Prevention of Cerebral Palsy in Preterm Labour (PReCePT)
A scalable quality improvement initiative co-designed, with parents, obstetric, midwifery and neonatal clinical teams in West England to increase the uptake of Magnesium Sulphate given intrapartum during preterm labour.
Being born preterm is the leading cause of Cerebral Palsy (CP), with lifelong impact on children and families. Magnesium Sulphate (MgSO4) given intrapartum during preterm labour reduces the relative risk of CP in very preterm infants by 30% 1. The number needed to treat (below 30 weeks gestation) to prevent one case of CP is 37 2, and yet UK use was inconsistent 3, leading to preventable health inequalities.
In West England we co-designed, with parents, obstetric, midwifery and neonatal clinical teams, a scalable Quality Improvement (QI) initiative called PReCePT (Prevention of Cerebral Palsy in Preterm Labour), which was piloted as PReCePT1 in five maternity units from 2015. The uptake of MgSO4 increased from 21% to 88% within 6 months 4. PReCePT1 influenced the UK national preterm labour guideline, which recommends intrapartum MgSO4 in preterm labour, < 30 weeks gestation 5.
a) scalable QI intervention ready for national adoption/spread
b) development of the national metric for MgSO4 uptake, in partnership with the National Neonatal Audit Programme (NNAP).
In 2018 the Health Foundation funded us to scale-up and research how best to support teams to adopt PReCePT 6. The national implementation of PReCePT was commissioned by NHS England to be delivered by the Academic Health Science Network (AHSN) across England 7.
The primary measure is percentage uptake of MgSO4 per unit as reported by NNAP. The size of the national adoption problem became evident in the 2017 NNAP report. Only 44% of preterm babies received the benefit of MgSO4 neuroprotection, with large variability (26-71%) between Operational Delivery Networks (ODNs).
Our improvement plan
For every maternity unit to adopt the NICE NG25 guidance and achieve 85% uptake of administration of MgSO4 to eligible mothers in preterm labour in England by April 2020.
A novel network QI delivery model:
- delivery by 15 AHSNs, aligned to Neonatal ODNs, in all 152 maternity/neonatal units
- regional QI and clinical leads, working with unit-level midwife champions (clinical time funded)
- PReCePT obstetric and neonatal lead in each unit, enabling a perinatal team approach
- standardised QI resources (toolkit, implementation guide, training presentations and promotional collateral) 7
- nested randomised control research trial, in 40 maternity units, designed to assess the effectiveness of two different QI implementation methods 8
Mean average MgSO4 uptake achieved in England in 2019 was 84.9%.
Variability between English ODNs was substantially reduced (range in 2016: 26-71% vs. range in 2019: 77.5-93.7%). The likely impact will be a substantial ongoing reduction of avoidable cerebral palsy. PReCePT enabled a national perinatal QI network and will provide best practice evidence for national scaling up of perinatal QI initiatives.
Supportive quotes from service users and perinatal teams:
Case example from Watford General Hospital:
Woodland Neonatal Unit at Watford General Hospital, West Hertfordshire NHS Trust is Local Neonatal Unit within East of England Neonatal Network and cares for around 1200 neonates each year. Our unit has actively engaged with National Neonatal Audit Programme (NNAP) since its inception in 2007. Research has shown that magnesium sulphate (MgSO4), given antenatally in threatened preterm labour, is neuroprotective and reduces cerebral palsy. In preterm infants born less than 30 weeks gestation use of antenatal MgSO4 is benchmarked as an NNAP audit measure.
Watford General Hospital was an outlier for this audit measure in the 2017 NNAP report (2016 data). In this case study, we demonstrate how we have used NNAP antenatal MgSO4 data benchmarks to guide our quality improvement project and improved MgSO4 uptake in eligible preterm deliveries. Moreover, we have raised team awareness, built intrinsic team capability, encouraged parent involvement and offered an informed treatment choice.
Our improvement plan:
Our improvement journey started in 2016, when we became aware that our neonatal service was an outlier for antenatal magnesium sulphate (MgSO4) administration with an uptake 15%, which was far below the national average (43%).
Strategy for change:
Using the Institute of Healthcare Improvement (IHI) model we aimed to increase the uptake of MgSO4 in eligible preterm deliveries. Improvement measure was defined as an increase in the uptake of MgSO4 from 15% in 2016 to 40%, hence reaching the then national average. Primary, secondary drivers were identified which informed change ideas. These changes were tested in iterative plan, do, study, act (PDSA) cycles.
What we did:
Development of a driver diagram allowed us to conceptualize the issue and determine the pathway to achieve our goal. Using this tool with its excellent visual display of change ideas, we could have brain storming sessions and engagement between the relevant stakeholders such as midwives, obstetricians and neonatal staff and discuss potential solutions:
We created a run chart, to display compliance data in % (y axis) over time (x axis). It’s a simple and effective QI tool we used to formulate the aim and engage the stakeholders by depicting the MgSO4 compliance monthly. In addition, the run chart was guiding the improvement team to determine if the changes we were making are leading to improvement:
We have increased awareness amongst the neonatal, obstetric and midwifery teams by presenting run chart data (Figure 2) in monthly Perinatal Mortality and Morbidity meetings. We commenced frequent bitesize MgSO4 awareness and engagement sessions with all the stakeholders. A new and simple guideline for MgSO4 administration was developed and implemented and we encouraged 1:1 midwifery care in labour. Safety “huddles”, twice daily board rounds, were introduced to identify all eligible women. Additionally, we involved the service users, by providing them with a parental information leaflet with the antenatal counselling pack and MgSO4 information were included in the antenatal counselling conversations and golden hour care checklist.
