Agenda item

to include Postpartum Haemorrhage

To follow

The Chairman welcomed Angela Helleur, Site Chief Executive – PRUH and South Sites and Frances Barnes, Senior Head of Midwifery – KCH, Denmark Hill to the meeting to provide an update on the King’s College Hospital NHS Foundation Trust.

The Chairman led Members in congratulating the Site Chief Executive on her permanent appointment to the role.

The Site Chief Executive informed Members that Epic, an electronic patient record system, had been jointly launched across King's and Guy's and St Thomas' (GSTT) on 5^th October 2023. The roll out had gone as well as expected. It was noted that they were still in the implementation phase and issues were being experienced in relation to reporting access which had been anticipated. There had been some issues specifically within primary care and they were working with colleagues to rectify this.

With regards to performance, Members were advised that the figures for elective recovery looked concerning, however this had been impacted by the reporting issues and they were monitoring the accuracy of this data. It was noted that some activity had been scaled down due to the implementation of Epic – there were challenges in addressing the elective backlog, however clear plans were in place. The cancer diagnostics were below trajectory, partly due to industrial action and Epic, but processes were in place to ensure patients were tracked. The Site Chief Executive advised that emergency performance was also below trajectory and remained a challenge. However improvement plans were in place, and they were working closely with community partners on admission avoidance and hospital@home services.

Members were informed that the new MRI at the PRUH was on track and a microwave thyroid ablation procedure had been completed. The mortuary redevelopment was also underway and on target for handover in January 2024. The new EV charging facilities in the car park would be installed by March 2024 and, following a question at the last meeting, it was confirmed that the stability of the car parking deck had been fully tested and there were no concerns. The endoscopy unit had now been signed off – there had been an increase in the cost due to the length of time for tenders to be issued and returned, but was on track to be completed by March 2025. In terms of next year’s programme, further works would be undertaken including a complete roof replacement; nurse call system replacement; and ward lifecycle refurbishments.

The Site Chief Executive informed Members that the annual King's Stars Awards event had been held on 2^nd November 2023 to celebrate the efforts of staff across the organisation. More than 300 nominations were submitted earlier in the year and winners were announced on the night.

In response to questions, the Site Chief Executive said that the challenges related to Epic had been anticipated as they were moving a number of electronic patient record systems onto one, but this would ultimately provide a number of advantages. There had been issues around transition, particularly for the Outpatients department, and it would take time for clinicians to familiarise themselves with the system. The challenges related to reporting were being resolved fairly quickly – data was being collected at a local level, but it did not automatically feed into the Epic system. Clinicians were highlighting issues around ordering tests – there were workarounds, but these took longer. A system of governance and escalation was in place for each clinical speciality, and they were also receiving support from Epic and other hospitals that already had the system in place. It was hoped that these issues would be fully resolved by January 2024. There had been a few incidents of patients receiving results/diagnosis before their GP surgeries and the text alert system had been turned off for a period. These were being looked at as ‘serious incidents’ – patients should not be getting alerts or access to records until they were offered a follow up appointment/discussion.

The Senior Head of Midwifery informed Members that a major postpartum haemorrhage (PPH) was blood loss of more than 1,500mls. It would additionally be defined as major obstetric haemorrhage in cases where more than 4 units of blood was transfused, and radiology was required to control bleeding. Pre-labour risk factors included previous caesarean birth; placenta praevia; raised BMI; increased maternal age; uterine abnormalities and ethnicity. Intrapartum (during labour) risk factors included induction of labour; prolonged first stage, second or third stage of labour; operative birth; and caesarean section.

In 2021 the rate of major PPH at the PRUH stood at 5.5%, which was higher in comparison to the national PPH guidance rate of 3.3%. It was noted that a study had been undertaken in 2022, which was much larger, and stated that the national average was 3.5%. The actual year to date PPH rate at the PRUH was 3.6%, and the rolling 12-month rate was 3.2% (as at July 2023) – these figures were comparable to Denmark Hill (3.5% and 3.4% as at June 2023). An audit and deep dives were continuing to be undertaken by the obstetric team at the PRUH – the most recent audit concluded on 15^th November 2023 had showed that the PRUH’s rate stood at 3.5%. Currently there were no majors concerns in relation to major obstetric haemorrhage at the PRUH site. A number of recommendations had been put in place including identification of risk factors; prophylactic uterotonics offered to all women for the third stage of labour; and early escalation of PPH had been added back into the face-to-face mandatory training. A Member enquired if an increase in the PPH rate would be related to more patients having underlying risk factors. The Senior Head of Midwifery said that this was a possibility, and this was monitored to ensure there were not any trends emerging. It was noted that the obstetrician leading the audit was looking at the finer details, including giving consideration as to whether there were any elements within the practices of those clinicians that were associated with the higher figures.

In response to questions, the Senior Head of Midwifery advised that during the pandemic training had been held online and included early escalation of PPH. When training returned to being held face-to-face it had unfortunately been missed off the list but had now been added back in. With regards to the number of emergency and elective caesarean sections that were affected by major obstetric haemorrhage, the Senior Head of Midwifery advised of the following rates:

-  category 4 (completely elective) – 4.34%

-  category 3 – 6.88%

-  category 2 – 4.74%

-  category 1 – 6.48%

It was noted that the PRUH’s PPH rate of 3.5% was for all births. For emergency caesarean sections there was always a consultant obstetrician available via telephone overnight, who was on call from around 9.00pm-7.00am and could be on site if required – there was a stipulation that they be able to arrive at the hospital within 30 minutes. The Site Chief Executive highlighted that they met current guidance in terms of consultant presence on the maternity unit, which was based on the number of births. The Senior Head of Midwifery highlighted that if complex cases were identified the consultant would not leave the hospital until the baby was delivered.

In response to further questions, the Senior Head of Midwifery advised that following all instrumental and operational births a debrief was held by an obstetrician in the post-natal period. Information was also provided electronically (via Epic and the website) and included a leaflet on increased blood loss. This would also be part of the discharge discussion and a midwife would conduct a home visit in the 24 hour period following discharge. It was noted that all women would be seen within 24 hours, at day 5 and again by day 10. If there were any concerns, further visits would be undertaken, and information was provided in terms of escalating post-natal bleeding.

In terms of the number of deaths as a result of major obstetric haemorrhage, the Senior Head of Midwifery advised that sadly there had been 14 deaths (2017-2019) and 17 deaths (2019-2021) – these figures were for the whole of the UK. It was noted that the deep dive looked at potential risk factors including ethnicity. It was confirmed that ‘Code Blue’ was well established within the maternity services – the theatre team, haematology support, obstetrician team and midwifery team were bleeped on the expectation of a Code Blue.

In response to a question regarding PPH potentially being an indicator for overall maternity care, the Senior Head of Midwifery said that there were no concerns that any of the underlying factors were due to the care provided. As mentioned there were a number of risk factors related to PPH which they would continue to monitor. Members requested that an update on postpartum haemorrhage be provided at the first meeting of the new municipal year.

The Chairman thanked the Site Chief Executive and Senior Head of Midwifery for their update to the Sub-Committee.

RESOLVED that the update be noted.