“For me as a clinical midwife, I've learnt so much stuff. It was a real steep learning curve. It was a real collaboration, certainly I couldn't have done it on my own.”
Project midwife
Overview

As one of the AHSN Network’s seven national adoption and spread programmes, PReCePT (Prevention of Cerebral Palsy in PreTerm Labour) is the first ever perinatal quality improvement (QI) programme delivered at scale across England, bringing together midwives, obstetricians and neonatologists in every maternity unit in the country.

This evidence-based, cost-effective project was designed to help reduce cerebral palsy in babies through the increased antenatal administration of magnesium sulphate (MgSO4) to mothers during preterm labour, costing from £1 per individual dose. For every 37 mothers who receive magnesium sulphate below 30 weeks gestation, one case of cerebral palsy is prevented.

PReCePT was developed in 2014 by the West of England AHSN in collaboration with University Hospitals Bristol NHS Foundation Trust, and involved both patients and staff.

The intervention was adopted by all five maternity units in the West of England using a QI approach over a six-month period. Projection modelling indicates that the impact of this first phase of  PReCePT was at least seven cases of cerebral palsy across the region were prevented, representing potential lifetime healthcare savings in the region of £5 million – and substantially more when including loss of productivity and social care costs over a lifetime.

Following the success of this locally designed and delivered QI project, coupled with the international evidence base for use of magnesium sulphate, PReCePT has been selected by NHS England as one of the AHSN Network’s seven national adoption and spread programmes for 2018-2020. The national PReCePT programme is led by the West of England AHSN.

This work is adopting a network approach, bringing together the 15 AHSNs supported by a suite of standardised resources . The aim is to achieve 85% uptake of administration of magnesium sulphate to eligible mothers in preterm labour in all maternity units in England by April 2020.

Between 3,000 and 4,000 babies are born before 30 weeks’ gestation in England per year and stand to benefit from the full national roll-out of the PReCePT programme through the AHSNs. Successful scaling up of PReCePT is likely to prevent several hundred cases of cerebral palsy per year, based on highest grade evidence1.

In addition, a sister project, the PReCePT Study, is also benefitting from £0.6 million in ‘Scaling Up’ funding from the Health Foundation. The PReCePT Study, nested within the programme, is providing enhanced QI support and resource within 13 maternity units to assess whether an enhanced QI intervention improves the uptake and sustainability of magnesium sulphate in preterm births over and above the national programme rollout.

  1. Crowther et al. 2017; PLoS Med 14(10): e1002398 https://doi.org/10.1371/journal.pmed.1002398

 

Challenge/ problem identified

Around one in ten babies of very low birth weight develop a form of cerebral palsy. It is estimated that the lifetime cost per patient with cerebral palsy, including health care, productivity and social costs, is in the region of €830,000 (1).

NICE (NG25) recommends administration of magnesium sulphate (MgSO4) in very preterm births as a core part of maternity care to substantially reduce the risk of cerebral palsy by 30%, based on accumulating evidence in support of its brain protective potential (2).

For every 37 mothers below 30 weeks gestation who receive magnesium sulphate, one case of cerebral palsy is prevented.

However, the uptake of MgSO4 in the UK remains relatively low, compared with the rest of the developed world, and this problem applies nationwide (with the exception of a few well-performing maternity units). The National Neonatal Audit Programmes report demonstrated an uptake of 44% for eligible babies in England in 2016, and 60% in 2017 (3).

  1. Kruse M, Michelsen SI, Flachs EM, Bronnum-Hansen H, Madsen M, Uldall P. Lifetime costs of cerebral palsy. Developmental Medicine and Child Neurology. 2009;51(8):622-8.
  2. 2015 NICE Guideline 25: Preterm labour and birth. National Institute for Health and Care Excellence (Available from: https://www.nice.org.uk/Guidance/NG25)
  3. National Neonatal Audit programme (NNAP) 2017 and 2018 [Available from: http://www.rcpch.ac.uk/improving-child-health/quality-improvement-and-clinicalaudit/national-neonatal-audit-programme-nn-3)
Actions taken

The West of England AHSN developed PReCePT in collaboration with University Hospitals Bristol to help reduce cerebral palsy in preterm babies by optimising administration of magnesium sulphate (MgSO4) to women in preterm labour (less than 30 weeks).

Co-designed with a wide range of stakeholders, including patients, clinicians and management, PReCePT provided a supported quality improvement (QI) toolkit, information materials as well as practical tools and training to raise awareness of evidence-based practice on use of MgSO4 compliance, supporting staff to consider MgSO4 in eligible pregnancies.

Between March 2014 and March 2015 with Dr Karen Luyt as the clinical lead, the West of England AHSN coordinated the introduction and supported the adoption of PReCePT in all five maternity units in the region(1), identifying lead midwives in each trust to champion the initiative.

PReCePT is now embedded in in the West of England’s five NHS Trusts, and was independently evaluated by NIHR CLAHRC West. This was published in the British Medical Journal Open Quality (2017).

