2012
Annual Review
Obstetric
2
Contents
Foreword
3
Introduction
4
Maternity
unit
5
What
we
offer
6
Workforce
7
Activity
measures
10
Quality
measures
11
Governance
16
Other
activities
20
Future
challenges
21
3
I am delighted to welcome you to the first annual review of Obstetric Anaesthesia at St George’s Healthcare NHS Trust. The High Risk Obstetric Anaesthetic Clinic team have been producing an annual review for several years. Our ability to achieve and maintain the highest standards of patient care depends on periodic reflection and critical evaluation of our practice.
Reviewing our practice over the past year has revealed an active year. Our performance compares favourably to national standards as set by the Royal College of Anaesthetists, the Obstetric
Anaesthetists’ Association and the Safer Chidbirth document. The recent award of CNST level 3 status to the maternity unit is a testament to that.These achievements have been the result of the quality, professionalism and hard work of staff on the unit.
Deciding on what anaesthetic quality measures to review has been influenced by the issues that women say matter most to them (receive care safely and quickly), the standards set by national bodies, risk and of course, the Trust.
It has been nearly 3 years since I became lead consultant anaesthetist for obstetric anaesthesia. I am very grateful to all my colleagues and staff for their co-operation and for almost always engaging with me to tackle issues and make the unit a better place.
I would like to introduce Dr Emma Evans as the next lead consultant obstetric anaesthetist. She starts from 1st April 2013 and I hope that she will receive excellent support from all.
In 2010, I wrote ‘fortiter in re, suaviter in modo’ (be tough in your aims but smooth in the way you put them into practice). I end my term with ‘brevis esse laboro, obscurus fio’ (when I labour to be brief, I become obscure).
Tony Addei
Tony Addei
Lead Consultant Obstetric Anaesthetist March 2013
Anaesthesia has a long tradition of improving clinical safety
and outcomes by continuous critical examination of our
practice.
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Introduction
St George’s Hospital has all the relevant specialties on site,
and has excellent facilities to care for women with complex
medical disorders in pregnancy and/or anaesthesia-related
problems in the South West Thames region.
The Obstetric Unit comprises both low-risk midwifery and consultant led units, an Obstetric HDU and a High Risk Obstetric Anaesthetic Clinic which is closely linked to the highly regarded Fetal Medicine Unit.
Anaesthetists are involved in some way or another in the care of about 60% of the women who enter an obstetric labour ward. Successive reports of the CEMD and CEMACH have emphasised the importance of anaesthetists as an integral part of the obstetric team and in the management of mothers who become seriously ill.
Our philosophy is to work in partnership with women and our obstetric and midwifery colleagues to achieve a safe and effective service.
Aims
• Provide women with the highest standard of care throughout pregnancy, birth and during the weeks that follow if required
• Ensure that the care women receive should not depend on what time they deliver • Ensure that our practice reflects the Trust values of
5
S
ignificant reduction in the total number of women booked and the total number of births as compared to 2011, after implementation of our capping policy, jointly agreed with our commissioners.T
he lowest Caesarean Section Rate in London (total rate 23.08% and emergency caesarean section rate 8.9%), which reflects good intrapartum care.O
ne of the lowest emergency caesarean section rates for failed instrumental vaginal births that reflects competencyin management of second stage of labour.
O
ne of the lowest Hypoxic Ischaemic encephalopathy (HIE) rates in the UK (1.1/1000).F
urther reduction in the number ofcomplaints relating to poor staff attitude and behaviour (6 in 2011 vs 3 in 2012) and a significant increase in formal compliments (17 in 2011 vs 54 in 2012).
The unit booked 5374 women in 2012 and delivered 5128
women as compared to 6193 and 5328, respectively, in 2011.
The Maternity Unit’s annual report (2012) noted the following
“
Our philosophy is to work in partnership
“
with women and our obstetric and
midwifery colleagues to achieve a safe
and effective service.
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What we offer
We run four services together as part of the commitment to
obstetric anaesthesia.
A round-the-clock emergency service
• Labour analgesia – epidurals, CSE, opioid PCA
• Emergency operative interventions - caesarean sections, instrumental deliveries, MROP, repair of genital tract trauma
• Obstetric high dependency care – principally haemorrhage and pre-eclampsia • Postnatal review of all women who receive an anaesthetic intervention
A planned caesarean section service on weekdays
• As part of a dedicated operating list Monday - Friday • Integrated with the emergency service
Antenatal assessment and planning service
• Assessment of women referred by midwives or obstetricians during pregnancy. The High Risk Clinic runs every Thursday morning.
