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

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Clinical governance Table 10.4 Panel comments on defi ciencies of communication between health professionals and women with type 1 and type 2 diabetes (table contains information following categorisation of free text) Number of women with deficiencies in communication (N=169) No. of comments % of women Total comments* 193 Suboptimal discussion about risks 77 46 Plan of care not discussed 31 18 Lack of professional interpreters for women with language diffi culties 23 14 Problem within health service (poor inter-professional communication, poor follow-up, clinician’s attitude etc) 19 11 Communication affected by social/lifestyle factors relating to woman 17 10 Wrong or confl icting information given 15 9 Documentation 11 7 * There were 5 comments where the issues were not described by panels 10.7 Conclusions It is encouraging that the majority of pregnant women with pre-existing diabetes fi rst accessed the hospital antenatal clinic within the fi rst trimester of pregnancy and three quarters attended a combined antenatal clinic. However, just over a fi fth of women in the enquiry were documented to have all members of the multidisciplinary team involved in their care, with the dietitian and midwife being the professionals least likely to be involved. While there may have been variations in interpretation of the term ‘midwife with special interest in diabetes’, patterns of working should be reviewed by local multidisciplinary teams to ensure that all women are receiving equivalent care and advice. In both the obstetric and diabetes antenatal notes, there was poor documentation about what care had been given and the plans for care. Many panels had concerns that the design of the maternity hand held notes were not fi t for purpose. For nearly two thirds of women, there were concerns about local diabetes guidelines. The main issues were a lack of clarity and insuffi cient detail, no antenatal guidelines, inadequate intravenous insulin regimes and no guidance on blood glucose targets in labour. There were concerns about communication between health professionals for half of women in the enquiry. A particular issue appeared to be poor lines of communication between the general maternity staff and the diabetes specialist team, and poor information sharing within the diabetes multidisciplinary team. 68
Some quotes from the panel discussions Documentation: • 'No difference from normal antenatal notes so no space to record observation plans relevant to diabetes.’ • 'No diabetic entries in the obstetric notes (if she had attended another unit there would have been no record in her hand held notes).’ • 'Big gaps in documentation. Very few glucose results included in notes.' Communication: • 'Infrequent visits offered. Poor communication between obstetricians and physicians during pregnancy. Little or no dietitian input.’ • 'Prolonged delay after referral before being seen. Poor communication with diabetic team postnatally - did not seem to get response.’ • 'Diffi culties with communication, interpreter needed, relatives used including children. Missed opportunity re advice prior to Ramadan festival.' • 'Hypoglycaemia awareness not addressed and no apparent warning re driving.’ Guidelines: • 'No target ranges. Sliding scale not adequate, too restrictive, would not maintain blood glucose levels appropriately.’ • ‘No protocol for antenatal care or for steroid administration.’ • ‘Wrong advice re Breastfeeding - protocol stated that it increased insulin requirements and risk of infection.’ • 'Protocol suggesting attendance at a combined clinic beginning only at 26/40 is considered inappropriate/poor practice.' • 'Rigid Delivery Day. No targets for blood glucose control. Routine admission of baby to NNU. 10.8 Recommendations Clinical 1. Commissioners should recognise the complexity of diabetes management immediately before and during pregnancy, and ensure that the available service provision includes all members of the multidisciplinary team. 2. Patient pathways of care including preconception counselling, pregnancy care and post-pregnancy management should be incorporated into the clinical record. 3. Services should review their local guidelines. The NICE Diabetes in Pregnancy guideline, due to be published in November 2007, is anticipated to provide current evidence for best practice. 69
Page 1 and 2:
Confidential Enquiry into Maternal
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Contents Acknowledgements .........
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• Members of the CEMACH Diabetes
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Erb’s palsy Injury to the nerve r
Page 9 and 10:
Neonatal unit A unit which provides
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Foreword This third and fi nal repo
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1. Introduction This is the fi nal
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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 and 24:
the pregnancies meeting this defi n
Page 25 and 26:
in order to remove any identifi abl
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: 10.6 Communication Effective commun
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
Page 91 and 92: Table 11.10 Differences in postnata
Page 93 and 94: Type 1 and type 2 diabetes have tra
Page 95 and 96: Panels were chaired by the panel ch
Page 97 and 98: In 57% (24/42) of cases, a junior d
Page 99 and 100: 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
Page 109 and 110: 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 130 and 131:
118 Appendix B: Diabetes enquiry pr
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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