  1. Gloucestershire Hospitals NHS Trust, Great Western Hospitals NHS Foundation Trust, North Bristol NHS Trust, RUH Bath NHS Foundation Trust, and University Hospitals Bristol NHS Trust.
Impacts / outcomes

PReCePT has led to improved compliance with NICE guidance, (NG25), through its publicity campaign to increase awareness about the use of magnesium sulphate (MgSO4) as a neuroprotector, developing care pathways and a range of tools to spread and embed this message.

  • During the first phase of PReCePT in the West of England, there was an an overall compliance of magnesium sulphate administration of 85%. Further quantitative evaluation of the project in late 2016 indicated that uptake of the recommended intervention remained consistent at 89% across the participating units.
  • By February 2017, modelling indicates that a total of 322 eligible births will have received the intervention since the start of the project. This is projected to have prevented at least seven cases of cerebral palsy across the West of England, representing a potential lifetime financial saving of up to £5.1 million(as of February 2017), including health care, productivity and social costs.
  • The project involved strong partnership working with five NHS trusts and engaged a wide range of stakeholders in the co-design of information materials, including patient representatives and clinical partners. Parent engagement was key; there was significant involvement from the charity BLISS, and parent representatives were core steering group members throughout the project.
  • Due to the success of the PReCePT in the West of England and the relative ease to roll it out at scale, and the project was selected as one of the AHSN Network’s seven national adoption and spread programmes, commissioned by NHS England.
  • PReCePT has received formal endorsements from:
    • Bliss, the charity for babies born premature or sick,
    • Tommy’s, which funds research into miscarriage, premature birth and stillbirth and provides information to parents-to-be
    • Tamba, the twins and multiple births association
    • The British Association of Perinatal Medicine
    • The Royal College of Midwives
    • The Royal College of Obstetricians and Gynaecologists.
Plans for the future

The AHSN Network’s national programme

Funded by NHS England, PReCePT is one of the seven local AHSN programmes to have been selected for adoption and spread across the national AHSN Network during 2018-2020. This work is being led by the West of England AHSN.

This work brings together the 15 AHSNs and the aligned drivers of the Maternal and Neonatal Health Safety Collaborative (MNHSC) and the national Patient Safety Collaboratives (PSCs) to support the aim of achieving 85% uptake of administration of magnesium sulphate to preterm babies in all maternity units in England by 2020.

The PReCePT programme is taking a network approach delivering it through the 15 AHSNs using standardised QI resources such as toolkits, implementation guides, dashboards, clinical role descriptions, training presentations and promotional collateral.  Midwife champions are funded to deliver PReCePT in each maternity unit and regional clinical leads are employed to support the delivery of the programme across each AHSN geographical area.

Over the two-year programme, the aim is to administer antenatal MgSO4 to a minimum of 1,000 additional mothers who go into labour before 30 weeks gestation. The number of women needed to treat to benefit from the use of antenatal magnesium sulphate (by preventing cerebral palsy in one child) is 37 (95% confidence intervals 23, 102)[1].  Therefore, the outcome of the national PReCePT programme will be the avoidance of at least 30 additional cases of cerebral palsy across England per year and ongoing if sustained.

1. Crowther et al. 2017; PLoS Med 14(10): e1002398 https://doi.org/10.1371/journal.pmed.1002398) – NNT calculated by the Crowther team from meta-analysed data.

The Health Foundation’s Scaling Up Improvement Programme

PReCePT is also benefitting from £0.6 million in ‘Scaling Up’ funding from the Health Foundation.

A cluster randomized trial nested within the national PReCePT programme, the PReCePT Study aims  to assess whether an enhanced QI intervention improves the uptake of MgSO4 in preterm births over and above the national PReCePT Programme.

40 maternity units in England have been randomly selected to either receive enhanced QI support from the PReCePT Study team (13 units) or be observed while implementing the standard support model delivered via the national AHSN Network programme (27 units).

The PReCePT Study aims to establish the added value (impact) and costs of the enhanced support model compared to the standard support model. Findings about the effectiveness of the two QI implementation models will provide evidence on the effect of these different approaches for any future perinatal improvement projects. This is important in our current NHS climate where change projects are necessary in all areas to improve patient care in a safe and cost-effective manner.

University Hospitals Bristol NHS Foundation Trust is leading PReCePT Study, working in partnership with NIHR CLAHRC West and the West of England AHSN. Read more here.

Start and end dates
  • West of England: March 2014 – March 2015 (with care pathways embedded in all participating trusts)
  • Health Foundation ‘Scaling Up’ project: April 2018 – November 2020
  • AHSN Network adoption and spread: April 2018 – March 2020
Contacts

National programme contact

Ellie Wetz, Programme Manager, West of England AHSN
E: [email protected]

Media contact

Vanesther Rees, Head of Communications, West of England AHSN
E: [email protected]

 

PReCePT: Reducing cerebral palsy through improving uptake of magnesium sulphate in preterm deliveries