowed staff to bounce ideas around and to challenge each other when needed. Ideas were circulated between meetings via emails with all having an equal voice. One visiting researcher commented on how engaged and inclusive the project team were – frank, open discussion was common, with ideas welcomed from everyone.

The project team had specialist midwifery and central IT support to extract data and enable reports to be pulled from electronic systems. The data was manually audited by the specialist midwife. This was a time consuming but important process to understand what data could be gathered in future and the work needed so that future data extraction would be as painless as possible. Having an expert midwife do this work was helpful, rather than a non-clinical IT expert, as she was able to interpret the data and identify the gaps in the system.

Building strong supportive relationships within the project team and with staff in other departments contributed to project success and the dissemination of information.. Speaking to people directly was important, to make sure that people understood what was needed and, to build personal contacts.

The project team made sure they increased awareness outside the group by talking about the project in meetings and staff training. Raising staff awareness from the beginning meant that the right people got involved from the start. Both NICE CG107 and QS35 were useful as benchmarking tools throughout the project duration.


Contact details

Name:
Funmi Buraimoh
Job:
QIPS Coordinator
Organisation:
Guy’s & St Thomas’ NHS Foundation Trust
Email:
funmi.buraimoh@gstt.nhs.uk

Sector:
Primary care
Is the example industry-sponsored in any way?
No