The Obstetric Anal Sphincter Injury - PowerPoint Presentation

1. The Obstetric Anal Sphincter Injury(OASI) Care BundleA quality improvement programme to reduce the incidence of third- and fourth-degree perineal tears

2. Current issues in OASI prevention in the UKInconsistencies in approaches to preventing OASIsInconsistencies in training and skills Lack of awareness of risk factors and long-term impact of OASIsVariation in practice between midwives and doctors1 Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOP). Int Urogynecol J 2011;22:1279–852 Ismail KM, Paschetta E, Papoutsis D, Freeman RM. Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey. Acta Obstet Gynecol Scand.2015 Feb;94(2):165-74. 3 Andrews V, Sultan AH, Thakar R, Jones PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth. 2006 Jun;33(2):117-22. 4 Naidu M, Kapoor DS, Evans S, Vinayakarao L, Thakar R, Sultan AH. Cutting an episiotomy at 60 degrees: how good are we? Int Urogynecol J. 2015 Jun;26(6):813-6.Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol. 2002 Feb 10;101(1):19-21. Our Care Bundle aims to address these issues

3. What is a Care Bundle?A care bundle is a small set of evidence-based interventions for a defined patient segment or population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually. Institute for Healthcare Improvement

4. There are three major components to the intervention which will be implemented together:Such as posters, pens, balloons, memory aidsChampions will attend a Skills Development DayTraining in interventionsGuidance and support in rolling out in their unitsTraining materials provided:E.g. videos, visual aids and a quiz4 evidence-based interventions that, when implemented together, will result in significantly better outcomes than when implemented individually. A Care Bundle Guide will be provided

5. The OASI Care BundleInform the woman about OASI and what steps can be taken to minimize her risk. (an information leaflet will be provided)Use of manual perineal protection Spontaneous births if position allows it (women who give birth in water are excluded)All assisted births (forceps and ventouse)Medio-lateral episiotomy (60 degree angle) at crowning to be used when indicated.Perineum must be examined after delivery and any tears graded according to the RCOG guidelines. Examination should include a per rectum check, even when the perineum appears intact. 1234

6. The intervention will be facilitated by: 1. Local clinical champions (one midwife and one obstetrician from each unit). They will champion the project including: ensuring that staff have completed the multi-disciplinary skills development module, monitoring local compliance with the care bundle, reporting on unit-level OASI rates, and participating in shared learning days with the other units in their block. 2. Leadership and support from professional organisations will be provided by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) who will actively promote the project and will provide a joint statement endorsing the use of care bundle. In addition, the professional and educational networks of the Colleges will be actively used to support the skills development module. 3. Continuous monitoring and feedback will allow participant units to measure their progress, by reporting their OASI rates, compliance with the care bundle, and uptake of the skills development module. Units will participate in shared learning days with other units to provide a forum to discuss the project as it progresses.

7. Evaluation of implementation outcomesStandardised delivery of the evidence based intervention Improved knowledge, awareness & skillsContinued uptake & sustainability of the intervention Survey of champions on Skills Development Day (A, F)Routine monitoring of basic data (F, C)Follow-up interviews with champions (S)Focus groups with champions at Shared Learning Day (A, F, S)Focus groups with clinicians during site visits (A, F, S)AcceptabilitySatisfaction with interventionFeasibilityExtent to which intervention can be appliedCoverageExtent to which population receive the intervention SustainabilityExtent to which intervention is maintained

8. Number of eligible women in each time period 32,800 women are potentially eligible to receive the care bundle over a 12 month period.

9. Project set-upBlock 1Roll-outImplementationBlock 2Block 3Block 4Evaluation Practice outcomesClinical outcomesDissemination PlanningRoll-outImplementationSkills development dayShared learning dayOverall programme planStages in each blockWhere we are now

10. Our project teamRanee Thakar Croydon Health Services NHS Trust Clinical lead Vivienne Novis RCOG; Frimley Health NHS Foundation Trust Midwifery lead Anita Dougall RCOG Director, Clinical Quality Louise Silverton RCM Director for Midwifery Jan van der Meulen RCOG; London School of Hygiene and Tropical Medicine Senior Methodology Advisor Nick Sevdalis Kings College London Quality Improvement Lead Ipek Gurol-Urganci RCOG; London School of Hygiene and Tropical Medicine Evaluation lead Alexandra Hellyer RCOG Project manager Posy Bidwell RCOG Research Fellow Louise ThomasRCOGHead of Quality Improvement Anita DougallRCOGSenior Director, Clinical QualityAlison Elderfield RCOG Head of the Lindsay Stewart Centre

11. Any questions?