Workstream Breakout: CPP Knowledge Sharing: Where are we now? What are we learning?

1. Workstream Breakout: CPP Knowledge Sharing: Where are we now? What are we learning? Early Years Collaborative Learning Session Two Day 1

2. Our CPP: Highland • Highland Council covers an area of over 26,000 sq. kms with a population of approx. 230,000 • 38,942 children aged 0 -15 in Highland (Census 2011), 14,477 aged 0 – 5 (SAPE estimates 2010) • Approximately 2,400 babies born each year in Highland • Integrated Children’s Service – Lead Agency Model established 2012. Public Health Nurses, Child Protection Advisers and AHP’s previously employed by NHS Highland now employed by Highland Council • Some services remain within the NHS Health and Social Care partnership including acute / community paediatrics, specialist children’s nurses, Tier 3 CAMHs, midwives and maternity services • Focused Improvement Groups to develop For Highlands Children 4 (Integrated Children’s Service Plan) are in place (supporting parents, early years, play, additional support for learning, mental health, health improvement, LAC, Youth Justice and Highland Practice Model) • NHS Highland Quality Approach informs the design and delivery of services across the CPP • Maturing of Lead Agency model – Family Teams

3. Our Portfolio of Early Years Projects Highland workstream 1 STCs • Use of the Antenatal Plan; additional support for mother and unborn baby, developed using the principles of GIRFEC • Family group conferencing project – Children 1st, for families affected by substance misuse • Uptake in the use of peer supporters for breastfeeding • Completion of the Scottish Birth Record to capture breastfeeding data • Practitioner requirements for the delivery of services in the Family Centre in Merkinch • Carbon monoxide monitoring during pregnancy • Numbers of babies diagnosed with Neonatal Abstinence Syndrome and follow up

4. Our Portfolio of Early Years Projects – STCs planned • Professionals’ understanding of early attachment from pre-birth • Changes to practice in relation to sepsis screening for babies at risk • Follow up of infants who require hip scans • Use of customised growth charts • Support for maternal mental health following the withdrawal of a voluntary support service • Paediatric admissions to the children’s ward during the 1st year of life – causes in the last 10 years • Examine the use of the midwife/health visitor handover protocol to ensure compliance in regard to families with additional needs • Examine the use of the weight loss protocol due to increasing number of babies being admitted to hospital, are these practice issues i.e. 3rd day weight not being undertaken

5. Our Learning To Date - linking to the stretch aims • Pre-work – Gain an understanding of any common factors that existed in stillbirths in Highland • Examined records from last 2 years • Also looked at records of last 20 high risk births (< 2.2 kg or pre-term) and infant deaths in 2012 • Stillbirth rate 6.7 per 1000 2012, 7.0 per 1000 2011 • Common factor was smoking • Being a former smoker was also noted • Therefore one of our priorities was given to smoking

6. Our Learning To Date - building our hypothesis – smoking in pregnancy • The reported level of pregnant women smoking in Scotland has decreased from 29% in 1995 to 18.1% in 2009. However, the level of ‘not known’ smokers has increased from 5% to 14.2% in the same time period. • In Highland 21.8% of pregnant women are recorded as smokers however ‘not known’ numbers are 3.6% suggesting that smoking numbers are being captured more accurately. • It is suggested that self-reported smoking during pregnancy in Scotland is underestimated by 17%

7. Smoking during pregnancy • When a woman smokes she inhales carbon monoxide (CO) which is a toxic gas • CO combines with haemoglobin to produce carboxyhaemoglobin which takes up the space in haemoglobin that would normally carry oxygen • This thereby reduces the amount of circulating oxygen to the woman and her unborn baby • The % of fetal carboxyhaemoglobin is 1.8 x higher in the baby than levels circulating in the mother • NICE Public Health Guidance 26 (2010) recommends that all women should be offered CO monitoring even if they don’t smoke as the risks from second hand smoke are just as harmful – practice adopted in Highland • If levels of over 7 ppm2 (parts per million in breath) are recorded on the breath test monitor then women should be offered smoking cessation services.

8. Smoking during pregnancy • Increases the miscarriage rate (27% higher in smokers) • Increases the stillbirth rate (33% higher in smokers) • Babies whose mothers smoke during pregnancy are born with smaller airways, making them more vulnerable to breathing problems such as asthma and chest infections • Increases the likelihood of a baby being born with an oral cleft lip and palate • Exposes the woman and her baby to the harmful properties of cigarettes (4000 chemicals, tar and 69 known human carcinogens) • Can cause serious health problems and can increase the risk of infant mortality by an estimated 40% (NHS Health Scotland 2007). Risk increases with the amount smoked • Exposure to second hand smoke also increases the risk of complications and UK data estimates that 50% of children are exposed to second hand smoke in the home

