APPENDIX 4
Memorandum by Miss Zoe Penn (MS 9)
SUMMARY
Training of health professionals is predicated
on an agreed schedule of care and procedures to enable professionals
to work to an agreed standard that should be evidenced based and
up to date. Although locally agreed multidisciplinary guidelines
remain the gold standard, in practise these have been slow to
develop and prove a heavy burden to maintain and update on a continuous
basis. The Chelsea and Westminster hospital have a comprehensive
set of guidelines that are produced locally by a multidisciplinary
team and we propose that these should be made available on a national
basis for local units to take on and customise and that the Chelsea
and Westminster should be provided with the monies to enable continuous
updating in line with current evidence and nationally produced
protocols.
AUTHOR
This memorandum is submitted by Miss Zoe Penn,
Consultant Obstetrician at the Chelsea and Westminster Hospital
and Honorary Senior Lecturer at the Imperial College School of
Medicine, London (020 8846 7902; e mail: zoe.penn@chelwest.nhs.uk).
Although she is submitting this memorandum as an individual the
work was undertaken by a multidisciplinary team at the above hospital.
She has submitted evidence on the use of guidelines to the Deaprtment
of Health in 2001 as a part of "Organisation with a Memory".
The electronic format of the guidelines was enabled with monies
from the NHS litigation Authority and "Datix": an electronic
database and search facility developed by Capsticks Solicitors.
MEMORANDUM
1. Training of health professionals to provide
the best advice and care for pregnant women needs a secure evidence
based guidelines. Without guidelines there is no agreed standard
and so no remedy for substandard clinical care, no explanation
for variations in clinical practise and no defence against litigation.
Any organisation that puts adverse incident reporting at the head
of its priorities for improving clinical care for mothers and
babies is committed to a future of special enquiries and the allocation
of blame to beleaguered professionals, already overwhelmed by
clinical duties, the tide of clinical information and national
initiatives, as well as the unwelcome attentions of the press
every time something goes wrong. Guidelines should be the first
step in training: the gold standard is established by reference
to the best evidence, this will help women understand the care
they can receive, achieve continuity of care, make professionals
feel supported and secure in their practice and give us an audit
tool to assess standards of care and log and understand adverse
incidents.
2. Without gold standards of clinical practice
it becomes impossible to perform clinical audit, since there is
no standard against it which to assess actual clinical care. Without
gold standards of clinical practise, laid down in guidelines,
it is impossible to fully inform women about what they should
expect from their maternity care. Without gold standards of clinical
care it is impossible to judge whether variations in practise
are acceptable or whether adverse incidents are due to system
failure, failures of education or defects in clinical knowledge.
Without gold standards of clinical practise it is impossible for
clinical staff to feel secure that they are practising optimally
for the well being of mothers and babies in their care and, additionally
to feel protected by their clinical colleagues. Without clinical
guidelines all adverse incident reporting is like erecting a wooden
wall against the incoming tide of litigation.
3. Guidelines should be available with ease,
and a computer system ensures that the guidelines are all available
at every clinical station. Guidelines should be locally developed
and kept up to date: we contend that without strong central direction
and given the current manpower crisis in the NHS this will be
impossible for local maternity units. Our guidelines have been
developed over six years and only now are they nearing completion
and have been enthusiastically embraced by all clinical groups
within the maternity unit. Other NHS maternity units will not
have the time or resources to undertake this kind of massive investment
of time and money.
4. However, our guideline system will need
to be locally customised with the names of local professionals
or phone numbers and taking into account the local physical constraints
and manpower arrangements. As such, local consultation measures
will have to take place. Local consultation ensures that the local
professionals will feel some ownership of the guideline and will
raise awareness of the guideline. Guidelines should also be practical
and useful to clinicians, often practising in a system that is
pushed for time and resources: our guidelines have been used for
a number of years in actual clinical practise, they have been
redrafted to take into account the views of our professional groups
and to be succinct and practical in their approach.
5. We propose that the Maternity Clinical
Guidelines, in use at the Chelsea and Westminster Hospital for
the last six years, are used as a national template for maternity
clinical guidelines. These guidelines have been in continuous
evolution for the last six years and have been developed by a
multidisciplinary team, including midwives, obstetricians, obstetric
anaesthetists, pharmacists, obstetric physicians, clinical risk
manager, haematologists, biochemists and many other stakeholder
professional groups. They have been subject to wide consultation
and have been used in clinical practise over a number of years.
6. The special features of this programme
are that it is practical and proven in clinical care, evidence
based and fully references, developed by a multidisciplinary team,
up to date and provide a "gold standard" against which
actual clinical practise may be audited. Risk management and logging
of adverse incidents have also been initiated against the standard
of these guidelines. Clinical guidelines are formulated, where
possible, alongside the production of a patient information leaflet
than conforms to the latest guideline.
7. The team at the Chelsea and Westminster
Hospital comprises an obstetrician, two midwifery managers, the
Director of Midwifery services, supervisors of midwives, Specialist
Registrars in Training, obstetric anaesthetists, obstetric physicians
and various other co-opted clinicians who are experienced in the
drafting and launching of clinical guidelines and are committed
to their long term support, to ensure that they are up to date
with the latest evidence.
8. The other unique feature of the Maternity
Clinical Guidelines at the Chelsea and Westminster Hospital is
that they are available electronically. The computer based system
was developed in collaboration with Datix Information Systems.
It is based on a Lotus Notes system. This provides an electronic
version of the Guidelines at every computer station in the hospital:
labour ward, antenatal clinic, antenatal and postnatal wards and
obstetric ultrasound departments. The guidelines can be printed
by the clinician and placed in the patients' notes. This enables
consistent bedside care, but also a contemporaneous record of
"gold standard" management of the future. Up to date
patient information leaflets can also be provided at every clinical
station. Where requested, the woman can also be provided with
a copy of the clinical guideline so that they know what the plan
of action for their pregnancy or problem will be.
9. The system administrator can continuously
update the guidelines to ensure that any new research data or
national initiative can be incorporated as soon as it appears.
The system administrator can also archive old guidelines so that
a record of best practise, at that date, is always available.
This will be of particular importance for the purposes of litigation
and claims management.
10. The Datix Maternity System is also interactive
so that all professional users can have a dialogue with the system
administrator and so contribute to improving the system and the
redrafting process. This ensures the involvement of all stakeholder
professional groups and also increased the ownership of the guidelines
by local professionals. The "start up screen" alerts
the user to the initiation of new guidelines or the presence of
new versions of guidelines to ensure that users are always aware
of changes in practise as they occur.
11. The electronic version of this system
is easily adaptable to any hospital and the site specific information
can be easily stripped out so that the subscribing hospitals can
customise their own guidelines, using the template, with the minimum
effort.
RECOMMENDATIONS
12. The Chelsea and Westminster Hospital
Guidelines group proposes that they run a group that will be responsible
for the drafting of guidelines to keep them up to date and fully
compliant with the latest research data.
13. They will also provide each client maternity
unit with redrafted guidelines and information sheets for women,
within a short time of new clinical information becoming available.
They will respond to enquiries from all subscribing maternity
units.
14. We must emphasise that these "guidelines"
are not "protocols", they are intended to facilitate
good clinical care and not to constrain thoughtful and individualised
practise: "guidelines" guide care whereas "protocols"
mandate care that may or may not be optimal for an individual
woman. We would intend subscribing maternity units to use the
national guidelines as an evidence based framework and we would
provide a practical "how-to" guide upon which to develop
their own local practice.
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