Birmingham Symptom specific Obstetric Triage System (BSOTS) (#3057)

Idea Description
Supplementary Information
Innovation 'Elevator Pitch':
We have successfully designed, implemented and evaluated a standardised triage system for use within maternity care. It is currently used in eight maternity units, with more planned.
Overview of Innovation:
Triage systems are designed to ensure the patient receives the level and quality of care appropriate to their clinical needs and resources available. Triage involves establishing the presenting problem, undertaking a standardised physiological assessment including vital signs and results in a score being assigned based on predictors of urgency which determines the priority of on-going care.
The physiological changes associated with pregnancy mean the standard triage tools may not be applicable. In addition, the underlying good health of the maternity population, which may mask the severity of maternal illness, and no assessment of the condition of the unborn baby reinforce the need for a specific maternity tool. While some informal triaging takes place within maternity care, a national survey showed that women currently wait to be seen in the order in which they arrive and that current prioritisation systems do not use clinical determinants.

Birmingham Symptom specific Obstetric Triage System (BSOTS)
The system was co-produced by clinicians and researchers in Birmingham to prioritise care for women presenting with pregnancy related complications or concerns.
The BSOTS bundle includes:
  • Completion of a standard clinical triage assessment by a midwife within 15 minutes of the woman’s attendance. This includes taking a brief maternal history, completion of baseline maternal observations, assessment of pain levels, abdominal palpation and auscultation of the fetal heart rate .
  • This assessment is used to define a category of clinical urgency using a 4-category scale, which guides timing of subsequent assessment and immediate care (by an obstetrician if required) using algorithms.
  • Standardised symptom-specific algorithms are used for allocation of clinical priority and the immediate care and further investigations of the eight commonest reasons for attendance (abdominal pain, antenatal bleeding, hypertension, suspected labour, ruptured membranes, reduced foetal movements, unwell/other, and postnatal concerns).
  • Documentation is provided to support and standardise completion of the clinical tasks required.

Implementation of BSOTS requires multidisciplinary training of clinicians which takes approximately three hours. The BSOTS training has also been developed and elevated by the team
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
Similar Content3
Innovation 'Elevator Pitch':
ScanNav is a software package providing discrete, real-time support to sonographers during the FASP 20 week fetal anomaly ultrasound scan. ScanNav acts as a helpful peer review, an intelligent checklist ensuring complete, fit for purpose scans.
Overview of Innovation:
ScanNav® is a software package that provides support to sonographers during the 20 week fetal anomaly scan. It gives real time feedback to the screener on whether paused images are fit for purpose, and on whether the protocol has been followed. It is a peer review, a checklist with which the sonographer may disagree at any time.
  • Trained by human experts
  • Consistent
  • Objective
  • Always available
  • Supports and assists in the supervision of newly qualified sonographers.
  • Provides oversight of locum sonographers.
  • Performs automated, prospective second trimester anomaly scan audit.
  • Provides real-time support for sonographers.
Newly qualified sonographers ideally need another sonographer in the room to assist with their scanning and with quality control, but peer review is time consuming, disruptive, subjective, and a more senior sonographer can’t be there 100% of the time.
ScanNav® automatically examines each image as soon as the sonographer presses pause.
It determines which (if any) FASP fetal anatomy view it represents. It then assesses fitness for purpose against the FASP criteria, reporting that opinion graphically, and giving the sonographer the option to disagree if they wish.
If the sonographer agrees, then no interaction is necessary.
If the sonographer choses to save the image, ScanNav® adds those criteria to the overall record of the view.
A separate interface allows managers to examine individual scans or aggregate performance against FASP criteria.  Over time, as the system observes many scans, statistics on scan completeness and quality are collated and can be presented as an audit report.
The sonographer always retains primacy. ScanNav® acts as a consistent colleague. ScanNav® always allows the sonographer to disagree with it.
Stage of Development:
Close to market - Prototype near completion and final form may require additional validation/evaluation and all CE marking and regulatory requirements are in place
WMAHSN priorities and themes addressed: 
Wealth creation / Innovation and adoption
Benefit to NHS:
ScanNav increases the efficiency of sonographers and managers in the 20-week FASP anomaly scan by
  • Supporting and assisting in the supervision of newly qualified sonographers.
  • Providing oversight of locum sonographers.
  • Performing automated, prospective second trimester anomaly scan audit.
  • Providing real-time support for sonographers.
Using ScanNav considerably reduces the effort required to provide comprehensive peer review and oversight of sonographers.

