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Research Projects: THISTLE Study publication

The THISTLE Study findings have recently been published in the BMJ Quality & Safety (July 2019). The THISTLE Study paper is an ‘Open Access’ paper and can be viewed via this link: https://qualitysafety.bmj.com/content/qhc/early/2019/07/12/bmjqs-2018-008625.full.pdf?ijkey=kXNjLlVnFx807zk&keytype=ref

We encourage you to read the paper in full, as it provides a very useful insight into the challenges of scaling up PROMPT; in particular, how best to implement the ‘active ingredients’ of PROMPT most effectively. The study has demonstrated that background policies and initiatives can sometimes conflict to reduce the effect of previously effective training programmes. We are now investigating a Social Franchising model, which includes more support for units to effectively implement PROMPT and we look forward to sharing our results soon.

We recommend the evaluation of all training programmes using robust study designs, to progress the evidence base for improvement, and ultimately benefit the whole health community.

Study summary

The THISTLE study was a multi-centre Stepped-Wedge Randomised Controlled Trial (SW-RCT) funded by the CSO (Chief Scientist Office) and conducted by the University of Aberdeen to assess the implementation of an intrapartum emergencies training package (PROMPT) across 12 maternity units in Scotland between 2014 and 2016. The primary outcome being measured was the proportion of infants born with a low Apgar score (score < 7 at 5 minutes) for each vaginal or emergency caesarean term birth (≥37weeks).

In 2014, a multi-professional team of staff (4-6 team members) from each participating unit attended a PROMPT Train the Trainers (T3) programme at the Simulation Centre in Larbert and took away the PROMPT training package (2nd edition). Following attendance at the T3 training, all units were requested to implement PROMPT courses locally within a specified time period as part of the SW-RCT. The units aimed to train 100% of their maternity staff over the following year and provided study information on numbers and types of staff trained, and also examples of their local PROMPT programmes, to provide information on the context of their local courses.

The units received no additional study funding to aid their set-up and roll-out of local PROMPT training, and no additional implementation support was provided by the PMF core faculty, other than the standard telephone and email support that is offered to all maternity units who undertake PROMPT T3 training.

Main findings

The main findings of the study were that local implementation of PROMPT training at scale across the Scottish maternity units was more difficult than anticipated, and that local PROMPT training, as evaluated in the THISTLE Study, had no effect on the rate of Apgar < 7 5mins during the study period.

Discussion

It is important that these findings are considered in context of both the appropriateness of the SW-RCT study design, and also the variation in content and authenticity of the implementation of PROMPT locally.

The stepped-wedge study design unfortunately proved difficult to employ for this training intervention, as it was reliant on units being able to implement local training within their allocated time step.  However, the study team had no control over the ability of the units to actually implement their local training within this allocated time slot, and therefore, this hampered the planned ‘intention to treat’ analysis.

Authenticity of local training implementation was inconsistent. Some core components of PROMPT, particularly the multi-professional intrapartum fetal monitoring training, was not included in the majority of local PROMPT courses, as there was a separate national fetal monitoring training programme introduced during the THISTLE Study period (only 3 of the 12 participating units included fetal monitoring training as part of their local PROMPT courses). Furthermore, all units struggled to train 100% of their maternity staff in the study period. Therefore, difficulties with implementation and the challenges of the policy landscape are likely to have had a major impact on the primary outcome.

We are very grateful to all of the Scottish maternity units for participating in this study, which has provided PMF, and the Improvement community more generally, with valuable information about the challenges of implementation at scale. We are now investigating a Social Franchising model, which includes more support for units to effectively implement PROMPT and we look forward to sharing our results soon.

We recommend the evaluation of all training programmes using robust study designs, to progress the evidence base for improvement, and ultimately benefit the whole health community.