Shared learning database

 
Organisation:
Betsi Cadwaladr University Health Board (BCUHB)
Published date:
April 2021

This project aims to share the challenges and learning in developing local strategies to minimise the risks of COVID-19 across Maternity Services in Betsi Cadwaladr University Health Board (BCUHB), North Wales. COVID-19 is a major public health threat and many asymptomatic infected pregnant women will present for care.

Pregnant women, with SARS-CoV-2 infection upon admission, are not reliably identified by symptom screening as up to 88% are asymptomatic (1) . Robust management plans including universal testing is therefore required. Pregnancy alters the body’s immune system (2) and pregnant women are considered clinically vulnerable. This presents a unique challenge for pregnant women requiring planned and unscheduled essential care. We referred to NICE guidelines to consider new ways of working to continue offering safe maternity services during the pandemic. NICE (NG179) defines what this should look like and emphasises the need to raise awareness amongst all NHS service users.

Authors:

Dr Hemant Maraj MRCOG, DFSRH, MSc , North Wales Clinical Lead for Women's Services, Betsi Cadwaladr University Health Board

Maria Grace Atkin, BN (Hons), LLM, Head of Operational Services - Womens Services, Betsi Cadwaladr University Health Board 

Dr Deepannita Bhattacharjee MRCP, FRCPath, DTMH (Liverpool school of Tropical Medicine) Consultant Clinical Microbiologist and Infection Prevention Doctor,  North Wales Microbiology, Public Health Wales.

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

As nationally recognised, maternity services provide essential and time sensitive care that must be maintained during the pandemic (3). Maternity care is a core service whereby vulnerable women require 24-hour access. Robust infection control measures are therefore essential to reduce the spread of infection in both maternity units and across the community care centres.

The aim of this project is to describe how such measures were put into place, supported by the COVID-19 rapid guideline: Arranging Planned Care in Hospitals and Diagnostic Services (NICE, 27 July 2020).

The objective is to demonstrate how implementing best practice can minimise the risks of SARS-CoV-2 infection. In turn, we aim to describe how universal testing offered to all pregnant women admitted for delivery, both planned and unscheduled, can minimise hospital acquired COVID-19.

A further widely recognised implication, is that many pregnant women have reported difficulty with self-isolation, as they have children who need to go to school and partners who are working. Maintaining antenatal care appointments also requires a degree of contact with various health professionals across various settings.

Best practice guidance (NG179) recommends self-isolation for a period of 14-days prior to any planned care, therefore in May 2020, BCUHB introduced measures by way of adoption of SARS-CoV-2 universal testing. The aim is to offer necessary safeguards to protect all pregnant women, hospital staff, and visitors.

Furthermore, and in-line with NICE (NG179) and RCOG guidance (4), the aim of this project is to develop cohort pathways that considers to the following issues:

  1. Women with scheduled admissions for birth often need to attend for maternity care in an unscheduled manner as the onset of labour is naturally unpredictable.
  2. Maternity interventions are frequently arranged at short notice and cannot be easily separated into ‘elective’ and/or ‘emergency’ care.
  3. If pregnant women test positive for SARS-CoV-2, elective birth cannot usually be safely deferred to incorporate an isolation period.
  4. Creation of an elective pathway with a 14-day pre-admission self-isolation period for the household is not always compatible with women being able to access essential antenatal care in the time leading up to birth.

Reasons for implementing your project

As recognised, NICE guidelines (NG179, 1.1, 3.3 and 3.5) advise that patients (and families) should minimise contact with others and may need to self-isolate before their planned care to reduce the risk of contracting COVID-19. Although pregnant women across North Wales have been advised accordingly, we recognise the many challenges this presents for pregnant women.

The reason for implementing this project was therefore based on the need to think creatively about our services and clinical pathways. Best practice NICE guidelines advise the need to assess patients for symptoms of COVID-19 on the day before and when they arrive for planned care and the need to discuss how the assessments will be done beforehand, for example, by telephone or video consultation to minimise face-to-face contact (NG179 3.4).