Advanced Level training in Obstetric Anaesthesia and
Analgesia
• Comprehensive modular training for senior trainees who wish to develop a special interest in the subspecialty to enable them cover daytime sessions in obstetric anaesthesia as consultants
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Workforce
We have consistently and progressively increased the pool
of consultant anaesthetists who provide cover for obstetric
anaesthesia and analgesia.
12 consultant obstetric anaesthetists provide 17-18 PA Direct
Clinical Activity obstetric anaesthesia sessions a week with
prospective cover.
Members of the Obstetric Anaesthesia Group are
• Dr Tina Wood
Obstetric Risk Management
• Dr Emma Evans
Lead for Training and Obstetric Simulation
• Dr Karen Light
Lead for Recovery
• Dr Rehana Iqbal
Programme Director Foundation Year 2 and Lecturer in
Medical Ethics & Law
• Dr Renate Wendler
High Risk Clinic, HDU, Care Group Lead Theatres
• Dr Cleave Gass
Director Medical Education, Associate Medical
Director
• Dr Frank Schroeder
High Risk Clinic
• Dr Sarah Hammond
High Risk Clinic, Labour Ward Forum, Deputy Lead for
Clinical Governance
• Dr Richard Hartopp
Research
• Dr Jonathan Springett
Labour ward
• Dr Khalid Syeed
Lead for Transfusion (flexible obstetric sessions)
• Dr Tony Addei
Lead Obstetric Anaesthetist
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Workforce
Analysis of our Anaesthetic Workforce Dashboard confirms
that there was 100% cover throughout 2012 for the following
• Duty obstetric anaesthetist with no other responsibilities available 24 hours/day • Obstetric Anaesthetic assistant (ODA) with no other duties available 24 hours/day • Consultant Obstetric Anaesthetist for risk management with dedicated clinical sessions • Consultant Obstetric Anaesthetist for the High Risk Clinic
Areas that achieved less than 100% were managed using the contingency plans in the staffing levels document to address the shortfalls.
Consultant Obstetric Anaesthetist cover for delivery suite during normal working hours was 100% in 9 out of 12 months in the year. During the other three months cover ranged between 91% - 98%. The decrease in March and April was due to the resignation of a consultant obstetric anaesthetist. A replacement was appointed and started in mid-April. The decrease in November was due to maternity leave and a locum consultant has been appointed to cover. In those exceptional circumstances, senior trainees undertaking Advanced Level Training in Obstetric Anaesthesia staffed the unit with a consultant anaesthetist (mentor) doubled up and immediately available to help from main theatres. The main issue identified was the 81% - 100% consultant delivered care for elective caesarean section lists. All lists that were not delivered by a consultant were managed by senior (Advanced Level) obstetric anaesthesia trainees with the consultant obstetric anaesthetist who was covering the delivery suite in close proximity or present in theatre. This was in addition to the duty anaesthetist covering delivery suite. The anaesthetic department has created a new post in obstetric anaesthesia to be appointed in the next financial year. This will increase the pool of consultant obstetric
10
Activity measures
1723
Theatre Cases
1600
Labour Epidurals
3323
Anaesthesia Procedures
31%
of women who delivered on the
unit received epidural analgesia
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Governance
• Approved documentation governing safe practice
• CNST
• Learning from adverse incidents
• Preparing for / preventing adverse incidents
Quality measures
Provide women with
• epidural and combined spinal epidual (CSE) pain relief in labour
• anaesthesia for operative interventions
Safely
Quickly
Ability to respond to emergencies
Ability to manage High Risk women
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Quality measures
Provide women with epidural and CSE pain relief safely
Measure
Results
Target
Accidental Dural Tap
0.5% (8)
<1%
Major Neurological / non-
Neurological complications
0
-Resite
4%
<15%
Provide women with epidural and CSE pain relief quickly
Measure
Results
Target
Response time within 1 hour
97%
>90%
Response time within 30 minutes
81%
>80%
Satisfaction at follow up
Measure
Results
Target
Satisfactory / Excellent
96%
>98%
Will have again
97%
There is unequivocal evidence that regional anaesthesia (RA) is safer than general
anaesthesia (GA) for caesarean section (CS) and the majority of women now wish to be
awake for their CS.
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Quality measures
Life-threatening events can happen suddenly or unpredictably
and require anaesthetists skilled in their management to
respond quickly in order to save mothers’ or babies’ lives.
Ability to respond to emergencies
Analysis of our Anaesthetic Workforce Dashboard confirms that there was 100% cover throughout 2012 for the following:
Duty obstetric anaesthetist with no other responsibilities available 24 hours/day Obstetric Anaesthetic assistant (ODA) with no other duties available 24 hours/day
During periods of excessive workload, the other resident senior anaesthetic registrars ( general or cardiac-neuro) were called to assist or escalate to the named consultant anaesthetist responsible for the unit.
