Table 1

Summary of Plan Do Study Act (PDSA cycles)

PDSA cycle A: referral criteriaWe wanted to reduce numbers of referrals, aiming, to prioritise women at high risk of PTB by reviewing up-to-date published literature and national guidelines.Remove lower risk criteria and/or risk factors whereby CL screening and cervical cerclage are of uncertain or limited benefit. The following risk factors were consequently removed from the referral criteria; previous FDCS, uterine anomaly, previous punch biopsy or trachelectomy.We found that simply publicising a revised referral criteria did not reduce the number of referrals.
We also had one woman who required an emergency cervical cerclage and her only risk factor for sPTB was a previous FDCS.
Introduced a vetting clinician to screen all referrals.
We reinstated women with a previous FDCS into the referral criteria.
PDSA cycle B: referral vettingWe thought vetting would reduce the number of women attending the clinic FTF.All referrals were vetted by a clinician who accepted/rejected the referral and decided on type and timing of appointment (remote or FTF).The number of FTF appointments decreased and the number of remote consultations increased. The vetting process was time consuming for the vetting clinician.If this process was to be continued in the longer term, more efficient processes could be tried, but the clinician time was thought to be well spent as the intervention was successful in reducing FTF consultations in the COVID-19 pandemic period.
PDSA cycle C: intensity of surveillanceWe thought we could reduce the number of unessential hospital visits following cerclages.We used telephone consultations to follow-up women after cerclage insertion, reverting to the minimum frequency of TVUS as stated in national guidelines.Weekly liaison across sites meant regular feedback from staff and patients, the acceptability of our new care pathway. Patient anxiety and volume of calls made to staff were noted.Reinstated offering FTF appointments to women following both history and ultrasound indicated cerclages.
PDSA cycle D: introduction of remote consultationsWe thought we could minimise non-essential FTF hospital visits.We used remote consultation for first consultations.Weekly liaison across sites and patient and staff survey on remote consulting.Telephone consultations were a successful and acceptable way to reduce FTF consultations. Overall, there was no evidence from the patient and staff feedback questionnaires to support the introduction of video over telephone as the format of remote consultations.
PDSA cycle E: procedural aspects of cervical cerclage placementWe wanted to reduce and where possible, eliminate, aerosol-generating procedures, such as a GA at the time of cervical cerclage placement. Guidance issued from Public Health England guidance stated that full PPE, including a water-resistant gown and visor to be worn for all GAs, whether COVID-19 was suspected or not.With input and direction from the anaesthetists, we aimed to insert 95% of cerclages SA. Regular liaison with all staff involved meant we could frequently gain feedback to ensure best contemporary practice, optimising patient and staff safety.20/21 cases were performed under SA. 1/21 required a GA due to contraindication to regional anaesthetic. Regional anaesthetic was found to be acceptable to women and staff.We decided to adopt this practice as long as the COVID-19 recommendation for full PPE during GA procedures were in place. It is unlikely that this practice will not be continued following the COVID-19 outbreak as regional anaesthesia increases the procedure and recovery duration. We also saw an increase in cases of urinary retention leading to prolonged hospital admissions.
  • FDCS, fully dilated caesarean section; FTF, face to face; GA, general anaesthetic; PPE, personal protective equipment; SA, spinal anaesthetic; sPTB, spontaneous preterm birth; TVUS, transvaginal ultrasound.