Yorkshire & the Humber Clinical Network Striving to Reduce Stillbirth Rates and Improve Bereavement Care Transforming and Modernising Maternity Care in England London 12 th July 2016
Content Yorkshire & the Humber geography Data National Saving Babies Lives Care Bundle Element 1: Smoking in Pregnancy Y&H Recommendations for Improving Stillbirth and Bereavement Care
12 Clinical Networks
National context Stillbirth Rate - England 5.7 5.4 5.3 5.2 5.1 5.2 5.1 5.2 4.8 4.6 4.6 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 ONS
Stillbirth rate per 1000 births Local context Y&H 3 yearly stillbirth rate 5.8 5.6 5.4 5.2 5 4.8 8% reduction 10% reduction Y&H s/b rate England s/b rate 4.6 4.4 4.2 2009-2011 2010-2012 2011-2013 2012-2014
Current position International The Lancet Report 2016: Ending Preventable Stillbirths National Saving Babies Lives Care Bundle RCOG: Every Baby Counts MBRRACE UK National Maternity Review NHS LA: Spotlight on Maternity Five Year Forward View NHS Business Plan 2016/17 Commissioning Improvement & Assurance Framework SANDS
Current position Regional SaBiNE project (2015) North Region Maternity Group Yorkshire & the Humber Y&H Recommendations Public Health England e.g. smoking cessation Regional Tobacco Group Local work & implementation
National work National Saving Babies Lives Care Bundle Smoking Cessation Fetal Growth Restriction Reduced Fetal Movements Fetal Monitoring 11 pilot sites across Y&H National launch March 2016
Element 1: Smoking Cessation Reducing smoking in pregnancy by carrying out Carbon Monoxide (CO) test at antenatal booking appointment to identify smokers (or those exposed to tobacco smoke) and referring to stop smoking service/specialist as appropriate Intervention Carbon monoxide (CO) testing of all pregnant women at antenatal booking appointment and referral, as appropriate, to a stop smoking service/specialist, based on an opt out system. Referral pathway must include feedback and follow up processes.
Y&H Benchmarking Smoking Cessation March 2016 benchmarking: Description Trust 1 Trust 2 Trust 3 Trust 4 Trust 5 Trust 6 Trust 7 Trust 8 Carbon monoxide (CO) testing of all pregnant women at booking appointment? Completely Completely Completely Roughly 75% achieved Completely Completely Completely Roughly 75% achieved Referrals (as appropriate) to a stop smoking service/specialist, based on an opt out system? Completely Completely Roughly 75% achieved Completely Completely Completely Completely Roughly 75% achieved
Stillbirth - Y&H work Recommendations for Improving Stillbirth and Bereavement Care for Y&H developed by stakeholders Engagement visits and workshops to inform the recommendations Approved by Y&H Commissioners and Providers Trusts Stakeholder launch event September 2015 http://www.yhscn.nhs.uk/children-maternity/maternitynetwork/maternity-documents-and-links.php
Y&H Current position Yorkshire & the Humber Recommendations Launched September 2015 Benchmarking current position Commissioners benchmarking Maternity services benchmarking Workshops and discussions at Maternity Clinical Expert Group to consider any challenges in implementation. Use of case studies and service user stories.
Stillbirth - Y&H Recommendations Risk reduction Bereavement care Stillbirth investigations Subsequent pregnancies Each element contains recommendations for: CCG commissioners maternity services future considerations
Y&H Risk Reduction Proposed Recommendations for Commissioners includes: 1. Commissioners should as a minimum, require Trusts to undertake a repeat CO test for all women between 28-36 week appointment (ASH 2013, NICE 2010). Proposed Recommendations for Maternity Services includes: 1. Trusts should provide all pregnant women (including low risk) with consistent messages regarding healthy lifestyle advice including nutrition and smoking cessation (NICE 2008). 2. Trusts should ensure they work in partnership with Smoking Cessation Services to develop services to meet the needs of pregnant teenagers (NCSCT 2014).
