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Solihull Maternity – The History

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Since 1996 babies have been delivered through an obstetrician led service at Solihull without on-site paediatric/neonatal support. This was because of the withdrawal of the paediatric service when the Deanery judged the paediatric throughput at the hospital was too low to meet the needs of trainees. The Solihull obstetric-led maternity service without on-site paediatric cover is believed to be a unique model of care.

The current models of obstetric provision across the three sites vary with Solihull being a low-risk obstetric unit with no onsite 24/7 paediatric cover and no special care baby unit facility. On booking, all mothers are risk-assessed and only those presenting as routine are booked for delivery at Solihull. Good Hope has a Level 1 (special care facilities) neonatal unit with 40-hour labour ward cover and Heartlands is a Level 3 unit (neonatal intensive care), again with 40-hour obstetric cover.

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[toggle title=”How many births happen at the different Hospitals?“]
In terms of maternity services, just over 11,000 births took place within the Trust in 2008. Obstetric-led maternity services are provided out of the three main hospital sites. Deliveries per site in 2008 were; Heartlands, 4,921; Good Hope, 3,601; and Solihull 2,792.
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[toggle title=”What has been done to increase maternity staffing and support at Solihull Hospital?“]

In 2008 the Trust had a total of 26 midwives with the additional voluntary qualification of Advanced Resuscitation of the New Borns (ARNBs) in Solihull. They were concerned about maintaining their ARNB training in view of the relatively recent elevated expectations about regarding resuscitation including umbilical vein catheterisation. They also requested additional support from paediatric nurses with neonatal nursing skills (qualification 405) at all times (estimated 1in 1,600 babies require this, this equates to one baby every six months at Solihull leading to an infrequent use of skills).

A business case was developed and submitted for this additional staffing. After approval of the funding, adverts were placed in September 2008. In addition, the College of Paediatricians was approached and asked if paediatric trainees could rotate through Solihull to be available to support neonatal resucitation, however the College training adviser confirmed that the College would not support trainees on a Solihull roster or any increase to the number of trainees. Three separate attempts were made to recruit additional paediatricians with the right level of skills, all were unsuccessful. The inadequate responses to adverts for additional nurses (405s) only generated eight applicants for 17.25 WTE post.

In 2008 a serious national shortfall of consultant paediatricians was reported to the Minister of Health in charge of workforce issues, with recognition that there will need to be additional training posts created as well as additional consultant posts. The media release following a workforce survey suggests a shortfall of 3,000 specialist paediatricians.

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[toggle title=”What changes have been made to meet these new safety requirements?“]

In 1995 following an accreditation inspection by the British Paediatric Association (fore-runner of RCPCH) the volume activity at Solihull Hospital was found to be below required levels for training and accreditation was withdrawn. This meant that the Hospital could no-longer attract paediatric doctors and had paediatric doctors in training.

In order to continue obstetric services in Solihull, some midwives in 1996 agreed on a voluntary basis to supplement their skills to be able to undertake immediate advanced newborn resuscitation for up to 40 minutes while specialist help came from Heartlands Hospital. This role is unique within the UK. A policy of accepting only low risk bookings at Solihull was put in place, with all other bookings being referred to Heartlands Hospital.

In 2005 new resuscitation standards were introduced by Resuscitation Council. This included the fact that adrenaline should now be given by intravenous or intraosseous route as the endotracheal route was thought to be less effective. This gave rise to a new skill requirement in umbilical vein catheterisation.

In 2007 minimum standards were agreed by the joint Colleges of obstetricians, midwives, anaesthetists and paediatricians. These stated that there must be 24-hour availability in obstetric units of senior paediatric colleagues who have advanced skills for immediate advice and urgent attendance, who will attend within 10 minutes.

There must also be 24-hour availability in obstetric units within 30 minutes of a consultant paediatrician (or equivalent SAS grade) trained and assessed as competent in neonatal advanced life support. All of these requirements are for medical attendance; where ANNPs are involved, this is only envisaged within Level 2 and Level 3 units.

An audit undertaken in 2007 showed no difference in neonatal outcomes between Heartlands and Solihull. Audit concluded “current booking, in utero transfers, neonatal resuscitation and retrieval transfer practices at Solihull appear overall to give the same outcome as if the baby had been born at Heartlands. On the basis of this audit … there is no difference in the effectiveness of neonatal support and outcomes between births in Heartlands and Solihull maternity units”. Heartlands neonatologists expressed concerns particularly about the maintenance of midwives’ advanced resuscitation competences given the infrequent use of their intubation and advanced support skills.

In 2008 the Trust had a total of 26 ARNBs in Solihull, but they were concerned about maintaining their ARNB training in view of the new expectations about umbilical vein catheterisation without 405 nurse support at all times (estimated 1:1,600 babies require this = 1 baby every 6 months at Solihull leading to an infrequent use of skills). A business case was developed and submitted for this additional staffing. After approval of the funding, adverts were placed in September 2008. In addition, the College was approached and asked if trainees could rotate through Solihull to cover neonates, however College training adviser confirms the College would not support trainees on a Solihull roster or any increase to the number of trainees. Three separate attempts were made to recruit additional middle grade paediatricians, all were unsuccessful. The inadequate responses to adverts for additional 405s only generated eight applicants for 17.25 WTE post.

Also in 2008 a serious national shortfall of paediatricians was reported to the minister of health in charge of workforce issues, with recognition that there will need to be additional training posts created as well as additional consultant posts. The subsequent media release following a workforce survey suggests shortfall of 3,000 specialist paediatricians.

A great deal of work has been carried out to make the service as safe as possible but they do not meet the full requirements and are not sustainable. They include:
  • January 2009 – A revised protocol for the “fast car” service was agreed. This however does not guarantee medical assistance for an emergency call in under 40 minutes (from call to arrival at Solihull) and could at certain times be longer
  • February 2009 ongoing – To enable us to meet changed European resuscitation guidelines, midwives offering Advanced Resuscitation of the New Borns (ARNBs) were offered additional training to insert umbilical vein catheters for the administration of emergency resuscitation drugs. As midwives successfully went through the training we were able to offer improved care in an emergency
  • April 2009 – The Trust started to allocate a Neonatal Intensive Care Nurse (ENB 405) each shift to Solihull to assist ARNBs with resuscitation, keep resus equipment checked and to further assist when an emergency team arrives from Heartlands Hospital. They also act as transport nurse if necessary. At first the nurses were allocated from 07:30 – 21:00 daily
  • June 2009 ongoing – Consultant paediatrians and advanced neonatal nurse practitioner (ANNP)s, agreed to do resident shifts at Solihull to provide second level resuscitation support in an emergency. In the first two months of the rota it was possible to cover around half of nights
  • July 2009 – ENB 405 Nurse cover becomes 24/7
  • August 2009 – Paediatric cover improved to 80% coverage of nights

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