Main challenge was to change staff’s ethos and perceptions, bring down the “barriers” and move away from the culture “this is how we do it for years and it works for our patients”. We achieved this by enhancing communication and knowledge sharing through safety huddles, identifying clinical champions to support the team, presentations in joint multidisciplinary team forums and empowering ward level leadership. Encouraging parent involvement raised further awareness of this important neuroprotective treatment.
According to NNAP 2016 report only 15% of eligible women received antenatal MgSO4 at Watford General Hospital, compared to a national average of 43%. The table below shows steady improvement from 2016 to 2018 with the implementation of change ideas. The 2017 data show that we met and surpassed our improvement target achieving a compliance of 55%, well above the national average. The 2018 NNAP data shows further improvement and a sustainable change. This sustainable improvement has a direct impact on the long-term neurodevelopmental outcomes and by extension to the quality of life of preterm infants born at less than 30 weeks of gestation:
Top tips for implementation:
- Identify an appropriate maternity-neonatal forum to share NNAP MgSO4 data
- Identify and engage stakeholders and frontline champions within maternity and neonates
- Use live NNAP dashboard on Badgernet to generate live run charts
- Partnering with parents for improvement
Justine Chung, Matron, Delivery suite
Bhavani Sivakumar, BadgerNet data analyst
Dr Sankara Narayanan (Consultant Neonatologist & NNAP lead), Dr Anastasia Katana (Locum Consultant Neonatologist), Ms Nanda Shetty (Consultant Obstetrician), Ms Marcellina Coker (Consultant Obstetrician)
Neonatal & Obstetrics Department, Watford General Hospital, West Hertfordshire NHS Trust
PReCePT Challenges and learnings
Lessons learnt to foster success:
- Place babies and families at the heart of the programme – parent advisers have strongly advised that MgSO4 be offered to all eligible mothers to help improve the life chances of preterm babies (see video clips below):
- Funded support/time for front-line clinicians to deliver the project key to successful delivery
- Fostering a perinatal team, joining together obstetric, midwifery and neonatal clinicians – developing perinatal clinical leadership in every unit (see video clip below):
- National strategic alignment to the Maternity and Neonatal Safety Improvement Programme and ODNs
- Positive use of social media to engage a truly national PReCePT community – see @PReCePT_MgSO4 and @PReCePT_Study on Twitter
- Designing a project that was responsive to differences in unit level culture and microsystems
- High number of stakeholders to engage/coordinate with, challenged by regional variation
- Access to real-time data to support the monitoring of MgSO4 uptake
Top tips for implementation
- Engage and empower perinatal clinicians to lead at local and regional level
- Provide the QI skills, evidence and support to effect change
- Create a social media community of practice and communication plan
- Development a metric for national measurement of MgSO4 uptake, utilising routine data
- Influence national policy; MgSO4 neuroprotection has become routine practice by inclusion in the NHS Long-Term plan 9, “Saving Babies’ Lives Care Bundle” 10 and NICE guidance 5, enabling sustainability of uptake.
- West of England Academic Health Science Network (WEAHSN)
- National Academic Health Science Network
- University Hospitals Bristol and Weston NHS Foundation Trust
- The Health Foundation
- National Institute for Health Research Applied Health Collaboration West (NIHR ARC West)
Authors: Karen Luyt (PReCePT Programme Clinical Lead and PReCEPT Study Chief Investigator), Ellie Wetz (Programme Manager), Pippa Craggs (PReCePT2 Project Manager)
Organisations: West of England AHSN and University Hospitals Bristol & Weston NHS Foundation Trust
First published in the NNAP Annual Report 2020
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Doyle LW, Crowther CA, Middleton P, Marret S, Rouse D: Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. The Cochrane database of systematic reviews 2009(1): Cd004661.
Crowther CA, Middleton PF, Voysey M, Askie L, Duley L, Pryde PG, Marret S, Doyle LW; AMICABLE Group. Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant data meta-analysis. PLoS Med. 2017 Oct 4;14(10):e1002398
Lea CL, Smith-Collins A, Luyt K. Protecting the preterm brain: Current evidence-based strategies for minimising perinatal brain injury in preterm babies and improving neurodevelopmental outcomes. Arch Dis Child Fetal and Neonatal. 2016 Dec 23. doi: 10.1136/archdischild-2016-311949.
Burhouse A, Lea C, Ray S, Bailey H, Davies R, Harding H, Howard R, Jordan S, Menzies N, White, Luyt K.Preventing cerebral palsy in preterm labour: a multiorganizational quality improvement approach to the adoption and spread of magnesium sulphate for neuroprotection. BMJ Open Quality 2017;6:e000189.
National Institute for Health and Care Excellence (2015) Preterm labour and birth. NICE guideline (NG25). 2015.
Health Foundation Scaling-up Improvement award. https://www.health.org.uk/improvement-projects/precept2-reducing-brain-injury-through-improving-uptake-of-magnesium-sulphate
Finding the best way to scale up a perinatal Quality Improvement initiative: The PReCePT study. https://arc-w.nihr.ac.uk/research/projects/preventing-cerebral-palsy-in-pre-term-babies-the-precept-study/
Saving Babies Lives Care Bundle. Element 5, p38 https://www.england.nhs.uk/wp-content/uploads/2019/07/saving-babies-lives-care-bundle-version-two-v5.pdf