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RHG Congress 2018 - Rachel Cutting

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Maximising success in IVF - the marginal gains concept - Presentation from the RHG Congress 2018. https://www.reproductivehealthgroup.co.uk

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RHG Congress 2018 - Rachel Cutting

  1. 1. Sheffield Teaching Hospitals Trust Improving standards in IVF: Introducing the marginal gains concept Rachel Cutting MBE PR / Principal Embryologist / Quality Manager
  2. 2. Sheffield Teaching Hospitals Trust Overview • What do we want to achieve: how do we define high standards / what do we want to improve? • What can we implement to drive high standards • Introduce concept of marginal gains
  3. 3. Sheffield Teaching Hospitals Trust What do we want to achieve in our IVF programme? – Superiority – Excellence – Safety / minimise risk – Consistency – Reproducibility – Happy staff – Lots of babies!
  4. 4. Sheffield Teaching Hospitals Trust • Quality is a process of meeting the needs and expectations of patients and health service staff (WHO 2000) • Quality is the degree to which care services influence the probability of optimal patient outcomes (American Medical Association, 1991) High standards liked to Quality
  5. 5. Sheffield Teaching Hospitals Trust Improving standards in IVF Success rates Safety Complications Multiple birth rates Incidents Patient satisfaction / complaints Staff competence
  6. 6. Sheffield Teaching Hospitals Trust How far we can reach depends on.....
  7. 7. Sheffield Teaching Hospitals Trust What can we implement to drive high standards?
  8. 8. Sheffield Teaching Hospitals Trust Quality Management System • QMS – Involves the whole organisation – Quality manual – Quality objectives – Quality policy – Quality assurance – Quality control
  9. 9. Sheffield Teaching Hospitals Trust Policy Manual (Signposting Document) Templates/forms- master document index Forms, Documents & Records) Operational Procedures Operational Procedures
  10. 10. Sheffield Teaching Hospitals Trust Practical examples of implementing high standards of working
  11. 11. Sheffield Teaching Hospitals Trust Training / Competency Assessment • Ensure defined training programme • Properly supervised • Competency assessed and signed off • CPD • Regular assessment of competence
  12. 12. Sheffield Teaching Hospitals Trust Comprehensive SOPs • Standard format • Title • Scope • Task description – What are you doing? • Describe each task in detail – How do you to it? – How do you record it? – What do you do with the information? • Involve everyone • Review frequently
  13. 13. Sheffield Teaching Hospitals Trust Quality Control • Measuring specific equipment • Continuous vs ‘spot checks’ – Incubators • continuous – Fridges • continuous – Heated stages • checked weekly
  14. 14. Sheffield Teaching Hospitals Trust How do we reach that bit higher?
  15. 15. Sheffield Teaching Hospitals Trust
  16. 16. Sheffield Teaching Hospitals Trust Marginal gains • The concept of marginal gains has revolutionised British Cycling • Nike have adopted the theory in an attempt to break the 2 hour marathon record
  17. 17. Sheffield Teaching Hospitals Trust
  18. 18. Sheffield Teaching Hospitals Trust Nike’s approach • At the start the athletes were immediately joined by six pacers, who adopted an arrowhead formation behind a Tesla electric car with a giant clock timer on it – Wind tunnel studies show that this formation would help them as it saves energy • carbohydrate-rich sports drink – delivered by helpers on mopeds so he did not have to slow down • Zoom Vaporfly Elite shoes – allows runners to roll through instead of bending toes and losing energy.
  19. 19. Sheffield Teaching Hospitals Trust
  20. 20. Sheffield Teaching Hospitals Trust What are marginal gains If you break down everything you could think of that goes into our service, and then improve it by 1%, you will get a significant increase when you put them all together
  21. 21. Sheffield Teaching Hospitals Trust
  22. 22. Sheffield Teaching Hospitals Trust Could the same approach also improve areas of our unit?