Y&H Recommendations - implementation Airedale Barnsley Bradford Calderdale & Huddersfield Harrogate Hull Leeds NLAG Rotherham Sheffield Doncaster & Bassetlaw Mid Yorks York Recommendations Same both sites Site 1: Doncaster Site 2: Bassetlaw Same both sites Site 1: Pinderfields Site 2: Dewsbury Site 3: Pontefract Same on all sites Site 1: York Site 2: Scarborough Red Amber Green Element 1: Risk Reduction Trusts should benchmark their Reduced Fetal Movements and 1 Small for Gestational Age policies against the RCOG green-top Yes Yes Partially Yes Partially Partially Yes Partially Partially Yes Yes Yes Partially Yes Partially Yes Yes 0 7 10 guideline recommendations. Trusts should provide all pregnant women (including low risk) 2 with consistent messages regarding healthy lifestyle advice Yes Yes Yes Yes Yes Yes Yes Yes Partially Partially Partially Yes Yes Yes Yes Yes 0 3 13 including nutrition and smoking cessation. Trusts should ensure they work in partnership with Smoking 3 Cessation Services to develop services to meet the needs of Yes Yes Partially Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 3 14 pregnant teenagers. Trusts should have a systematic approach to identify vulnerable isolated women at booking. There should be clear processes for 4 Yes Partially Yes Yes Yes Yes Yes Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes engaging non-attendance at clinics with consideration to 0 2 15 personalised care pathway. Trusts may consider an extra ultrasound scan at 16 weeks for 5 women with recognised recurrent risk e.g. a recessive genetic Yes Yes No Partially Partially Partially Yes Yes Yes Yes Yes Yes Partially Yes Yes Yes Yes 1 4 12 condition, neural tube effect. Trusts should ensure guidelines include definition, management 6 Yes Partially Partially Yes Yes Yes Partially Yes Yes Yes Yes Yes Yes Partially Yes No No and fetal risk assessment in the latent phase of labour. 2 4 11 Trusts should ensure women getting consistent advice for latent 7 phase from Labour Ward, Triage or Community. Rotation of staff Yes Yes Partially No Yes Yes Partially Yes Yes Partially Partially Partially Yes Partially Yes Yes Yes 1 6 10 & appropriate skill mix may facilitate this. Element 2: Bereavement Care Trusts should benchmark their Bereavement Care policies against 8 Yes Yes Partially Yes Partially Partially Partially No Partially Yes Yes Yes No Yes Partially Yes Yes the RCOG green-top guideline recommendations. 2 6 9 Trusts should provide training which aims to be multidisciplinary and include: update on unit policies and procedures causes of stillbirths care of a woman with an intrauterine fetal death 9 postnatal care following a stillbirth Yes Partially Yes Partially partially Partially Partially Partially Partially No Yes No Partially Yes Partially Partially Partially 2 11 4 effective and sensitive communication with bereaved parents including self-awareness cultural or religious aspects postmortem funeral arrangements Trusts should ensure clinical and psychological support, along 10 with mentoring, is provided for staff providing bereavement care, Yes Yes Yes Yes Partially Partially Partially Yes Yes Yes Yes Yes Partially Yes Partially Partially Partially 0 7 10 with an opportunity to debrief following the event. Trusts should ensure that students are exposed to bereavement 11 Yes Yes Yes Yes Yes Yes Yes Yes Yes Partially Partially Partially Yes Yes Yes Yes Yes care if the opportunity arises. 0 3 14 Trusts should, where possible, inform bereaved mothers what to 12 bring into the hospital with them in preparation for Yes Yes Yes Yes Partially Partially No Yes Yes Yes Yes Yes Yes Yes Yes Partially Partially 1 4 12 labour/induction and what to bring in for the baby. Trusts should aim to allocate bereaved mothers the same midwife 13 for all or the majority of their care and the midwife should not be Yes Yes Partially Yes Partially Partially Yes Yes Yes Partially Partially Partially Yes Yes Yes Partially Partially 0 8 9 allocated another woman to care for. Trusts should ensure that pain relief is offered in the same way 14 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes as for any mother. 0 0 17 Trusts should ensure that there are no restrictions on visiting 15 times throughout delivery and aftercare meeting the wishes of Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 0 17 the mother. Trusts should ensure that parents who may not wish to see their baby straight away should be offered the opportunity to see their 16 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes baby at any time during their stay and following discharge prior 0 0 17 to the funeral. Trusts should ensure that consent for clinical photographs (including those taken for the health records) is provided by the 17 Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes parents. Where consent is verbal, this must be documented as 0 1 17 obtained. 