Pre-pandemic, maternity appointments had no restrictions upon contact, and women would often present at hospital for pre-admission consultations. This supported the relationship between the woman and her clinical team, providing opportunities to ask questions and gain prior insight into the acute maternity setting to help familiarise and prepare for admission and delivery. NICE guidance (NG179) has therefore provided the Women’s Directorate with an opportunity to take an evidence-based and careful risk stratified approach to planning services with new pre-admission pathways.

Scheduled care; planned caesarean sections or induction of labour, required a pre-admission test of 24 - 72 hours. This needed to be performed during preoperative assessment visits or via access to designated drive-through testing centres.

The change in pathways required a test by means of a polymerase chain reaction (PCR) based platform with a 24-hour turnaround time and such arrangements discussed with women prior to admission, to consider any special requirements (NG179 3.4).

BCUHB is the largest health organisation in Wales providing care for a population of around 694,000 people. The regional demographics vary widely from densely populated towns such as Wrexham to rural areas in Gwynedd. We therefore needed to consider and coordinate access for women across 3 district general hospitals and multiple community centres.

The need for new innovative practice required approval from the North Wales Clinical Advisory Group to support clinical governance requirements, learning and compliance with best practice guidance.


How did you implement the project

Developing clinical pathways and procedures in line with key national priorities, helped inform practice in accordance with NICE (NG179), RCOG (2020) Coronavirus (COVID-19) Infection in Pregnancy, Information for Healthcare professionals (V7) and the Welsh Government (2020) Framework for maintaining Life Saving and Life Impacting Essential Services during the COVID-19 Pandemic.

The measures undertaken were implemented by applying three key principles, as offered above:

  1. Maintain high quality care for women throughout the pandemic.
  2. Reduce the transmissions of COVID-19 to pregnant women.
  3. Provide safe care to pregnant women with suspected/confirmed COVID-19.

The first and most crucial stage was to implement universal testing for pregnant women, whom required both planned and unscheduled care by PCR testing. Women attending for unscheduled care were offered rapid PCR testing with a 2-4 hour turnaround time. Although access of this resource was limited, PCR testing was obtained by close working with the microbiology lab services, supported by the risk assessment of all alternative options. Testing was also performed alongside ongoing universal screening of patients for symptoms of COVID-19 infection.

The risk stratified approach used (in addition to self-isolation where possible) helped minimise the transmission rates of SARS-CoV-2, supported by regular clinical audits to help determine local needs and trends (NG179). Challenges included access to the necessary estates to maintain clinical pathways and threats of staff deployment to support other services. Liaison with hospital management teams and workforce colleagues to clearly identify maternity needs were crucial. Red, Amber (women awaiting results) and Green zones were created across all three hospitals and services in the community were relocated with staff distributed accordingly.

Regular review and updates to pathways, using a multi-disciplinary approach with service users, neonatal, anaesthetics and critical care colleagues helped define the approach.

By implementing the above, the following services were maintained:

  • Early Pregnancy Assessment Units on all 3 hospitals
  • Antenatal Screening and ultrasound services
  • Midwifery Led and Consultant Led Antenatal Care
  • 24hr Maternity Assessment Service on all 3 hospitals
  • Obstetric and Midwifery Led Care Inpatient Services on all 3 hospitals
  • Midwifery Led Unit and Obstetric Intrapartum Care on all 3 hospitals
  • Postnatal Acute and Community Services
  • New-born Hearing and Blood Spot Screening

Key findings

In summary, this project has seen the undertaking of universal testing, providing safe care through the development of new clinical pathways, adapting means of patient contact to minimise risks of exposure, developing new pre and post admission assessments, promoting infection prevention and re-configuring estates to safely manage confirmed positive cases and confirmed negative cases and/or pending results.

Ultimately, the actions taken have enabled the Health Board to safely manage pathways for pregnant women who are not always able to self-isolate for the 14-day period. Robust planning and careful monitoring of clinical effectiveness also ensured minimal infection rates across the service.

Our total testing results and positive rates are outlined in table 1. Note that the rate of positive results prior to universal testing was higher as we only tested symptomatic women at that point.

