The Confidential Enquiry into Maternal & Child Health (CEMACH) reported evidence of substandard care in more than 50% of all maternal deaths in the UK, with a lack of multi-professional team working and communication failures identified as contributory factors.
The NHS Litigation Authority introduced a risk management programme specific to maternity care and an insurance assessment scheme called the Clinical Negligence Scheme for Trusts (CNST). The scheme gave financial incentives to maternity units that complied with specific CNST standards, which included multi-professional training for obstetric emergencies and teamwork training. A multi-professional team of staff at Southmead Maternity Unit in Bristol, UK, developed a 1-day ‘in house’ obstetric emergencies training programme with the intention of ALL maternity staff in the unit attending the training day on an annual basis. A mix of senior and junior midwives, obstetricians, anaesthetists, health care assistants and other maternity staff attended each training day.
A research grant from the UK Department of Health to conduct a regional randomised control trial to review obstetric emergencies training was received by the South West based multi-professional group. The aim of the SaFE Study (Simulation and Firedrill Evaluation) was to establish if it was more effective for staff to attend training within their own maternity units rather than sending them to a central simulation centre for training. In addition, the study aimed to determine if including teamwork training in the obstetric emergencies courses improved the team’s management even further.
Using a train-the-trainers’ style approach, eight hospitals from the South West of England participated in the SaFE Study and the trial demonstrated improvements in knowledge, clinical skills and team working during simulated emergencies following training. The improvements were the same for both local and simulation centre courses, which meant more economical training was equally as good as expensive courses in simulation centres. Added benefits were identified with local training, in that staff that would be managing the emergencies in real life practised together, and local knowledge of equipment and guidelines could be included in the training.
A multi-professional team of trainers from Bristol took a pilot train-the-trainers package, based on the ‘in house’ course that had been running at Southmead Hospital, to be piloted by Carl Weiner and his team at Kansas University, USA. They successfully ran local courses, and began evaluating the effect.
The pilot train-the-trainers package was also taken to some maternity units in Australia (Perth, Melbourne, Townsville) and also Auckland, New Zealand.
North Bristol NHS Trust evaluated the effect of their local training day. They compared maternal and neonatal outcomes in the four years before training and four years after the training had been introduced. It was found that the training not only improved, knowledge & teamworking, but was also associated with significant improvements in outcomes:
- 50% reduction in neonatal hypoxic brain injuries
- 70% reduction in injuries after shoulder dystocia
- Improvements in Category 1 emergency caesarean sections
As a result of the positive findings of the SaFE Study and also the associated outcome improvements at Southmead Hospital, the PROMPT (PRactical Obstetric Multi-Professional Training) Train-The-Trainers package was developed by a dedicated group of health care professionals based in maternity units in the South West of England, UK. The package was designed to be used locally and to improve outcomes for mothers and their babies.
The PROMPT ‘Course in a box’ was published with the assistance of the Royal College of Obstetrics and Gynaecology (RCOG). National recommendations for multi-professional obstetric emergencies training for all maternity staff in the UK, coupled with data demonstrating improved outcomes for mothers and their babies led to PROMPT being adopted by most units in the UK.
International interest grew, and in 2008 PROMPT was introduced to TY Leung and his team from the University of Hong Kong, and they have been running PROMPT Courses for obstetricians and midwives in Hong Kong since that time.
PROMPT was introduced in Fiji after a Fijian team of midwives and doctors attended a PROMPT workshop in Auckland, New Zealand. Following this success, the New Zealand PROMPT faculty helped to establish PROMPT training in the Cook Islands. We are hopeful that PROMPT can be disseminated to other Pacific Islands in the future.
A multi-professional team lead by Malcolm Barnett, introduced a PROMPT training pilot (VicPROMPT) to eight hospitals in Victoria, Australia in a pilot project, supported by the Victoria Managed Insurance Authority (VMIA). The aim of the project was to implement PROMPT training in all eight hospitals and see if they could demonstrate similar results to those achieved at North Bristol NHS Trust.
The first Irish PROMPT Train-The-Trainers (T3) course was held in Dublin, for multi-professional teams from across Ireland. PROMPT training is now run in many units across Ireland.
A PROMPT Train-The-Trainers (T3) course was held in Trinidad and Tobago.
To realise the audacious goal of making PROMPT training available, whether that be in developed or low resource settings, additional funding was required. The PROMPT Maternity Foundation (PMF) was registered in England and Wales as a Company Limited by Guarantee (Company No 07506593) and as a charity with the Charity Commission for England & Wales (Charity No 1140557)
In 2011 North Bristol NHS Trust (NBT) and Mpilo Central Hospital in Bulawayo, Zimbabwe, were linked through a Research Health Partnership funded by the UK Government organisation Tropical Health and Education Trust (THET). As part of this partnership a team of midwives, obstetricians, a paediatrician and anaesthetists from NBT and the Zimbabwe Health Training Support (ZHTS) travelled to Zimbabwe in November 2011 to run a PROMPT Train-The-Trainers (T3) programme which had been adapted for this setting.
Since the visit, midwives and doctors at Mpilo have run 9 local PROMPT training courses at Mpilo with 203 members of staff at Mpilo trained; 88% of these staff had never previously attended any obstetric emergency training. In addition to running the PROMPT training, staff from the maternity unit have made changes to their working environment including the introduction of a labour ward board, emergency boxes and Maternity Obstetric Early Warning Score (MOEWS) Charts.
