Trust in collaboration introduces an initiative to reduce cases of cerebral palsy in young children due to preterm births, increasing MgSO4 uptakes and enhancing the quality of maternity care

Outline:

Preterm birth is the leading cause of brain injury and Cerebral Palsy (CP) with a lifelong impact on children and families. The average lifelong healthcare cost of CP is around £800,000 per individual. Magnesium Sulphate (MgSO4) given to mothers during preterm birth is very effective at protecting the babies’ brain (see portfolio of evidence A1). High quality evidence (Cochrane Meta-analysis) suggests that CP can be reduced in a third of cases by using MgSO4. The number needed to treat is 37, so for every 37 mothers treated in preterm labour, one case of CP can be prevented (F1,2).

The UHBristol NHS Trust perinatal team at St Michael’s Hospital were early adopters of this life altering treatment. We discovered that use was not widespread in 2014, with fewer than 10% of UK mothers in preterm labour (below 30 weeks gestation) receiving MgSO4 (A2,3).

The PReCePT (Prevention of Cerebral Palsy in Preterm Labour) Quality Improvement Initiative was developed in collaboration with the West of England AHSN in 2015. The five Trusts in the West of England collaborated. We developed a care pathway and trained maternity teams, led by midwife champions, using QI coaching in the clinical setting. Visual data management and tools to ‘nudge’ to remind staff were utilised to encourage behaviour change (A4). Patients who had lived experience of preterm birth were part of the project team. The QI package evolved and was further refined by site specific innovations contributed by each of the maternity teams.

Challenges:

The challenge was that MgSO4 is a treatment given to a mother in preterm labour by the maternity team, whereas Cerebral Palsy, the condition it prevents, is diagnosed by the neonatal clinical team at 1 to 2 years of age. The benefit was therefore not obvious to the maternity teams and there seemed to be a gap in translation.

The positive factors: - MgSO4, given in the same way/dose, was routinely given for pregnant women with severe preeclampsia. Therefore, midwives were already comfortable with the use. - The evidence base was clear that MgSO4 was effective in preventing CP when given in preterm labour before 30 weeks gestation. - MgSO4 is a very affordable, cost effective treatment.

Our goals were to: 1. Improve MgSO4 uptake in 5 West England Trusts to at least 65% (the best international uptake at the time). 2. Develop a scalable QI Intervention through co-production with the 5 maternity teams and patients (A5). 3. Develop a plan for national adoption/spread.

Outcomes:

Goal 1: The first PReCePT phase trained 664 perinatal staff in 5 Trusts. The baseline MgSO4 uptake was 22%, and increased to above 65% in every Trust within 6 months (B1). Based on a number needed to treat of 37 (F2), between 5-10 cases of cerebral palsy have been prevented since 2015 in the W-England, with an estimated healthcare saving to the NHS of ~£5 million (F4).

Goal 2:

Through co-design/production with the 5 perinatal teams and patient experts we developed and refined a QI package (patient information leaflet, QI toolkit and implementation manual) and published the rationale and method in BMJ Quality (B2).

Goal 3:

• We developed the national metric for MgSO4 in the BadgerNet dataset, which was adopted into the National Neonatal Audit (NNAP), providing complete national measurement of MgSO4 uptake for the first time in 2017(B3.1).

• The PReCePT steering group, influenced the NICE guideline (F3) for preterm labour to include MgSO4 for fetal neuroprotection, which ensured that national evidence based guidance was in place.

• We started planning a funding application to the Health Foundation’s annual “Scaling-up” funding round and approached the AHSN National Network for inclusion of PReCePT in the National Implementation Programme.

Spread:

PReCePT was awarded Health Foundation Scaling Up Improvement funding (2017), to deliver the QI intervention at scale in a national cluster randomised trial (PReCePT Study) to test and evaluate different methods of implementation in 40 maternity units (C1). NHS-England supported national adoption/spread of PReCePT (£1.0 Million funding), delivered through the AHSN Network (15 AHSNs). This will enable implementation in all 152 maternity units in England (C2).

The national PReCePT Programme provides QI support and training using a network approach, with funded time for regional clinical obstetric/neonatal leads and PReCePT midwife leads in every maternity unit. The PReCePT study is nested within the national programme, and provides additional QI coaching, QI materials and funded time for a perinatal team (midwife, obstetric and neonatal champions) at unit level. PReCePT is the first perinatal QI intervention to be delivered at national scale in this way. PReCePT teams are now in situ in every unit.

Use of MgSO4 in preterm birth is now a recommended treatment in the NHS 10-year plan to reduce brain injury in preterm babies (C3). This will ensure that every mother in preterm labour will be given the choice and every preterm baby will reach their full potential.

Value:

Quantitative Value: From 2015 West-England managed to sustain high level MgSO4 uptake (~80%) as a direct result of PReCePT. With a Number Needed to Treat of 37 (below 30 weeks gestation), it is estimated that around 5-10 cases of cerebral palsy have been prevented, with predicted healthcare savings of around £5 million, which excludes social and societal costs. The cost of severe cerebral palsy to children and families is unquantifiable.

Qualitative Value: Co-production: We put our patient/parent representatives in the centre of the project team and they became essential to the design and delivery of PReCePT. Parents and babies were at the heart of it and we were led by their needs and experiences.

Collaborative perinatal team work: The legacy of PReCePT is the fostering of perinatal teams, obstetric, midwifery and neonatal colleagues all working together to optimise outcomes for both mother and baby. An approach which paves the way for countless opportunities of collaborative and innovative working (D1.4,D1.9).

Culture of continuous improvement: Many of the clinical teams involved in PReCePT are now fully paid up members to the QI school of thought and have applied the learning from this project to other maternity and neonatal areas for improvement.

Involvement:

PReCePT had full buy in and support of the CEOs of the lead (D1.1, D1.2) and 4 adopting Trusts, with representation on the WEAHSN Board. This meant that project implementation in each site could be enabled, reducing bureaucracy and imbed at speed.

Patient/parent involvement was sought from inception of the project. Bliss was approached who put the project team in touch with two mothers, Monica and Elly, who had both lived the experience of preterm birth (E1.2, E1.3, E1.4). Our parent advisors were part of the project team and contributed to all QI materials, communication plans and they wrote the patient information leaflet. Both parent advisors are members of the PReCePT Programme Board and Study Steering committee. Elly has gone on to do media interviews and lectures to educate maternity teams and to raise public awareness of preterm birth and brain injury.

PReCePT launched the first combined meeting of the South West Obstetric Network and South West Neonatal Forum. For the first time maternity and neonatal consultants and midwives shared learning and experience and produced the draft PReCePT clinical pathway and clinical toolkit in an afternoon. There was complete clinical buy-in and a productive perinatal collaboration was forged (D1.4,6,7,8).