Diabetes in pregnancy: are we providing the best care ... - HQIP

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Methodology 4.3.2 Panel composition Each panel for the diabetes enquiry consisted of two of each of the following disciplines: • Obstetrician • Midwife • Diabetes specialist nurse • Diabetes physician. At least one clinician from each specialty was required to be present in order for the panel meeting to take place. Under exceptional circumstances the panel chair could participate as a full assessor if there were no other clinicians available from their specifi c discipline. If it was not possible for at least one clinician from each specialty to be represented then the panel meeting was cancelled. Additional panel members whose input was relevant to particular enquiry cases were invited to attend meetings as required e.g. general practitioners, pathologists, neonatologists. Previous confi dential enquiries had not included lay panel assessors. For the diabetes enquiry, CEMACH sought to include lay assessors on the enquiry panels. Criteria for lay panel assessors were agreed with Diabetes UK, and the initiative was piloted in 2 regions. One lay member attended 5 panel meetings in Yorkshire and Humberside region. Observers were allowed to attend (with due notice) but were not expected to contribute to the discussion during assessment. In total, 647 health professionals contributed over 5000 hours to panel enquiries over the course of the enquiry module, with 70 additional observers attending one or more panels. The median number of cases reviewed by each assessor was 8 (range 4-48). 4.4 Enquiry documentation Panel members were provided with the medical records for each case pertaining to care in the antenatal, delivery and postnatal periods. These included diabetes and maternity notes plus any relevant drug charts, haematology, biochemistry and histology results. Neonatal notes up to day 3 post delivery were also provided where applicable. Following a feasibility exercise at the outset of the project it was deemed impractical to collect all medical records pertaining to diabetes care prior to the pregnancy of interest. In order to allow some assessment of care in the pre-pregnancy period a pre-pregnancy pro forma was also completed by a health professional involved in the preconception care of the woman, either within the adult diabetes service or in primary care (see Appendix A). In addition, any professional correspondence relating to diabetes management within the year preceding the last menstrual period was requested. Women were not contacted directly at any stage of this process, and information about social and lifestyle issues and clinical care was therefore based solely on documentation provided by the health professionals involved in the care of the woman and her baby. In order to maintain confi dentiality of the women, their families and the health professionals involved in their care, all notes provided to panel assessors were anonymised by the CEMACH regional managers 12
in order to remove any identifi able information. This included patient identifi ers, hospital identifi ers and staff identifi ers. Where names of staff were anonymised, the designation (grade) of the staff member was entered onto the documentation, to enable panel assessment of whether care had been provided by the appropriate grade of staff. 4.5 Assessment of care The scope of this enquiry included preconception care, care during pregnancy, labour and delivery, and postnatal and neonatal care up to 3 days post delivery. A structured enquiry pro forma (see Appendix B) was developed by the CEMACH central offi ce with advice from members of the CEMACH Diabetes Professional Advisory Group. This pro forma contained a mixture of factual questions and assessments of care from review of the medical records, after a round-table discussion and after panel consensus had been reached. Panel assessors were asked to grade their opinion of the quality of care as ‘optimal’, ‘adequate’ or ‘poor’. ‘Optimal’ indicated that there were no issues with care, while ‘adequate’ indicated that there were some issues of concern. ‘Adequate’ and ‘poor’ care were aggregated as ‘suboptimal’ care for the purpose of analysis. If concerns had been identifi ed, panels were asked to describe the key issues contributing to this assessment and to code the issues according to the following categories: PD PO PC PA PN Duration or severity of diabetes. Issues relating directly to the patient and/or family issues Other complicating medical or social and / or lifestyle factors which may hinder optimal management e.g. management-intensive medical conditions such as thrombophilia or cardiac disease, and social factors such as housing problems or lack of family support. Woman actively chose not to follow the medical advice given e.g. refusal to undergo induction of labour until 42+ weeks of gestation. Woman’s actions detracted from optimal management e.g. infrequent home blood glucose monitoring, not following dietary instructions. Woman did not attend appointments e.g. failure to attend for clinic visits or ultrasound scans. HP HC HR Issues relating to the provision of health services Clinical practice e.g. no timely discussion of timing and mode of delivery. Communication. This could be a failure of communication between professionals caring for the woman e.g. inadequate discussion between obstetrician and physician, or a failure of communication between professionals and the woman e.g. interpreting services were not adequate despite diffi culties with English. Resources including staffi ng e.g. no dietitian in the antenatal clinic, lack of midwifery staff on labour ward, problems with accessing timely fetal surveillance such as growth scans. Panels were asked to code up to four issues that were appropriate to the judgment of ‘adequate’ or ‘poor’ care. During analysis, these codes were used as a guide for the analysis of the themes arising from the free text. 13
Page 1 and 2: Confidential Enquiry into Maternal
Page 3 and 4: Contents Acknowledgements .........