In conjunction with the introduction of PROMPT training, staff at Mpilo are now able to monitor their clinical outcomes through a monthly maternity dashboard produced by the Reproductive Health Officer. The introduction of PROMPT led to a 34% reduction in maternal mortality at Mpilo Hospital.
A PROMPT Train-The-Trainers course was held in the Bahamas in February 2011.
The Second Edition of the PROMPT ‘Course in a Box’ was produced, with a series of PROMPT 2 Train-The-Trainers (T3) days being run by the PMF team to update existing PROMPT users and also train new users. Training in the UK is hosted by the RCOG in London, and maternity units/institutions can send a multi-professional team of staff to the T3 Day, to gain experience and receive training materials to enable them to run PROMPT training courses in their own unit.
In collaboration with Aberdeen University, and funded by the Central Scottish Office (CSO), a PROMPT Train-The-Trainers programme was delivered to 12 maternity units in Scotland as part of the THISTLE Study.
Some of the PROMPT team ran a PROMPT Train-The-Trainers programme in Laos. The World Health Organisation (WHO) are now supporting the translation of the PROMPT Course Manual into Laotian, and the first PROMPT courses have been run locally.
The Tropical Health and Education Trust (THET) provided further funding for PMF and the Zimbabwe Catholic Bishops’ Conference to work as partners to implement a 2 year project replicating the success of Mpilo Central Hospital project by the dissemination of PROMPT in four more hospitals within Zimbabwe.
Project Hope (PH) provided funding for PMF to work jointly with them to deliver the PROMPT Train The Trainers (T3) programme to health staff from 8 selected maternity units in the Philippines with the aim of reducing post-partum haemorrhage through improvements in the quality of hospital-based maternal and child health service delivery.
A PROMPT train-the-trainers programme was held in Dubai in September 2015.
The 1st PROMPT Symposium, ‘Making Childbirth Safer – Together’ was held in historic Bath in the UK where 265 delegates attended from 23 countries.
In early 2016 a PROMPT Train-The-Trainers course was held in Barbados.
Professor Amr El-Noury and his team from Cairo University, Egypt, hosted an extremely successful PROMPT Train-The-Trainers session where the local teams recognised the importance of training together.
PROMPT training has progressively expanded to 31 hospitals in Victoria, Australia with clinical evaluation of outcomes from these maternity units expected in late 2016.
Carl Weiner and his team at University of Kansas Hospital published their experience of seven years of PROMPT training; leading to better team communication, a 100% reduction in brachial plexus injury, better umbilical cord blood test results, and a 30% reduction in caesarean section rates. The projected savings, in terms of reduced litigation and costs, totals US$38 million.
The Third Edition of the PROMPT ‘Course in a Box’ is launched in January 2017. PROMPT 3 includes new modules, algorithms, implementation tools, scenarios and videos.
A second PROMPT Train-The-Trainers course held in Dubai in September 2017.
PROMPT Lead Research Midwife, Cathy Winter, was awarded, in November 2017, the honorary degree of Doctor of Science by the University of the West of England (UWE ) in recognition of her contribution to service and education in leading and championing multi-professional education for maternity services that promotes maternal safety at a national and international level. http://info.uwe.ac.uk/news/UWENews/news.aspx?id=3736
The PROMPT 3 Train the Trainers programme continues to be rolled out across the UK with to date over 60 teams attending from units wishing to implement PROMPT locally to date. T3 courses are now available to attend in London and Bristol.
In March 2018 PMF Faculty members delivered a 2 day programme at the SingHealth Academic Medical Centre in Singapore. Teams from Kandang Kerbau (KK) Hospital and SingHealth attended the T3 training with the newly introduced T4 programme that has been developed to advise licencees on the administration of PROMPT in their licenced territories abroad and included:
- Quality assurance
- Authenticity of implementation of PROMPT
- Sustainability and financial support
- Supporting research
The PROMPT Team have launched training videos on the YouTube channel :
- Training for shoulder dystocia
- Sepsis training demonstration
- PROMPT CTG training demonstration
- PROMPT vaginal breech training
The PROMPT team have been successful in securing a grant from the Health Foundation to generate a deeper understanding of the potential of Social franchising and Licencing models for scaling effective health and social care interventions within the NHS. PMF will be supported by Spring Impact, who have been recruited on behalf of the Health Foundation, to develop a replication model for scaling up PROMPT from its original site.
January 2019 – A multi-professional team from PROMPT comprising an anaesthetist, midwives and an obstetrician have just returned from a visit to Freetown to perform a scoping exercise; investigating the potential of implementing PROMPT in Sierra Leone. They spent five days between Princess Christian Maternity Hospital (PCMH) and Aberdeen Women’s Centre (AWC), the two busiest maternity units in the country.
Time was spent understanding local issues and processes, and talking to staff, women, management and NGOs. The team also performed PROMPT training demonstrations for multi-professional staff in both units, incorporating local guidelines and policies, which was very well received by 31 staff at PCMH and 35 at AWC.
Sierra Leone has amongst the highest rates of maternal and infant mortality in the world, and has been devastated by the 2014 Ebola epidemic, with a significant impact on medical care and resources. Having gained valuable information, the PROMPT team will continue to liaise with agencies and further explore bringing PROMPT to Sierra Leone.