With ScanNav, the sonographer has immediate feedback on any paused image, identifying which criteria are present, and an automatic intelligent checklist that keeps track of progress through the scan. At the end of the scan, the user or their supervisor can see exactly what has been saved, and can comment, or take further action to complete the scan, as appropriate.

Supervisors can, at any time, easily see overall statistics on sonographer performance, enabling them to instantly examine any images where
  • The scan is not complete.
  • The sonographer has disagreed with ScanNav (ruling in or out criteria).
  • The sonographer has continued to save images where the view was already complete.

This can help guide training and support. ScanNav fits naturally into the standard workflow to enable time savings. Further efficiency savings are expected to be demonstrated once the initial software rollout start in mid-2017.

For managers, ScanNav® LFR enables automatic 100% audit of FASP 20 week views, something that is currently impractical.
Quality goal.

It is also hoped that ScanNav will improve outcomes. A retrospective audit at one NHS trust showed that nearly 50% of scans had at least one missing view. There are many reasons why this might legitimately be the case – e.g. high maternal BMI or unhelpful fetal position, but ScanNav helps to ensure that any views missed are done so explicitly, with reasons for the missing view recorded. This has both quality and medico-legal benefits, allowing compliance with protocol and due diligence to be easily and reliably demonstrated.
Initial Review Rating
3.67 (3 ratings)
Benefit to WM population:
It is well known there is a continued shortage of sonographers. With recruitment being difficult, training and retaining sonographers to reduce reliance on agency workers is the ideal solution, but this inevitably increases pressure on experienced sonographers.

Experienced staff invest a lot of effort and time when training and supporting newly qualified sonographers. Likewise, locum sonographers may require significant supervision from experienced members of the team - adding to an ever-increasing workload. ScanNav will considerably reduce the time needed to provide this support, increasing capacity and reducing costs.

It is also hoped that ScanNav® will improve outcomes. A retrospective audit at one NHS trust showed that nearly 50% of scans had at least one missing view. There are many reasons why this might legitimately be the case – e.g. high maternal BMI or unhelpful fetal position. ScanNav helps to ensure that any views missed are done so explicitly. The live automatic checklist makes it easy to see if any views are still outstanding, and the software will prompt the sonographer to easily record the reason for any missing views at the end of the scan, eliminating accidentally missed views.
Current and planned activity: 
ScanNav has been trained using a team of experienced NHS sonographers and over 370,000 ultrasound images, and tested with 60 professionals across 31 clinical and governance institutions, A prototype has been used at the John Radcliffe in Oxford. A demonstration of the software has been shown to two UK trusts so far, and the sonographers preferred ScanNav to manual peer review.

This demonstration of the software is now available to potential Limited First Release (LFR) partners. We want sites to use the CE marked beta software free of charge to assess utility and report back as part of a post market surveillance exercise.

We would like to work with sites to assess how the software enables them to change practice. As a part of this, we would perform an anonymous analysis of one year’s prior images saved under FASP. A full analysis of the completeness and fitness for purpose would be undertaken, allowing a direct comparison of performance before and after the introduction of ScanNav LFR.
What is the intellectual property status of your innovation?:
IP held by company. Simulator is not applicable to patients. LFR release will hold a medical CE mark.
Return on Investment (£ Value): 
Return on Investment (Timescale): 
Ease of scalability: 
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Innovation 'Elevator Pitch':
Good quality maternity information is essential to provide safe care. We will evaluate the Mother’s Information Application (MiApp), a personalised electronic, fully interoperable version of the Perinatal Institute’s hand-held notes. 
Overview of Innovation:
Currently hand-held paper notes are the primary record for maternity. The Perinatal Institute’s maternity notes have become the standard, used in approx 60% of pregnancies in England -

The Perinatal Institute have been successful in combining the utility of a standardised, evidence based record for clinicians, with details on the care the mother should expect at the various stages of pregnancy, outlining her choices as well as essential information and key messages to ensure best possible maternal engagement in her care.

