Nil By Mouth: Safety or Sufferance?

R.Williams, I. Fabre, E. Muscat, K. Mohuiddin

Results 4

Pre-op fastingdecreasesthevolumeandacidity of the stomachcontents, thereforereducingtherisk of aspiration.

Ensuringsurgical ward staff understandtheclinical NBM preventsunnecessarydelays to proceduresand excessive fasting of patients

Aim 2

To reduce excessive fasting of patients by improving ward staff knowledge of NBM guidelines.

Oral intake cut-off times pre-op (NICE, 2020):

Meals:6hours

Milky drinks:6hours

Clear fluids:2hours

Medications: 30 minutes

Methods: PDSA 3

Cycle 1: Ward staff survey

Cycle 2: Foundation doctor teaching + ward posters

Cycle 3: Retained posters, guidelines emailed to nursing staff + foundation doctor teaching

Interpretation 5

Improvementbetween1st +2nd cycles for nursing staff andHCAs across individualnutritionoptions andcompleteanswers; however, correct answers from both staff classes declined in the3rd cycle.

Reduction in fully correct answers from doctors between1st +2nd cycles;however,answersimproved in the3rd cycle

Next Steps 6

Initialsuccessfulapplication of ward posters.

Posters eventuallyremoved, staff reallocation

Amixedresponsethat may bedue to staff turnover, position in theacademicyearandteachinguptake.

Further cycles shouldbeconductedwithinashorterperiod of time to assess knowledgewithin each rotation of doctors.

Next intervention:visualpromptusingbedside NBM signs with guidelines,andteachingsessions for foundationdoctors on notonlytheguidelines,but also clear documentation in thenotes for mealandfluidcut-off times

Is this improving patient care?

It’s difficult to assessif knowledge is beingapplied,butauditingdocumentation in thenotes may be an option. Also, despitebest laid plansthe vast majority of patients are on emergencytheatre lists which are liable to orderchanges.

Miss.Krishna Murala, Consultant Obstetrician and Gynaecologist

Mrs.Stephanie Larcombe , Transformation midwife

Stephanie.Larcombe@ydh.nhs.uk

Project Aim: To reduce the overall incidence of PPH at YDH

To reduce the overall incidence of post-partum haemorrhage (over 1500mls) in singleton pregnancies by 2% in order to align Yeovil District Hospital Maternity Unit with the best performing units in England and Wales (top 20%) by September 2020

Background

YDH were identified as a outlier for postpartum haemorrhage above 1500mls in 2018/2019. The National Maternity and Perinatal Audit benchmarked PPH of 1500 or above at 2.9%. YDH rates were identified as 4%, 1.1 % higher. Blood loss between 500-1499 mls were also higher at 38%, the NMPA average 34.1% Post partum haemorrhage (PPH) and massive obstetric haemorrhage (MOH) are associated with maternal morbidity and mortality outcomes that have a negative impact upon the postnatal wellbeing of the woman and her family.

Reducing the incidence of postpartum bleeding above 500mls at YDH by introducing processes and strategies to identify risks factors, and respond to the cause will improve maternal and neonatal outcomes and the overall health and wellbeing of the woman and her family and ultimately reduce PPH over 1500mls.

Approach taken

• Staff SCORE Survey. Debriefs with staff, poster of themes from the survey/debriefs Measures of improvments included data collection via notes audit, maternity dashboard and maternity IT systems.

• Data plotted on run and SPC charts, outcome and process measures used.

• PDSA cycles to trial small test of change.

• Weekly skills drills to embed the culture

Change ideas

• Measured blood loss through the introduction of digital scales in each labour room.

• Implemeneted a validated risk assessmnet tool designed through two tests of change and audit its use

• MVP to collate patient experience of postpartum haemmorrhage

• Administration of syntocinon IV and tranexamic acid for all Caesarean sections

• Learning from excellence template

Outcome and impact

At this stage of the project the data shows that PPH rates has reduced to 3.3% . Data audit has increasing compliance in using the scales to measure blood loss and use of the risk assessment ,regular skills drills are contributing to reducing PPH rates in the unit.

Learning & Next steps

Service user feedback on their experienece of PPH as qualitative data has been powerful during skill drills to inform practitioners of the language we use when managing PPH and how we can improve on our practice for the women we care for.

We are confident that we will see further improvement in reducing PPH of 1500mls or above as we continue on our MatNeoSip journey, continued review of the risk assessment, weekly audit of the use of tools and PPH skill drills with staff on the labour ward and in mandatory training, will embed the use of staged management of PPH in theatres to make further reductions in PPH.