Rapid introduction of virtual consultation in a hospital-based Consultant-led Antenatal Clinic to minimise exposure of pregnant women to COVID-19.

The COVID-19 global pandemic dictated rapid change to outpatient services within our London-based maternity hospital. Coupled with long waiting times in the Consultant-led Antenatal clinic, we aimed to reduce hospital footfall and unnecessary contact with a clinically vulnerable patient population by reducing face-to-face consultations. Numerous specialties have already successfully implemented safe and effective teleconferencing, allowing remote review while reducing the risks posed by face-to-face contact. A target to see at least 15% of women remotely was set to reduce footfall in the Consultant-led Antenatal Clinic. We aimed to reduce face-to-face waiting times to a mean of 30 min. In March 2020, clinics were prevetted by the clinic consultant to carefully select appropriate women suitable for video or telephone consultations. Clinic templates were changed, increasing appointment times by 5-25 min each. 'AccuRx' software was tested and used to communicate appointment details and conduct the consultation. In-person waiting times in the clinic and number of virtual consultations over a 3-month period was recorded, along with qualitative feedback from service users and staff through surveys and departmental meetings. Mean waiting times were reduced by 33% from 45-30 min and multiple service-user benefits were noted, including partner involvement, convenience of waiting for appointments at home and removing requirement for childcare. However, limitations of internet connectivity, need for time to prevet clinics and lack of a robust administration system to inform women of their appointment type were highlighted. Further work is required in these areas to ensure sustainability and improvement of this process for the future.

Use of quality improvement methodology to improve care of women with hypertensive disease in pregnancy and haemorrhage in Yemen (low-income, high-insecurity setting).

This safety improvement project used quality improvement methods in a Comprehensive Emergency Obstetric and Newborn Care facility in Yemen, managed by an international humanitarian non-governmental organisation. It is responsible for about 6500 deliveries per annum. Following a local review of maternal deaths and serious incidents in 2020-2021, care for women with severe hypertensive disease in pregnancy and postpartum haemorrhage were highlighted as potential areas for improvement. These are also the two most common reasons recorded for maternal mortality in Yemen (and in many low-income countries worldwide). We also wanted to foster an open and honest safety culture within the department that encouraged learning from error.We used an inclusive approach in designing the improvements, with change ideas collated via frontline doctors, midwives and nurses working in the maternity unit. Data were collected via manual audit, and through routinely collected data. We focused on the following measures: number of incidents reported per month, documentation quality of antihypertensive prescriptions, fluid restriction practices in women with severe pre-eclampsia, number of minutes taken to control severe hypertensive episodes, postpartum haemorrhage identification rates and tranexamic acid stock usage. We evaluated the efficacy of team simulation training through precourse and postcourse questionnaires.We found demonstrable improvement in our measures relating to treatment of women with hypertensive disorders of pregnancy, and in postpartum haemorrhage identification and treatment. Team simulation training was a difficult intervention to sustain but was received well with positive results during our test session. Incident reporting showed a temporary increase, but this effect was not sustained.We concluded that quality improvement methodology is a valuable tool even in challenged healthcare settings such as this one, in an active conflict zone. Behaviour change in team culture and safety culture is harder to sustain and demonstrate without a long-term strategy.

Rapid quality improvement in a preterm birth clinic care pathway during the COVID-19 pandemic.

BACKGROUND: Preterm birth (PTB) occurs in 8% of births in the UK. At Imperial College Healthcare NHS Trust, our PTB prevention clinic manages the care of approximately 1000 women/year. Women referred to the clinic are seen from 12 weeks of pregnancy with subsequent appointments every 2-4 weeks to measure cervical length (CL) using transvaginal ultrasound (TVUS). Women with a history of cervical weakness or short cervix on TVUS are offered a cervical cerclage. LOCAL PROBLEM: During the COVID-19 outbreak, pregnant women were strongly advised to avoid social mixing and public transport. The National Health Service had to rapidly adopt remote consultation and redesign clinical pathways in order to reduce transmission, exposure and spread among women at high risk of PTB. METHODS: We focused on Specific, Measurable, Achievable, Realistic and Timebound aims and used a driver diagram to visualise our changes. We used a series of Plan Do Study Act cycles to evaluate and adapt change ideas through the UK's national lockdown during the COVID-19 pandemic between 23 March and 29 May 2020. RESULTS: We reduced the number of face-to-face appointments by 54%. This was achieved by increasing remote telephone consultations from 0% to 64%, and by reducing the intensity of surveillance. The rate of regional anaesthetic was increased from 53% to 95% for cerclage placement in order to minimise the number of aerosol-generating procedures. Patient and staff satisfaction responses to these changes were used to tailor practices. No women tested positive for COVID-19 during the study period. CONCLUSIONS: By using quality improvement methodology, we were able to safely and rapidly implement a new care pathway for women at high risk of PTB which was acceptable to patients and staff, and effective in reducing exposure of COVID-19.