2012Annual Review

Obstetric Anaesthesia

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ContentsForeword 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

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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.

Foreword

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IntroductionSt 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

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Significant 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.

One of the lowest emergency caesarean

section rates for failed instrumental

vaginal births that reflects competency

in management of second stage of labour.

One of the lowest Hypoxic Ischaemic

encephalopathy (HIE) rates in the UK

(1.1/1000).

Further reduction in the number of

complaints 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.

Maternity Unit

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What we offerWe 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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WorkforceWe 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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WorkforceAnalysis 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

anaesthetists to help us achieve 100% cover.

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Activity measures

1723 Theatre Cases

1600 Labour Epidurals

3323 Anaesthesia Procedures

31% of women who delivered on the unit received epidural analgesia

5128 Women Delivered

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Governance • Approved documentation governing safe practice

• CNST

• Learning from adverse incidents

• Preparing for / preventing adverse incidents

Quality measuresProvide women with

• epidural and combined spinal epidual (CSE) pain relief in labour

• anaesthesia for operative interventions

Safely QuicklyAbility to respond to emergencies

Ability to manage High Risk women

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Quality measuresProvide 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% -

Reference: Royal College of Anaesthetists | Raising the Standard: a compendium of audit recipes | 3rd Edition 2012

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.

Category 4 = Elective CS Category 1-3 = Emergency CS

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Quality measuresLife-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.

High Risk Clinic

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GovernanceClinical 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 Sacco

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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 ConsultantsGOAL 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.

Future challenges

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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.

What women and their families need and want from a maternity service

Annual Review 2012