Page 5 and 6: • Members of the CEMACH Diabetes
Page 7 and 8: Erb’s palsy Injury to the nerve r
Page 9 and 10: Neonatal unit A unit which provides
Page 11 and 12: Foreword This third and fi nal repo
Page 13 and 14: 1. Introduction This is the fi nal
Page 15 and 16: 2. Key fi ndings of the CEMACH Diab
Page 17 and 18: Suboptimal fetal surveillance of ba
Page 19 and 20: 3. Summary of recommendations This
Page 21 and 22: 2. Patient pathways of care includi
Page 23: the pregnancies meeting this defi n
Page 27 and 28: When deriving odds ratios for any p
Page 29 and 30: Associations are reported in Chapte
Page 31 and 32: Table 5.1 Characteristics of women
Page 33 and 34: Table 5.4 Characteristics of women
Page 35 and 36: was no information available to pan
Page 37 and 38: 6. Factors associated with poor pre
Page 39 and 40: Table 6.2 Association of clinical c
Page 41 and 42: Table 6.5 Association of specifi c
Page 43 and 44: Table 6.8 Association of postnatal
Page 45 and 46: folic acid before pregnancy (19% of
Page 47 and 48: Table 7.2 Panel comments on social
Page 49 and 50: 7.5 Conclusions One of the key fi n
Page 51 and 52: 11.Dex S, Heather J (eds). Millenni
Page 53 and 54: 8. Clinical care issues: preconcept
Page 55 and 56: chance of induction of labour was r
Page 57 and 58: 8.6.1 Enquiry fi ndings Just over h
Page 59 and 60: Some quotes from the panel discussi
Page 61 and 62: Apart from the explanation of pregn
Page 63 and 64: was associated with poor pregnancy
Page 65 and 66: of women after the fi rst trimester
Page 67 and 68: 9.5.1 Panel comments on suboptimal
Page 69 and 70: During labour and delivery, the maj
Page 71 and 72: Just 52% of 383 women (38% of 164 c
Page 73 and 74: • ‘No serial growth scans perfo
Page 75 and 76:
The panel enquiries, which are in e
Page 77 and 78:
10.3.1 Enquiry fi ndings Seventy fi
Page 79 and 80:
10.6 Communication Effective commun
Page 81 and 82:
Some quotes from the panel discussi
Page 83 and 84:
working between primary and seconda
Page 85 and 86:
we therefore selected 7.2% of pregn
Page 87 and 88:
11.4 Preconception behaviour The CE
Page 89 and 90:
enquiry related to a 12 month prior
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Table 11.10 Differences in postnata
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Type 1 and type 2 diabetes have tra
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Panels were chaired by the panel ch
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In 57% (24/42) of cases, a junior d
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Infant formula given as fi rst feed
Page 101 and 102:
2.1 hours in babies remaining with
Page 103 and 104:
12.7.1 Panel comments on suboptimal
Page 105 and 106:
The concerns described here probabl
Page 107 and 108:
External commentary Patricia Hamilt
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informed and motivated to manage th
Page 112 and 113:
100 Appendix A: Pre-pregnancy care
Page 114 and 115:
102 Appendix B: Diabetes enquiry pr
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Appendix C Association between demo
Page 134 and 135:
Appendix C Association of preconcep
Page 136 and 137:
Appendix C Association of postnatal
Page 138 and 139:
Appendix D Association of social an
Page 140 and 141:
Appendix D Association of diabetes
Page 142 and 143:
Appendix E Association between demo
Page 144 and 145:
Appendix E Association between prec
Page 146 and 147:
Appendix E Association between post
Page 148 and 149:
Appendix F - CEMACH advisory groups
Page 150:
Appendix F - CEMACH advisory groups
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Diabetes in pregnancy: are we providing the best care ... - HQIP

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