18 All Trusts should have a cold cot or cuddle cot available. Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes 1 0 16 Trusts should ensure that follow up arrangements with a senior member of staff should include the bereavement midwife and 19 Partially Yes Partially Partially Partially Partially Partially Yes Yes Yes Partially No Partially Partially Partially Partially should be held in a venue away from pregnant women, other 1 11 4 mothers and babies. Trusts should ensure that bereaved mothers and families are 20 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes offered postnatal visits on an individual basis. 0 0 17 Trusts should ensure that all parents who have agreed to a post mortem are able to discuss the results within 2 weeks (or at most 21 3) of the results being received by the referrer (60% results should Partially Yes Yes Yes Partially Partially No No Yes Partially Partially Partially No Yes Yes Partially Partially 3 8 6 be received within 6 weeks, 90% received within 8 weeks unless complex and a specialist opinion is required). Trusts should ensure that all staff seeking post mortem consent should be appropriately trained to do so e.g. Human Tissue 22 Yes Yes Partially Partially Partially Partially Yes Yes Yes Partially Partially Partially No Yes No Yes Yes Authority training. This training must be recorded and kept up to 2 7 8 date as required. Trusts should ensure that where a coroner s post mortem is required, the bereavement midwife or if unavailable, a trained 23 Yes Yes Yes Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Partially Yes Yes clinician explains why it is necessary and why it may take a while 0 3 14 to get the results. Trusts should ensure that a discussion about dressing the baby 24 Yes Yes Yes Yes Partially Partially No Yes Yes No No No Yes Yes Yes Yes Yes for the cremation/burial takes place with the mother and family. 4 2 11 Each Trust should review their funeral contract to support the 25 No Yes Yes Yes No No Yes Yes Yes Partially Partially Partially No Yes Yes Yes No families choice of cremation or burial. 5 3 9 Trusts should provide discharge information including the following information as a minimum; Follow up arrangements Bereavement services/midwife contact details Counselling contact details 26 Partially Yes Yes Partially Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Partially Yes Yes Loss of baby information 0 5 12 Charities with contact details Chaplaincy contact details Consider information for the father/partner and extended family Trusts should consider requesting feedback on bereavement care 27 Partially No No Yes Partially Partially No No Yes No No No Yes Yes No No No at the follow-up appointment. 10 3 4 Trusts should ensure that learning points are shared at local risk and governance meetings and consider other methods of sharing: 28 Yes Yes Yes Yes Partially Partially Yes Yes Yes Partially Partially Partially Yes Yes Yes Partially Partially newsletters, handovers, supervisor of midwives meetings, 0 7 10 regional meetings, meetings with commissioners. Element 3: Stillbirth Investigations 29 30 31 32 33 34 Trusts must consider the auditable standards in the RCOG greentop guideline No.55 Late Intrauterine Fetal Death and Stillbirth when auditing follow up care. Trusts must explore the possibility of setting up secure nhs.net accounts to receive results in a timely fashion. Trusts should ensure that, all women are offered appropriate full stillbirth investigations, including post mortem. Trusts must ensure a checklist of investigations is used, based on RCOG guidance and allows for recording which tests are undertaken and supports individualised care. Trusts should ensure that all staff involved in bereavement care receive training and support to enable them to care sensitively and confidently for parents whose baby is dying or has died. Trusts should ensure that all women are offered a written summary of the discussions at their follow up consultation, including investigation results and plans for subsequent pregnancies. No Yes Yes Yes No No No No Yes No No No No Yes No No No 12 0 5 Yes No Yes No Partially Partially No Yes Partially Yes Yes Partially Yes Partially No No 5 5 6 Yes Yes Yes Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 2 15 Yes Yes Yes Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 2 15 Yes Yes Yes Yes Partially Partially Partially Yes Yes No No No Partially Yes Partially Yes Yes 3 5 9 Yes Yes Yes