  23. 23. Sheffield Teaching Hospitals Trust Patients Stimulation regimen Laboratory design Egg retrieval Culture Conditions Staff Laboratory environment Equipment Technology
  24. 24. Sheffield Teaching Hospitals Trust Appointments Egg Collections Labs Embryo transfers Waiting room Daily MDT meeting Forms Recovery space Staff Admin Embryology Clinical Nursing
  25. 25. Sheffield Teaching Hospitals Trust SOP Review • Each member of the team checks another one • Juniors to check seniors against SOPs • Identifies non conformances / deviations • Discussed at lab meetings
  26. 26. Sheffield Teaching Hospitals Trust Embryologist assessed: ……………………………… DATE............... Poor Borderline Competent Expert Is all the paper work in place for the embryo transfer? Is the Embryo Transfer Sheet in the patient’s notes completed? Is the verbal witness procedure carried out with the doctor and nurse present in theatre? Are the details of the embryos clearly explained to the patient? Is the Embryo Freezing Advice Sheet completed if embryos are being cryopreserved? Is the type and batch number of catheter recorded? Has the embryo(s) been transferred to a glue dish at least 30 mins before the procedure? Is the catheter prepared correctly and warmed?
  27. 27. Sheffield Teaching Hospitals Trust At the end of the procedure is the media flushed through the catheter to check for retained embryos? Is sterile technique used at all times during processing? Is the laboratory record completed and signed? Is the heated stage used throughout and are the dishes kept outside the incubator for a minimum time to maintain viability Overall performance Suggestions for development: Any deviations observed from SOP Agreed action Assessor’s signature:…………………………………………………Date:……………………… Assessed against 10 Is the dish ID check performed through the hatch with the scan nurse and the IVF witness check completed? Are the embryos loaded correctly into the catheter?
  28. 28. Sheffield Teaching Hospitals Trust Temperature Monitoring - Accuracy • Heated stages – Use dishes as use for treatment (RI tags) – Test full range of dishes used (slight differences) – Probe holder to keep stable in the drop
  29. 29. Sheffield Teaching Hospitals Trust Egg Collection • Temperature control • Flush syringes • Needles • Theatre temperature • Level of flush tubes • Speed • Oocyte viability – Time in MOPs plus
  30. 30. Sheffield Teaching Hospitals Trust
  31. 31. Sheffield Teaching Hospitals Trust Lab heated stage
  32. 32. Sheffield Teaching Hospitals Trust Improvements • Pre warm needles (incubator in theatre) • Flush syringe 10mls – max 2 mins • Stabilise theatre temperature at 24o C • No overfilling of flush tubes • Doctor and embryologist work at similar speed • Oocytes placed in GIVF in incubator when change sides
  33. 33. Sheffield Teaching Hospitals Trust Osmolarity o C pH
  34. 34. Sheffield Teaching Hospitals Trust Dish preparation • Simple task – but not one to be complacent with! • Prevent changes in osmolarity – 1 dish at a time (embryoscope) – Cold stage / prep at room temperature / bottles not on heated stages – Care with oil overlay in dishes in non humidified incubators (embryoscope) (increased volume of oil) – Use opened bottle within 1 week
  35. 35. Sheffield Teaching Hospitals Trust Cryopreservation Programme Improve survival rates?
  36. 36. Sheffield Teaching Hospitals Trust Warming solutions • Ice formation on warming is of comparable or greater importance to ice formation on cooling in determining survival of cryopreserved samples. • Focus on warming rate • Temperature mapping exercise • Aim to maximise survival rates
  37. 37. Sheffield Teaching Hospitals Trust mins O C
  38. 38. Sheffield Teaching Hospitals Trust Thaw order
  39. 39. Sheffield Teaching Hospitals Trust Little steps are good!  Consistency in quality  Staff are competent and safe  Reduces risk  Ensures continuous improvement  Shares / promotes best practice  Pushes success rates a little higher?
  40. 40. Sheffield Teaching Hospitals Trust Conclusions • Positive attitude towards improvement – Engage your whole team

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