Ability to manage high risk women
Team management is essential to good obstetric practice with high risk mothers. We run a
multidisciplinary High Risk Obstetric Anaesthetic Clinic closely linked to the Fetal Medicine Unit and the Maternal Medicine team every Thursday morning.
A team of three consultant anaesthetists (Dr Hammond, Dr Schroeder and Dr Wendler) ensure continuity of anaesthetic care for patients attending the ever expanding High Risk Clinic.
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Governance
Clinical governance is about ensuring that patients are safe
and risks are managed.
Clinical Negligence Scheme for Trusts (CNST)
Healthcare organisations are regularly assessed against agreed risk management standards which have been specifically developed to reflect issues which arise in the negligence claims reported to the NHSLA. Obstetric anaesthetists play a crucial role in ensuring that those standards are met. The unit has recently achieved level 3 status. Dr Addei, Dr Evans and Dr Light were clinical leads for some of the criteria, against which the unit was assessed.
Preparing for / preventing adverse incidents
We run a robust orientation to the delivery suite for anaesthetic trainees who work on the unit. This is conducted using a standardised format with the help of a form and includes a physical tour of delivery suite, obstetric theatres, the learning environment and other relevant areas. At the end of the induction, the trainee and the consultant who conducted the induction both sign the form.
‘Fire drills’ have been shown to improve staff performance. Within obstetric practice they have been used to help to identify system problems. It is recommended that all obstetric units institute labour ward based team training using simulation. Our unit runs multidisciplinary skills and drills for haemorrhage, eclampsia, sepsis and other scenarios. Dr Evans is lead for training and obstetric simulation.
Learning from adverse incidents
Consultant anaesthetists are members of the maternity SI panels (Dr Addei, Dr Hartopp), Labour Ward Forum (Dr Hammond) and Risk Management Team (Dr Wood).
Approved documentation that governs the safe practice of
obstetric anaesthesia on the unit has recently been updated.
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Advanced Level Training in Obstetric Anaesthesia & Analgesia
Comprehensive modular training introduced in 2007
(Currently consultant anaesthestist elsewhere,St George’s hospital or trainee)
February
August
2007 A Comberr A Hapgood O Thompson 2008 S Foster K Rahman M Rowlands E Combeer W Hosein N Muller 2009 C Bailey P Bathke K Syeed S Bourke S Hammond R Hartopp S Saxena 2010 C Johnston S Kunnumpurath A Sherrington E Hipwell M Ravindran S Williams 2011 L Boss E Clarke V Cowie P Goyal W Birts J Teare A Riccoboni 2012 V Felmine R Savine A Whelan A Lim A O’Neil D Tong J Teare 2013 L Kelliher J Ezihe-Ejiofor A Shonfeld H Bagia D Sacco19
Audit/Publications
• Numerous audit projects
• Posters and oral presentations at local,
regional, national and international events
• Publications in academic journals
• Contributions to chapters / section editor for
books
Members of the group have been involved in multiple
activities
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• We contribute yearly audit data to the National Obstetric Anaesthetic Database
(NOAD) and the South West Thames Regional Obstetric Anaesthetic Audit
• Our 5th Annual Obstetric Update for consultant anaesthetists was held on 29th
November 2012 and very well received
• We hosted the Group of Obstetric Anaesthetists in London (GOAL) autumn meeting
on 19th October 2012 at the Royal College of Anaesthetists. There was an excellent
attendance of 105 anaesthetists from London!
Audit data
Annual Obstetric Update for Consultants
GOAL meeting at the Royal College of Anaesthetists
“
Many thanks for organising a great GOAL
“
meeting. The talks were all excellent. The
informal feedback I received was highly
complimentary and appreciative.
Other Activities
Nuala Lucas Consultant Anaesthetist Chairman, GOAL
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• Improve the % of women satisfied at follow up visit with their
epidural for pain relief in labour from 96% to > 98%. We need to
understand why the 4% were not satisfied.
• Work towards providing 24 hour obstetric anaesthetic consultant
cover for the maternity unit as part of the commitment to ensure
that the care women receive should not depend on what time they
deliver. This is a London Health Programmes standard. Discussions
are ongoing to introduce a separate obstetric on call rota for
consultant anaesthetists.
• Maintain our achievements and explore other measures to
benchmark our practice.
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Giving birth is an emotional and life-changing event, which a
woman and her family will remember for life. Having had either
a positive or negative experience can influence the level of
engagement a woman has with maternity services for any future
pregnancies.
