What was the aim of the project?
There is evidence to suggest that magnesium sulphate given before anticipated early preterm birth reduces the risk of cerebral palsy in surviving infants.
The preventing cerebral palsy in preterm births (PreCePT) project aimed to increase the numbers of eligible women offered and receiving treatment of magnesium sulphate in preterm labour in the West of England to 60%. It did this by training core staff to understand the benefits of using magnesium sulphate for neuroprotection and supporting system change in five NHS trusts to embed this practice as ‘business as usual’.
Who was involved in the project?
The quality improvement team at the West of England AHSN worked with five hospitals across the West of England:
- Gloucestershire Royal Hospital (Gloucester Hospital NHS Foundation Trust)
- Royal United Hospital (Bath NHS Trust)
- St Michael’s Hospital (University Hospitals Bristol NHS Trust)
- Southmead Hospital (North Bristol Trust)
- Swindon Hospital (Great Western Hospitals NHS Foundation Trust)
What was the aim of the evaluation?
The aim of the evaluation was to determine whether the PreCePT project had a positive effect on the uptake of magnesium sulphate for eligible women in the five trusts involved and whether the approach used created sustainable change.
Who was involved in the evaluation?
The qualitative evaluation report was completed by Jess Haskins, an Independent Research and Evaluation Consultant. The quality improvement team at the West of England AHSN analysed the quantitate data.
What did they do?
The quality improvement team began the design phase of the project in Spring 2014 and produced a range of materials and resources including:
- Clinical tools and prompts such as a standardised checklist
- Clinical and patient information
- Training pack
- Implementation plan
- Evaluation strategy
- Update of national database to include a field to record the use of magnesium sulphate.
These materials were co-produced with clinical champions from each site to ensure a good cultural fit. Resources were also provided to assist with the micro-training approach required to reach so many staff working a range of shift patterns.
Clinical champions were provided with initial training in quality improvement approaches, and were then provided with coaching support to enable the delivery of multiple plan/do/study/act (PDSA) cycles, enabling an iterative approach to improvement based on rapid feedback from implementation sites.
In order to evaluate the effectiveness of the resources and materials, focus groups were held at each of the five sites. They were attended by a total of 23 staff members.
What did they find?
A total of 89 preterm deliveries happened over the lifespan of the project (August 2014 to March 2015) and 76 received the magnesium sulphate, representing 85% uptake – the initial target was 60%.
Over the five sites undertaking the project 584 core staff were identified for training and over the lifespan of the project 664 received training, which again is an overachievement of the original aim. The training was found to be of high quality and effective.
The evaluation focus groups highlighted that different staff groups wanted different types of training – the medics required more of the evidence based information, whilst the midwives required information on the practical elements of the treatment.
The focus groups also revealed that finding the time to do widespread training was difficult and many of the innovations developed by the midwives concentrated on how to deliver the training quickly and efficiently.
All the sites emphasised how important having a local ‘champion’ for the project was to its success.
All the sites found that the changes were sustainable and now operate as ‘business as usual’.
Who was the evaluation shared with and why?
The evaluation has been written up for publication in two peer-reviewed journals (in review at time of writing).
The PreCePT project has been selected by the Health Foundation to be part of an ambitious £3.5 million improvement programme.
What has changed as a result?
As part of the journal submission, the longer-term impact of the project has been evaluated from the conclusion of the project in March 2015 to April 2017. In addition to 76 eligible births treated during implementation, it has been projected that approximately 276 additional eligible births may have been identified (12 per month). Further quantitative evaluation indicates uptake now at 89%. It is projected that a total of 322 eligible births will have received the magnesium sulphate which equates to seven instances of cerebral palsy being prevented across the West of England area.
The estimated lifetime cost per patient with cerebral palsy, including health care, productivity and social costs, is €860,000 for men and €800,000 for women. For this project, therefore, the projected reduced financial impact may be in the region of €6 million (£5.1 million).
Successes and challenges
Potential saving of approximately £5.1 million.
The main challenge was the availability of staff to undertake a baseline assessment and the quality of the data collected. It was also a challenge to support ongoing project implementation despite provision of funding to support backfill.
- Costantine MM, Weiner SJ, Eunice Kennedy Shriver National Institute of Child H, Human Development Maternal-Fetal Medicine Units N. Effects of antenatal exposure to magnesium sulfate on neuroprotection and mortality in preterm infants: a meta-analysis. Obstet Gynecol. 2009;114(2 Pt 1):354-64)
- 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
- BMJ Quality Improvement Report. Preventing cerebral palsy in preterm labour: a multiorganisational quality improvement approach to the adoption and spread of magnesium sulphate for neuroprotection (October 2017)