Prevention of Cerebral Palsy in PreTerm Labour (PReCePT)

Prevention of Cerebral Palsy in PreTerm Labour (PReCePT)

The antenatal administration of magnesium sulphate (MgSO4) to mothers during preterm labour has been demonstrated to reduce the incidence of cerebral palsy. Initially developed by the West of England Academic Health Science Network (AHSN) in collaboration with University Hospitals Bristol NHS Foundation Trust the national PReCePT project sought to increase uptake to 85%.

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The 2018 Neonatal Audit Programme highlighted that the West Midlands region had the worse UK MgS04 administration performance in 2017. Over the 12 months to March 2019, the West Midlands region achieved only 66.3% administration of MgS04. There was much unit variation within the region.

The West Midlands Maternity Clinical Network, working in partnership with the West Midlands AHSN, Staffordshire, Shropshire & Black Country Neonatal Operational Delivery Network and the Southern West Midlands Neonatal Operational Delivery Network held a regional launch event on 19 March 2019 to support the rollout of the PReCePT programme to all 13 trusts in the West Midlands.

There was a very strong start and according to BadgerNet Neonatal data, the region achieved an administration rate of 84.6% during April 2019. Throughout late spring and the summer more units launched their projects and administration rates varied as we collectively got to grips with MgS04 data and reason for MgS04 not being administered. Unit led innovations to local problems became the norm and the administration rate once again went above the 85% target in November 2019 where it has remained for the last four months of the project.

To support project delivery, the Clinical Network project team formed a Regional Clinical Leadership Team. Informed by the principle of distributed leadership, an Obstetric Trainee ST5 acted as the project clinical figure head and was supported by an Obstetric Consultant (both of whom from Birmingham Women’s and Children’s NHS Foundation Trust), Consultant Neonatologist (from The Royal Wolverhampton NHS Trust) and Consultant Paediatrician (from Sandwell and West Birmingham Hospitals NHS Trust).

In a bid to understand the reasons for MgS04 not being given, the PReCePT project team reviewed the reasons reported by trusts over the period June – October 2019.  Over that period, 30 instances of ‘MgS04 not given’ were reported by half of the region’s units. There were 22 instances where ‘Delivery imminent’ was recorded, making it by far the most commonly cited reason for not administering.

The regional PReCePT Clinical Leadership team were keen to learn more about why MgS04 was not being given, and in particularly those instances reported as delivery imminent. A network of Obstetric trainees was developed to collaboratively audit where MgS04 was not given which was collated as a region wide audit. This regional audit was led by an ST4 Obstetrics and Gynaecology Registrar (from Worcestershire Acute Hospitals NHS Trust). The aim was to understand the challenges of administration and support generation of innovative ideas to increase and sustain administration of MgS04 in the West Midlands.

The clinical leadership team also championed development of a West Midlands regional guideline for the administration of MgS04. Using a participatory approach, it was designed to bring about consistency of practice but to also foster closer cross organisational and professional working.

Impact & Outcomes

From March 2019 – February 2020, the West Midlands region saw a total of 455 eligible mothers, of which 392 mothers received MgSO4 i.e. 86.2%. It is estimated that for every 37 mothers treated (<30 weeks), potentially 1 case of cerebral palsy is prevented (whereby the average health care cost per individual is approximately £800,000), which equates to potentially 12 cases prevented for the region (saving ~£9.6million).  

The project has been effective in establishing local ownership which has been highlighted by the number of unique innovations developed by units e.g. cake/cupcake/t-shirt/staff-quiz unit launches, display boards, posters, stickers on drug charts/delivery notes, guideline prompt cards for lanyards, updated local guidelines, translated parent leaflets in 5 languages Arabic, Pushto, Romanian, Polish and Urdu, moodle online training, PReCePT grab boxes in triage, using social media Twitter, FaceBook, WhatsApp, Newsletters, Trust Websites, staff email, screensavers, modifying IUT transfer form, staff updates during huddle/governance meetings, including training slots in mandatory study days.

Also, the project has contributed to strengthening partnerships and network building by the initial visits to units at the outset of the project and then by maintaining regular email communication with each units project teams involving midwives, obstetricians and neonatologists. Also, the project has been appropriately responsive to the needs of local stakeholders and their changing priorities which was evident when issues around data validity was highlighted and explored by the project team prompting key advice.

As a result of this project, the greatest achievement was observed at The Shrewsbury and Telford Hospital NHS Trust who have been at 100% since April 2019 to February 2020. The Trust has achieved this through a variety of methods including holding monthly training as part of Obstetric Emergency/ PROMPT study days and enhanced this further through regular evaluation which has been very positive from staff. They have displayed posters in all clinical areas and offered ad hoc face-to-face support/training. They have implemented PReCePT Grab boxes within the Delivery Suite. They have promoted the project with a launch event offering cupcakes, pens, magnets, info packs and patient leaflets in antenatal areas. They have spread word of their project via their Trust Newsletter and Twitter pages. They have also overcome barriers and have established a dedicated pump allocated for PReCePT use only, and a Tracka Box for Drug Cupboard Keys. Further they have shared a presentation detailing their approach which will be shared widely so other units can learn from them.