Lessons from a critical review of stillbirths?
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Lessons from a critical review of stillbirths? Malcolm Griffiths
description
Lessons from a critical review of stillbirths?. Malcolm Griffiths. Avoiding avoidable stillbirths. Defining the unavoidable (lessons from an audit of stillbirths at L&D). Malcolm Griffiths. Background. CEMACH Data 2004 (E&W&NI). CEMACH Data 2004 (E&W&NI). CEMACH Data 2004 (E&W&NI). - PowerPoint PPT Presentation
Transcript of Lessons from a critical review of stillbirths?
Lessons from a critical review of stillbirths?
Malcolm Griffiths
Avoiding avoidable stillbirths
Malcolm Griffiths
Defining the unavoidable(lessons from an audit of stillbirths at L&D)
Background
CEMACH Data 2004 (E&W&NI)
CEMACH Data 2004 (E&W&NI)
CEMACH Data 2004 (E&W&NI)
SB rates
2000 2001 2002 2003 2004
E&W
NI
5.4 5.4 5.7 5.8 5.7
L&D 8.9
Aims of the project
Reduce the number of stillbirths to women resident in Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital
By reducing avoidable stillbirths
Methodology
Retrospective auditCritical incident review of each case by a
multidisciplinary panelOpen non-punitive discussionClassification of avoidable/non-avoidableFurther review of common issues
Contributors
Kathy WallerHelen LucasKatie ChiltonEleanor MirzaiansTracey ScivierMartina McIntyre
Sandra WhiteHilary HemmingSue JalaliHVStephen RamsdenMalcolm Griffiths
Topics
Retrospective Audit (Sandra White)Critical analysis of cases
Risk factorsAvoidabilityIssues
Birthweight studyAreas for improvement/action
As we go along!Reprise!
Retrospective dataMassive amounts of data
Each stillbirth told its own story
More common in primips
Many of the women had had multiple attendances
Much higher rates by
•Ethnic origin
•Practice
•Electoral wards
Avoidable Stillbirths
• More appropriate actions by clinical staff likely to have altered outcome
• More appropriate actions by mother or family likely to have altered outcome
Avoidable & Unavoidable Stillbirths
Unavoidable
Avoidable - staff
Avoidable-patient/family
More appropriate actions by clinical staff likely to have altered outcome
• Failure to consider induction of labour in high risk case (raised BP)
• Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour
• Failure to recognise non-reassuring CTG
More appropriate actions by clinical staff likely to have altered outcome
• Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring)
• Failure of GP to mention recent treatment for diabetes in referral letter
More appropriate actions by clinical staff likely to have altered outcome
• Failure to consider induction of labour in high risk case (raised BP)
•Feedback to clinician
More appropriate actions by clinical staff likely to have altered outcome
• Failure to comply with current policy (regarding fetal monitoring) where patient declined induction of labour
•Feedback to clinician
•Emphasising policy
•Empowering other staff to intervene
More appropriate actions by clinical staff likely to have altered outcome
• Failure to recognise non-reassuring CTG
•Feedback to clinician•Increased training•Emphasising policy•Empowering other staff to intervene
More appropriate actions by clinical staff likely to have altered outcome
• Failure to continue intensive fetal monitoring (IUGR – failed IOL – no further monitoring)
•Feedback to clinician
More appropriate actions by clinical staff likely to have altered outcome
• Failure of GP to mention recent treatment for diabetes in referral letter
•Feedback to clinician
More appropriate actions by patient or family likely to have altered outcome
• Late booking – failure to receive anti-HIV therapy
• Delay in seeking help (decreased movements & APH)
• Refused appropriate induction of labour
• Delay in seeking help (APH)
More appropriate actions by patient and staff likely to have altered outcome
• Patient being followed up in DAU due to be reviewed in ANC - DNA
More appropriate actions by patient and staff likely to have altered outcome
•Meeting with members of the community•Access to minority language link-workers by mobile phone•Specialist HIV midwife•Policy for chasing DNAs
“Unavoidable”
Missed IUGR
Missed IUGR in twins
Missed diagnosis of “diabetes”
“Unavoidable”
Missed IUGR
•Customised Growth Charts pilot•Customised Growth Charts RCT•Possible need for work with ultrasonographers
“Unavoidable”
Missed IUGR in twins
•Review evidence for more frequent scans•Review policies in other units•Consider greater use of SFH charts
“Unavoidable”
Missed diagnosis of “diabetes”
•Ask NICE to consider merits of screening for gestational diabetes•Local review – possible selective screening
Birthweights
Are “unexplained” stillbirths missed intra-uterine growth
retardation (IUGR)?
0 to25
25 to50
50 to75
75 to100
Observed0
5
10
15
20
25 Observed
Expected
•Feedback to clinician•Increased training•Emphasising policies•Empowering other staff to intervene• Meeting with members of the community•Access to minority language link-workers by mobile phone•Specialist HIV midwife•Policy for chasing DNAs
Reprise!
•Integration of community midwifery and health visiting•Improve access of ethnic minority women to service•Expected HV involvement would be welcome by bereaved families and would allow late feedback –
not so!
And also!
Lessons for others•The critical incident review approach is useful and could be used in other areas (operative deaths, ITU deaths, readmissions)•But needs
•Manageable numbers•Multidisciplinary input•Openness & Strict approach•Enthusiasm & Ownership•“Nagging voice”
Aims of the project
No proof yet that we have achieved our aim Reduce the number of stillbirths to women resident in
Luton/South Bedfordshire or those delivering at Luton & Dunstable Hospital
By reducing avoidable stillbirths
But we are hopeful
• Gestation specific birth weight centilesFrom January 2005 onwards, CEMACH has collected adequate information to allow the application of appropriate gestation-specific birth weight centiles to stillbirths and neonatal deaths. This will enable us to estimate the number of deaths that are of babies who are small for gestational age. This, coupled with a further question on evidence of fetal growth restriction, will allow some exploration of the association between growthrestriction and stillbirth and neonatal death at a national level.
