Venous thromboembolism is the most frequent direct cause of maternal death. We have created two multi-professional guidance and documentation tools for the implementation of thromboprophylaxis in pregnancy and the puerperium. These cover NICE & RCOG guidance jointly.
TAUNTON & SOMERSET NHS TRUST
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?
Consistent correct implementation of NICE (& RCOG) guidance using a simple multiprofessional tool. Rapidly incorporate NICE guidance into routine practice. Provide a simple, efficient tool that provides guidance which enables rapid assessment and accurate documentation - for all maternity professionals working within community and hospital settings. Enable efficient audit of practice.
Pregnancy and the Puerperium are recognised as major risk factors for venous thromboembolic disease - the commonest direct cause of maternal death. That risk can be reduced by appropriate thromboprophylaxis. NICE have already estimated that the risk in medical and surgical patients can be reduced by 60% and 70% respectively. Before the recent guidance, there had been no team briefing and we had no system for implementation. An audit in 2008 showed a low level of compliance with the exception of women undergoing caesarean section. Two clinical incidents highlighted this as an important safety issue for women attending our unit. Identifying risk during pregnancy is difficult because of the various patient pathways that involve several professional teams. Moreover, the guidance is complex - risk factors can be overlooked, and they can also change as pregnancy progresses. Finally, guidance comes from two sources (NICE & RCOG), each covering different aspects of the woman's journey. To simplify the system, there are separate documents for antenatal and postnatal care. A formal guideline acts as a reference tool for questions. The document provides structure to new changes in clinical practice and also allows for ease of audit. Other integrated care documents in our Maternity Unit had been successful in implementing new practice.
New guidance was issued by the RCOG in 2009 & by NICE in 2010. Two multiprofessional documents give information & a systematic means of documentation, promoting consistency & aiding continuity of care. Safety is promoted through guidance on contraindications and dosing. This is particularly helpful for new team members who might not have encountered the scheme previously. 1. A local guideline was written as a reference document, by a core multiprofessional team, derived from NICE and RCOG documents. 2. This was sent for local peer-review with the maternity guidelines forum, two consultant anaesthetists, and a consultant haematologist. Suggestions were considered & change made by the core guideline development team. 3. The new document was ratified by the Maternity Governance Team. 4. The reference document was then reviewed, modified & ratified with the Trust Thrombosis Group. 5. The core team then sought to create two implementation tools - one for antenatal & another for postnatal care. Each had to sit within two sides of A4 paper. They contained implied guidance on risk assessment, clinical interventions, contraindications and dosing. There was space for documentation for clinical actions taken and for revisions in light of changing risk assessments. These documents were sent for internal review and piloted. 6. An education cascade with a ten slide talk was undertaken. A key part of the talk was to emphasise the importance of the guidance, the reference document, open culture for asking questions, & the desire for feedback. 7. The two documents were piloted & comments received by the practice development midwife. 8. A separate patient information group drew up a leaflet to support communication with the women. 9. Document was revised after initial pilot: it was clear that further definition and guidance was required in some sub-sections. In particular, midwives & doctors wished for better definition of what constituted chronic medical disease.
We audited the risk assessment tool and found 83% compliance with the forms within one month. This has since risen to over 90%. This compares with a very low rate of implementation of the 2004 guidance for which no tool was developed. A review of 100 consecutive deliveries showed that 71% of women had short-term low-molecular weight heparin under NICE guidance while in-patient, and that 43% of women were recommended patients required enoxaparin for seven days or more under RCOG guidance.
1. Creating a reference document formed the foundation of the development of the tools. 2. Using a core team of different professions aided communication and drew ideas from different perspectives. 3. Local peer-review substantially improved the document - second eyes, second vision. 4. The education cascade aided knowledge dissemination but should have been started earlier - not all team members had seen the talk before launch. 5. Piloting the tools allowed for further feedback and again resulted in substantial improvements in their structure. It particularly drew important comments from community midwives who had not been part of the core team. Something to be corrected for future projects. 6. The use of separate Antenatal and Postnatal risk assessment tools meant each was simpler to use than a single sheet covering all parts of care. 7. The two-tool system also highlighted the importance of review after delivery when different risk factors and contraindications may arise. 8. Colour-coding the two-forms enabled risk assessment documentation to be located easily within maternal notes. 9. Provision of a patient-information leaflet at the initial risk assessment enabled autonomy in decision-making about prophylaxis. 10. Clear reference to the guideline and emphasis that users can consult haematology and obstetric experts with queries, particularly with regard to women at very high risk.
TAUNTON & SOMERSET NHS TRUST
Is the example industry-sponsored in any way?