Table 1. Monthly analysis of SARS-CoV-2 testing and positive rates.

Month

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Total swabs

23

55

104

460

722

705

730

700

695

725

758

 

 

 

 

 

 

 

 

 

 

 

 

Positive swabs

4

8

2

12

6

0

3

9

14

8

28

Cumulative Positive

4

12

14

26

32

32

35

44

58

66

94

Positive rate

17.39%

14.55%

1.92%

2.61%

0.83%

0%

0.41%

1.23%

2.01%

1.1%

3.69%

A wide variation in the prevalence across three maternity units is shown in table 2. In the initial month of implementation of universal testing the prevalence ranged from 1.68% in West to 4.43% in East. 69% of positive cases were asymptomatic confirming that pregnant women with SARS-CoV-2 infection are not reliably identified using symptom and temperature screening alone.

Mar

Apr

May

Jun

Jul

Sep

Oct

Nov

Dec

Jan

Total

West

1

4

1

3

1

1

5

16

Central

3

1

3

1

2

6

2

2

7

27

East

4

6

4

1

3

11

6

16

51

Total

4

8

2

12

6

3

9

14

8

28

94

As of January 2021, nearly 100 women with SARS-CoV-2 infection have been successfully managed with excellent clinical outcomes. 3% of our women required critical care admission and we had 0% maternal mortality. There have been no cases of health care associated COVID-19 infections in any of our three hospital maternity units to date.

Patient experience to date, has seen positive feedback and information provided to women have been developed in various formats, including the Welsh language and all reason adjustments maintained (NG179 1.1).


Key learning points

Sharing our experience with the National Maternity and Neonatal Network and benchmarking with other Health Boards across Wales has supported the cycle of learning. This triangulated approach, working with all key stakeholders including Women’s Voices groups, has resulted in a strong collaboration and togetherness during the pandemic.

We have learnt that communication and adaptability is a vital part of developing COVID-19 plans. We have in place a Women’s on Call Manager with 24-hour support, advice and guidance to staff throughout the COVID response. Local information hubs on each of the delivery suites provides resources to women and staff. All clinical pathways are easily accessible on the intranet.

Working with women via the Maternity Voices forums with established social media platforms helped raised awareness of the key principles to minimise the risk of COVID-19 across maternity services. Working differently and using technology to consult with women on rapid service development, during a period of progressive change also supported strong working in partnership.

In conclusion, the swift development and continuous review of clinical pathways has provided a safe and secure framework to maintain essential maternity services and the health and safety of all service users and staff during the COVID-19 pandemic.

Applying NICE Guidelines in practice and undertaking universal testing has allowed the service to safely manage the large number of admissions, maintain red, amber and green designated areas on all acute sites and minimise the risks of healthcare associated infections. Furthermore, audit and incident review of all positive cases help us further understand the trends, prepare and predict how services may be affected in the future. Adaptability of the infrastructures and staff responsiveness to the pandemic has been commendable across North Wales. Strong leadership at all levels has enabled the successful delivery of safe maternity services.

References:

[1] Sutton D, Fuchs K, D’alton M, Goffman D. Universal screening for SARS-CoV-2 in women admitted for delivery. New England Journal of Medicine. 2020 May 28;382(22):2163-4.

2 https://www.rcog.org.uk/globalassets/documents/guidelines/2021-02-19-coronavirus-covid-19-infection-in-pregnancy-v13.pdf

3 Maintaining Essential Health Services during the COVID 19 Pandemic – summary of services deemed essential (Welsh Government, May 2020)

4 https://www.rcog.org.uk/globalassets/documents/guidelines/2020-05-29-principles-for-the-testing-and-triage-of-women-seeking-maternity-care-in-hospital-settings-during-the-covid-19-pandemic.pdf


Contact details

Name:
Hemant Maraj
Job:
North Wales Clinical Lead for Women's Services
Organisation:
Betsi Cadwaladr University Health Board (BCUHB)
Email:
hemant.maraj@wales.nhs.uk

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