Yes Partially Partially Partially Yes Yes Yes Yes No Yes Yes Yes Partially 1 4 11 Trusts should have a process is in place that provides the woman with easy access to the maternity service. Woman could be ensure they have the option of contacting a health professional early in their subsequent pregnancy. Trusts should have a process to ensure all maternity staff who experienced a previous perinatal loss. Trusts should involve the woman to develop a pathway of the lead clinician who will co-ordinate her care. Trusts should provide an early referral for an obstetric should be available for this appointment. Trusts should ensure a management plan for the current plan regarding next pregnancy. Trusts should ensure that women with a previous unexplained 26-28 weeks gestation to screen for gestation diabetes. Element 4: Subsequent Pregnancies 35 provided with the contact details of a bereavement midwife to Yes Yes Yes Yes Yes Yes No Yes Yes Partially Partially Partially Partially Yes Partially No No 3 5 9 36 Trusts should offer an early referral for a reassurance scan. Yes No Yes Partially Partially No Yes Yes Partially Partially Partially Partially Yes Partially Partially Yes 2 8 6 Trusts should provide a subsequent pregnancy service for 37 Yes Yes Yes Partially No No No No Yes No No No Partially Yes Yes No No bereaved families for all subsequent pregnancies. 9 2 6 38 see a bereaved mother for an appointment are aware that she has Yes Yes Yes Partially Yes Partially Yes Yes Partially Partially Partially Partially Yes Yes Partially Yes Yes 0 7 10 39 communication that she is comfortable with including agreeing Yes Yes Yes Yes No No Yes Yes Yes Partially Partially Partially Yes Yes Yes Partially Partially 2 5 10 Trusts should ensure continuity of care with the offer of regular 40 Yes Yes Yes Yes Yes Yes Yes Yes Yes Partially Partially Partially Yes Yes Yes Yes Yes assessment and extra support. 0 3 14 41 consultant appointment. Full set of women s hospital notes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 1 0 16 pregnancy is developed including a review of previous 42 Yes Partially Yes Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes pregnancies e.g. cause of stillbirth, documented management 0 3 14 Trusts should ensure that timing and mode of birth is discussed 43 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Partially No with women and documented. 1 1 12 44 stillbirth should have an antenatal glucose tolerance test (GTT) at Yes Partially Yes Yes Partially Partially Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 0 3 14 END OF AUDIT
Y&H Maternity Dashboard Supports improvement activities Includes smoking at booking and at time of delivery Includes stillbirth indicators Smoking at time of booking rate The proportion of women who are known to be smokers (as per woman s selfreported smoking status) at the time of booking Percentage of women who were smokers at time of booking by the total number of women booked (% = smokers at time of booking indicator 1 x 100) Aim for 11% or less by the end of 2015 Healthy Lives, Healthy People: a tobacco control plan for England. (DH 2011) health risks to mother and baby, before and after birth denominator for smoking cessation calculation Smoking at time of delivery rate The proportion of women who are known to be smokers (as per woman s self-reported smoking status) at the time of birth Percentage of women who were smokers at time of birth by the total number of women delivered (% = smokers at time of birth indicator 3 x 100) Aim for 11% or less by the end of 2015 Healthy Lives, Healthy People: a tobacco control plan for England. (DH 2011) health risks to mother and baby, before and after birth numerator for smoking cessation calculation
Next Steps.. Stillbirth Steering Group Commence a Peer Review sub-group to consider recommendations from the RCOG Each Baby Counts report: Key messages from 2015 Currently ensuring action plans against the SBL Care Bundle are updated Second Y&H benchmarking July 2016 Continue to monitor and share Y&H rates through the Y&H Maternity Dashboard Consider version 2 for the Maternity Dashboard e.g. CO monitoring vs self reported smoking rates Continue to drive improvements
With thanks and permission from Rachel & Baby Cory
References NHS England (2016) Saving Babies Lives Care Bundle NICE (2015) Smoking: Stopping in Pregnancy and after Childbirth [PH26] ONS online RCOG (2016) Each Baby Counts: Key messages from 2015 Y&H SCN (2015) Recommendations to Improve Stillbirth and Bereavement Care in Yorkshire and the Humber [available online at: http://www.yhscn.nhs.uk/childrenmaternity/maternity-network/maternity-documents-andlinks.php]