9. Carbon Monoxide (CO) monitoring STC • Aim - All pregnant women in Highland should be offered CO monitoring • Objective of 1st STC - to find out if all pregnant women are offered CO monitoring as part of their antenatal screening scan clinic appointment at Raigmore • 1st STC - interview 20 women at the clinic and check notes • Plan -Tasks required: develop an audit template, discuss with ultrasound staff, interview women, check notes, complete template • Prediction - 15 women will have been offered CO monitoring • Measure - number of women offered monitoring • Do - undertake tasks • Study - only 7 women were offered CO monitoring, much lower than predicted • Act - Discuss with clinic staff, examine the patient flow process • 2nd STC - Find out why all women are not offered CO monitoring at their scan appointment at Raigmore

10. Our Big Wins & Successes:Measurement Development • 1st STC - numbers offered the test • 2nd STC - improvements to patient flow process • 3rd STC - increase in numbers Quantitative measures used and provided ease of measurement, particularly useful in early tests Gaining women’s experiences of the process would also provide useful qualitative data in terms of common themes identified particularly around the benefits they gained from testing and reasons why some may have declined the test

11. Lessons Learned:Measurement Development 1stSTC demonstrated a gap in the patient flow process but also highlighted that there were other factors that impacted on the measures • There was confusion as to who had responsibility for offering CO monitoring, now there is a patient flow in place • Some community teams had been issued with monitoring equipment and therefore an assumption was made that some women may already have been offered the test • A number of women had declined the test and this wasn’t accurately recorded in their notes • There had been a problem with the initial top-up supply of the correct mouth pieces which had interrupted provision of the service

12. Our Big Wins & Successes:IterativeTesting - achievements • Understanding the Model for Improvement and being clear what the aim is before you begin your first STC ensures you don’t waste time • Learning to start small – small numbers, small tests • Fortnightly workstream 1 sessions where we all have a chance to meet and discuss ideas for projects and progress of STC – not everyone can attend but ideas can be shared • Prompts members to undertake joint work and tests where they have a common interest and shared aim, avoiding duplication • Collaboratives are being formed where they didn’t exist before • Developed a work plan that includes a brief summary of what all members are doing in relation to aims and tests – work plan updated monthly and distributed to all members • Some members of the workstream also sit on the Maternity Care Quality Improvement Collaborative and this work may be used to inform their work – sharing ideas, collaborating and pooling resources In relation to CO monitoring - now that women are only being offered the test at their booking ultrasound appointment ensures a more robust system for ensuring consistency in offering monitoring

13. Our Big Wins & Successes:IterativeTesting- lessons learned • Begin with the Aim in mind not the STC – we didn’t and got a bit lost • Take time to develop your first PDSAs – discuss with colleagues, it gets easier • One STC leads to another – be patient even if you think you know what the outcome for the project will be the STC will give you the evidence to support improvements in practice • If the objective of your STC has ‘and’ in it chances are it requires 2 tests not 1! • Don’t do too many at once – slow down

14. In the next 3 – 6 months… • Repeat STC in Caithness General Hospital • Re- test at Raigmore in 6 months to ensure this change has continued • Working with Health Improvement colleagues to ensure smoking cessation services are maintained and that pregnant women remain a priority group • Highlighting with managers that training for staff in motivational interviewing and behaviour change principles are important when supporting women to stop smoking • Our staff to view every contact as a health improvement contact and as an opportunity to discuss smoking and offer specialist referral. Any misinformation can also be corrected

15. Issues to share and discuss with colleagues • Smoking prevalence generally increases with deprivation. In Scotland 30% of pregnant women in the most deprived areas report smoking compared with 6.7% in the least deprived areas • There should be an awareness of the difficult circumstances and sociodemographic factors which may impact on pregnant woman who smoke: service provision must be sensitive and culturally relevant • Women should be informed that support from specialist smoking cessation services can double the chances of successfully quitting • Children and infants are more vulnerable to second hand smoke as they have smaller airways, faster breathing rates and immature immune systems. Be aware of second hand smoke - promote smoke free homes and cars. • The children of parents who smoke are highly likely to take up the habit themselves with all the potential health risks becoming generational problems within families

16. Ask all women what they know about smoking and second hand smoking in pregnancy Correct any misinformation, emphasis benefits of quitting at any stage. • Offer ‘Fresh Start’ and ‘Smoke-Free Homes and Cars’ leaflet to all women. • Offer ‘Aspire’ magazine for partners. Give positive feedback and record in notes Establish if they or anyone in the household smokes. • No • Yes Accept answer non-judgmentally. Leave offer of help open, state that they will be asked frequently if they want help throughout pregnancy as motivation to quit varies. Reinforce that they can self-refer at any time and that contact details of specialist help are on the back of ‘Fresh Start’ leaflet Not interested in stopping Record in notes and try to establish if they or other smokers in the household are interested in stopping smoking • Interested in stopping Examples of motivational questions: What have you heard about smoking in pregnancy? Would you be interested in receiving help to stop? Have you ever considered stopping smoking? Have you ever tried to stop smoking before? What might help you stop smoking? Can you imagine how it would be for you if you stopped smoking? Offer referral to specialist services outlining benefits of this (more likely to succeed). Smokeline: 0845 757 3077 www.smokefreehighland.co.uk Advise that community pharmacists also offer smoking cessation service.