Every baby deserves the best possible start in life, and for their mum, a safe and happy culmination of their pregnancy. Providing top quality care for them both is a priority for Imperial College Healthcare NHS Trust, and they work tirelessly on behalf of over 10,000 babies and their mothers every year.¹
Having immediate and remote access to a patient’s electrocardiogram (ECG) within a single integrated digital record allows clinicians to treat patients quicker, thereby improving outcomes. This helps to save time, improve flow and provide a positive patient experience.
The relationship between a baby’s heart rate and the mother’s contractions helps clinicians understand and react appropriately to the health of the baby during labour – and cardiotocographs (CTGs) are an integral part of this process. That is why they set out to ensure accessible, real-time information is available, alongside more robust capture of CTG readings and annotations.
Previously at Imperial, as is common practice in many hospitals worldwide, midwives monitored contractions, plus fetal and maternal heart rates using CTG devices. Fetal strips were printed on rolls of paper, meaning that they were difficult to share, contained handwritten clinical observations, were prone to fading over time, and were possible to misplace. During labour, midwives interpreted CTGs with other clinical factors and made critical decisions about the management of labour.
Providing safe, high-quality care for mum and baby is a clear priority for all - however, the misinterpretation of CTG readings can have devastating consequences. Incorrect interpretation of CTGs is one of the top risks in intrapartum care in maternity and can result in death or serious neurological injury to the baby during delivery.
Failure to act on CTG content can also have legal implications. Across the NHS, in ten years from 2000 and 2010, there were 300 claims relating to CTG misinterpretation reported to the NHS Litigation Authority. The majority of these claims cite failure to recognise an abnormal CTG and failure to act, meaning that care may have been harmful to patients, and cost the NHS approximately £466million.²
In their annual report, Imperial reported a reduction in clinical incidents relating to misinterpretation of CTGs thanks to the introduction of FetaLink® coupled with education initiatives.
Digitising and integrating CTGs is essential to delivering a positive, safe maternity experience.
The Trust chose to utilise Cerner’s FetaLink solution, a maternal and fetal monitoring system seamlessly integrated within the Trust’s Millennium® electronic health record (EHR) platform. FetaLink enables digital transmission from CTG monitors into the EHR in real time and gives a graphical display of the relationship between fetal heart rate and the mother’s contractions, which can be monitored from any location – at the bedside, at the midwives’ desk by the shift co-ordinator and also remotely by the consultant in other parts of the hospital.
Additionally, clinicians can hide or display any waveforms. This is especially useful when viewing the readings of twins or triplets as an individual baby’s reading can be selected to view. Clinicians can also quickly view annotations on the fetal strip.
Monitoring the readings for multiple pregnancies and clearly differentiating between each individual baby is also easier. Muna Noori, consultant obstetrician at Imperial, likes the way multiple pregnancies are shown, with each baby’s reading clearly shown as a different colour on the display.
Introducing FetaLink was a multi-disciplinary team project, with involvement from the maternity team, the Trust IT team, medical device team, and estates, as well as Cerner. This ensured that it wasn’t just a case of turning on a new solution, but considered how the environment can impact and support the workflow and clinical need. The team went through a rigorous testing process that encompassed hardware, software, and environmental considerations.
The estates team focused on ensuring that rooms had plug sockets available and bulky trolleys were replaced with wall-mounted equipment and monitors to free up space, while the medical device team worked to upgrade and integrate wireless-enabled Philips FM30 CTG machines. The Wi-Fi network connection was also tested in those areas to ensure the bandwidth was available to support reliable real-time data transmission, and to ensure that the firewall didn’t hinder this data exchange.
Clinical champions helped engage maternity staff to gain buy-in and understanding. This was reinforced throughout preparation and deployment by demonstrations to build confidence, a ‘train the trainer’ programme, classroom-based training for clinical staff, eLearning tools, onsite support from Cerner and expert floorwalkers, 24/7 in-person support at go-live, and IT helpline to help with day-to-day issues.
Maternity staff can now view electronic graphical displays of heart rates and contractions for all mums and babies on all the labour wards right across the Trust. They can follow a mother and baby as they progress through the system, spot signs of distress and take action quickly, improving patient safety. All the data is recorded in the EHR.
“If we see something concerning on the CTG display, we can go straight to the labour room to assist even before the emergency bell has been pulled.”
- Paula Beckles, midwife
Second opinions are also easier to source as standard, and midwife Nicola Sale is pleased that “now there are always two pairs of eyes on CTG readings”, ensuring that they are being seen, doublechecked for correct interpretation and acted upon as soon as possible.
The process has removed the duplication of record-keeping on paper and the EHR. This has released up to 20 minutes of time for each birth for midwives to spend on caring for their patients. With 10,000 babies per year, that equates to up to 3,333 hours that can be better used for patient care.³
Within the EHR, the team are also able to tailor patient acuity and customise alert thresholds. For example, if a patient is tachycardic, alerts are specific and relevant for support staff. These alerts are visible anywhere, such as the maternity team’s main office.
FetaLink stores the CTG output in an electronic format that can be accessed at any time and eliminates the risk of lost or faded paper strips. NICE guidance states that electronic fetal monitoring traces should be kept for a minimum of 25 years and that systems should be developed to ensure the electronic storage of CTG traces.⁴
This supports the Trust’s audit capabilities, and their ability to defend medical negligence cases based on CTG misinterpretation or failure to act.
“We have seen a reduction in the number of clinical incidents where misinterpretation of CTG was a contributing factor, with no incidents of this type since August 2018. There has also been a reduction in complaints and claims relating to CTG interpretation.”
- Annual Report 2018/19, Imperial College Healthcare NHS Trust
Ultimately, FetaLink supports the Trust and their staff to provide the best care for their newest patients and their mothers.
Benefits of Cerner FetaLink include:
¹ Imperial College Healthcare NHS Trust (2019) Annual Report 2018/19, p.13. www.imperial.nhs.uk/~/media/website/about-us/publications/annualreport/annual-report-2018-19.pdf
² NHS Litigation Authority (2012). Ten years of maternity claims: An analysis of NHS Litigation Authority data, p.99. www.resolution.nhs.uk/wpcontent/uploads/2018/11/Ten-years-of-Maternity-Claims-Final-Report-final-2.pdf
³ 10,000 births per annum at up to 20 minutes per birth. 10,000*20/60
⁴ National Institute of Clinical Excellence (2014). Intrapartum care for healthy women and babies (CG190) p.52. www.nice.org.uk/guidance/cg190
Imperial College Healthcare NHS Trust calculated their own claims and shared them publicly via http://future.nhs.uk. Cerner has not validated the accuracy of these claims.
Client outcomes were achieved in respective settings and are not representative of benefits realised by all clients due to many variables, including solution scope, client capabilities and business and implementation models.