Hot Issues Forum

1. Hot Issues Forum HRT0910 Maternity Benchmarking Group

2. What is your model of care for diabetic women (Fury) • Women remain with midwife (either IMW or secondary care) clinic once a week with physician / dietician / diabetes (Lynx) • Woman continues to see midwife but care obstetrician / endocrinologist led but all available to women at appointment (Hera2) • Some to all risk caseload (option) (Scorpio2) • Dionysis: • If insulin requiring  specialised clinic ‘team’ or share care with current model • If not requiring insulin remains in current model • All women attend diabetes clinic, see endocrinologist at same clinic. Group education with diabetes educator. Email BSC to DIE weekly (Cougar3)

3. How do you determine what is the correct LOS for women with vaginal birth? • For normal vaginal births, in best interest of woman. Lowest is 4 hours. Community / DOM support available. • In best organisation, 2.5 days • Agree with above – think awareness and information of support networks in community should be made available. With early discharge especially in relation to breastfeeding. • Support at home • Remove this as a benchmark! Individualise it to take into account all factors – • one department, • support, • hospital / GP services, • women’s preference • Ask the women during her pregnancy care – then discuss (Scorpio2) • Make sure woman have access to lactation support in community – they don’t often need it but want to know it is there if needed

4. Specialist antenatal clinics – room allocation for multidisciplinary consults – women to care provider vs care provider to woman (Dionysis) • Learn from preadmission processes in New Zealand – patient centred, multidisciplinary team • Woman visit has all disciplines required present at initial visit • Usually have to move one room. Would love woman stays, doctors move around her (Cougar3)

5. How can we improve the booking system / process (iPM)? • Midwife triage (RMO triage patients?)  risk assessment  next appointment triaged on any risks •  low risk  midwife, RMO @ 20 weeks •  high risk  consultant / registrar • Consider case note review of midwives triage of uncertain cases (weekly) • Fury: Midwife grades referral daily, HR d/w consults as required • Low risk booked midwife clinic only unless risk identified in pregnancy • High risk booked midwife clinic and given obstetric appointment when appropriate • Very high risk to clinic of diabetes clinic for obstetric, physio, midwife care

6. How can we attract quality medical staff to a secondary hospital? • Core team of leadership – pay $$$ • Staff specialist full time • Planning - strategic day every 5 years • Formal links with tertiary sites for education, support, standard P+P, referral pathways • Good clinical leadership, model of care, shared philosophy, career pathway

7. Views on labour-birth-recovery-postnatal rooms (LBRP) rooms • Elective caesareans • Emergency caesareans • Preparation for this model antenatal • Staff engagement (Scorpio2): • OH+S issue • Anaesthetic buy in for epidurals • More space • More rooms! (Hera2) • Reduces LOS • Consider equipment requirements, staffing level / skill mix, high caesarean rates  heavy workload • Plan for increased demand as these rooms are not as flexible • In Victoria, LBRP not able to be achieved as the vision was impractical given number of LBRP rooms funded in each building • Can only see concept working well in primary unit (low risk community hospitals / birthing centres)

8. How do we encourage women to seek care close to home? • That this should be done centrally as such. Not that the hospital is “bad guy” and says no. • Central booking – information to women that care at local hospital / community is the same • Take away the option – positive promotion of other services (Antares4) • Driver from the carer (midwifery), positive encouragement to women • Regional sites market and education re: • Birth as a normal life event • Intake process for referrals • Encourage community connections • Minimal options for low risk women (Fury) • Promotion in the community • Philosophy shared across the service • Women booked locally not centrally and seen in their locality

9. How do we enhance IT support to improve flexibility and access i.e. hospital care, home care, community care? (Scorpio2) • Is it flexibility and access for the health professional to work in any site? • Talk to Apple, IBM, vendors, etc • Give every woman a USB stick

10. How do we set up a VBAC clinic? (Cougar3) • How to keep it positive • Very few ELCS as option. Default to have VBAC (Hera2) • Do we include those who require elective LSCS • Yes, call it NBAC • Who do we see and when? • Obstetric review @ 16 weeks and 36 weeks. For caseload women 16 weeks and post dates (Hera2) • Do we provide continuity in clinc i.e. same consultant • When? • Do we can routinely to EFW late (>36/40) ? • Not routinely (Hera2) • Do we undertake pro-op anaesthetic review? • Good evidence information available (Hera2) • What do we give the clients to inform them of pros and cons? • Does anyone else measure scar thickness by ultrasound at 36/40? • Hera2 – not us

