Reducing the impact of nausea and vomiting in pregnancy - an ambulatory approach. (Green Maternity Challenge)

Project completed as part of the National Green Maternity Challenge 2024-25 by the Norfolk & Norwich University Hospitals NHS FT (NNUHFT) team.

Reducing the impact of nausea and vomiting in pregnancy - an ambulatory approach

Team members:

• Beth Laverick, Consultant Obstetrician, Maternal Medicine Lead.
• Laura Allen, Quality Improvement Lead Midwife
• Sophie Holland, Obstetric Medicine Fellow

Setting / patent group: Maternity Services

Issue: 

Maternity unit at NNUHFT is a 5,400-birth unit, where 90% women experience NVP and 4% experience HG. Nausea and Vomiting in Pregnancy (NVP) and Hyperemesis Gravidarum (HG) can lead to dehydration, weight loss, electrolyte abnormalities, venous thromboembolism and Wernicke’s encephalopathy. It can also affect the fetus causing growth restriction, grey matter heterotopia and neurodevelopmental issues. It can also cause an increase in suicidal ideation and risk of abortion. It affects a patient’s ability to intake oral medications and also causes change in lifestyle.

The treatment is relatively simple; IV fluids, antiemetics and vitamin replacement. However, there are gaps in providing this care due to factors such as beliefs held by women that it is normal to feel a bit sick during pregnancy, reluctance in taking medications during pregnancy, lack of knowledge about the associated risks and presence of conflicting evidence. Even in cases where such treatments are given, patients need to face long waits and attend multiple locations within the community and the hospital. Follow ups are infrequent and the accessibility of returning to care is insufficient. A survey was conducted to understand the issue from staff and patients’ perspective, which identified uncertainties in referral pathway, inappropriate staff training regarding HG, and unclear discharge plans following admissions.

Intervention: 

The main aim was to improve care for pregnant women experiencing NVP/HG by working together to bring multiple streams of practice development and service users to develop a sustainable model of care that minimises the impact of NVP/HG on patients.

A laminate of written information was designed and implemented to make women aware about what to expect, and informed decision making about medications and other basic amenities.

A follow up virtual appointment was also established for women discharged from the wards, to ensure continuity of care and appropriate follow up. A Virtual Ward policy was put into place which allows for early discharge from hospital by providing remote monitoring, regular virtual reviews, and medication management. A new ‘Hyperemesis Pathway’ was also designed as a part of the Virtual Ward Hub, increasing accessibility of healthcare for women without the need for travelling to the hospital. Training and education were also provided to multiple health care professionals and local guidelines were updated according to national guidelines.

Outcomes: 

Environmental

Majority of emissions associated with the previous pathway was due to the inpatient stay, medications and consumables to provide IV fluids and antiemetics. After the introduction of Virtual Hub, emissions reduced to 1,266 kgCO2e from 1,804 kgCO2e, with a savings of 538 kgCO2e over a period of one month. Extrapolating the results, annual GHG emissions savings of 6,461.5 kgCO2e can be achieved.

Social

Getting appropriate care at home reduced the impact of treatment on work, family life, relationships and daily activities. It also raises staff confidence in providing treatment for NVP/HG and job satisfaction.

Clinical

Patient centred care ensures women are listened to, and that their care is adapted to best suit them in terms of medication regime and location of care. Improved care and outcomes for women with pre-existing medical conditions and requiring regular medication (e.g. women with diabetes could continue their usual medications).

Financial

Financial savings from reduction in the number of bed days (£127,874 previously to £64,434) and the cost of medications & IV Fluids (£761.88 previously to £669.66). This is estimated to bring a total annual savings of £762, 044. 

Key learning point:

This project has been successful in improving care options and outcomes for women with NVP/HG, which is confirmed by the reduction in repeat admissions and need for overnight stays. As shown above, this has resulted in significant reduction in financial costs, carbon footprint and most importantly clinical outcomes. Qualitatively, this has led to patients feeling supported and listened to, while also reducing the financial and social burden for women and their families. Key factors that led to the success of this project was the strength of the multidisciplinary nature of the core team, which was constantly driven by the voices of service users and their families.