11. What is everyone else doing? (Cougar3) • Dionysis: • VBAC clinic commenced 09. • Continuity of specialist not registrar. • Antenatal anaesthetic consult • Routine ultrasound is under discussion. • VBAC education sessions and information sheet given • Review previous C/S notes • Lynx • Do no offer ELLSCS for women with one previous caesarean as VBAC mortality / morbidity no different to primip • Do not scan unless queried IUGR • 1 visit to consultant clinic, rest of antenatal care by midwife, usually ~32/40 • Antares4 • NBAC – including repeat caesarean • First contact immediately postnatal after 1st caesarean by midwife • Get post caesarean pack • Invited to postnatal group session with midwife • Continuity of consultant philosophy • Contact Tracy Martin 08 9340 2222 • VBAC – Alison Sharter book for the women • Dedicated clinic visits • Do not offer elective caesarean • Could be an option to centre care for these women so they can support each other with facilitators

12. How to break down barriers between obstetricians and midwives (Poseidon) • All education done together • Fury • Multidisciplinary approach for high risk women valuing each others’ skills and / each has ownership and autonomy of practice • Team meetings • Social activities together • Have them work side by side – have a combined leadership structure (Jaguar) • Rather than in competition • Weekly teem meetings • Joint responsibility • Midwives and doctors presenting case reviews together • Start at the top – midwifery / obstetric colleges need to lead by example; med student attachments to midwife clinics • Open case reviews for all disciplines to interact and discuss cases. Start with caesarean, forcep / ventouse deliveries and some normal – three weekly with food • Strategic planning 5 year plan – together

13. Ideas, how to, problems etc re implementing an all risk caseload management model of care? How do we introduce this model? (Hera2) • Venues – lots of hard work, pester! • Caseload model can look after women with appropriate consultation with secondary / tertiary (midwifery lead) – high risk need to be under secondary team but maintain midwifery input (obstetric lead) (Fury / Lynx) • Don’t have midwife led or obstetric lead, have women centred (Jaguar) • Just do it! • Use Caroline Homer’s work to support introduction • Watch and wait Dionysis aiming to trial this ASAP • Need and clinical leadership role – a good system to insure not burnt out. Do it quickly and on large scale to gain traction.

14. What strategies have been implemented to manage security issues in delivery suite and postnatal units. (Poseidon) • E.g. potential abductions, security of newborns, custodial care • Top down approach to zero tolerance • To violence • Clear care and protection responsibilities for staff & women • Security tagging system on newborn is very expensive • More trouble than they are worth! (Antares2) • Apollo agrees • Increase security presence. Lock down ability. Use of alias. (Jaguar) • Drug room – sorry! Keypad with keys inside on drug cupboard. • Swipe care access everywhere! All babies transported in cots to alert potential abduction if babe in arms. • Lock down at night (Dionysis) • Lock down 24 hours if risk identified

15. How would we go about introducing centering pregnancy? (Achilles0 • Specifically engagement of midwives • Inclusion for caseload through to tertiary • Support and understanding from obstetricians • Ring Caroline Homer – volunteer as pilot site • Start small and consult widely – get ‘buy in’ • Agree with above – starting small, happy to share experiences on our views etc and our experiences. (Hear2) • Promote saving time re explanations / information re birth planning / BF etc. Promote value of inviting women who have birthed with baby

16. How do you embed / introduce a model of care and service delivery into multiple antenatal sites? • Community sites (midwife only)  return to main site for medical, AH consult, etc (Dionysis) • Standardise processes across sites, criteria applied to site selection, standardised room setup • Now linked to obstetric team for consult • Fury • We have 24 sites in community for antenatal clinics • Midwifery ‘teams’ in each one of 5 geographical areas • Consultant linked to geographical area and see women when high risk identified • Consultant clinics either in some community or in central outpatient facility • Processes standardised across all clinic services