The hand-held notes are the master record allowing complete inter-operability with all care providers, but require double or triple entry of data to ensure electronic systems are up to date. With increasing development of information systems, electronic records are starting to become the principal maternity record, which takes information and control away from the mother. Instead they carry either:
  • Print outs of certain aspects of care (being paper heavy and complicated to navigate) or
  • Minimal information in the form of a summary ‘co-op card’ or appointment card.
This results in a lack of routine pregnancy information being given to women, an absence of specific information available to the mother about her own pregnancy, and a lack of inter- operability between the systems used at different facilities meaning other care providers do not have access to the mother’s record if required.
The Mother’s Information Application (MiApp) is a personalised, electronic, fully interoperable version of the Perinatal Institute’s hand-held notes available on smart phones, tablets or desktop computers. It returns control of the health record to the mother, and allows her to make her maternity healthcare record available to her designated care providers, directly or through integration with local information systems.
MiApp is able to:
  • Provide expectant and new mothers with relevant information about their pregnancy, explaining what to expect at each stage and listing options to allow informed choices.
  • Act as the master document for recording and updating details about the care received,
    including results of screening tests, investigations, risk assessments, referrals, and management plans.
Stage of Development:
Close to market - Prototype near completion and final form may require additional validation/evaluation and all CE marking and regulatory requirements are in place
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Innovation and adoption / Patient and medicines safety / Person centred care
Benefit to NHS:
MiApp is able to:
  • Provide expectant and new mothers with relevant information about their pregnancy, explaining what to expect at each stage and listing options to allow informed choices.
  • Act as the master document for recording and updating details about the care received, including results of screening tests, investigations, risk assessments, referrals, and management plans.
  • Give mothers control over their data with complete national inter-operability (using industry standard HL7 messaging) allowing her various care providers to access details and include additional information as appropriate.
  • Avoid the need for double entry of data, reducing the administrative burden on clinicians and administrators and thus increasing time for clinical care.
  • Provide high quality data for clinical care as well as for secondary uses, and support evidence based commissioning, service planning and performance monitoring.
  • Increased cost savings because of reduced double entry of data, reduced clinical coding time, reduced litigation costs and reduced clinical time spent on record keeping (a separate cost benefit analysis will be provided).
  • Integrated messaging system between patients and clinicians as well as between clinicians, which reduces unnecessary appointments and enhances quality of care.
Online Discussion Rating
5.86 (7 ratings)
Initial Review Rating
3.80 (1 ratings)
Benefit to WM population:
There are a number of health and weatlth benefits to the West Midlands population, including:
  • Good quality data produced from MiApp will support commissioners to tailor services according to local needs.
  • Individual NHS Trusts can use the data produced to benchmark their services and therefore recognise areas for further improvement. 
  • Clinical risks are greatly recuded through the interoperability, as the West Midlands population will be able to move between healthcare providers with a fully accessible, complete healthcare record.
  • In recognition of the diverse West Midlands population, the record incorporates translation into 18 languages along with information in video format. The aim is that families from all backgrounds and of all capabilities have access to information that they can understand and use appropriately to improve their health.
  • MiApp enables access to the wider health and social care system by highlighting services that are available to all, empoweing women to take control of their own health.
  • Promotes standardised care for the West Midlands population in line with national guidelines.

Current and planned activity: 
The Perinatal Institute is a national not-for-profit organisation set up to enhance the safety and quality of maternity care. It is a qualified provider of
maternity support services, including education and training in standardised maternity records, fetal growth assessment and perinatal audit.

The Perinatal Institute has won numerous national awards including most recently the 2016 Queens Award for Enterprise, the 2015 BMJ Award for clinical leaership and the 2015 Patient Safety Award for IT and Technology

The conduct of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems.
What is the intellectual property status of your innovation?:
The intellectual property belongs to the Perinatal Institute
Return on Investment (£ Value): 
Return on Investment (Timescale): 
1 year
Ease of scalability: 
Regional Scalability:
The service can be scaled rapidly and efficiently across the region. Our business case means it is likely to be cost-efficent in a very short space of time making it an attractive proposition for commissioners.
A robust evaluation of MiApp will establish the feasibility of using this type of solution and provide a measure of it’s transferability to maternity care across the region and ultimately the UK. 

The project will consist of a quantitative and qualitative evaluation of the MiApp system in comparison to current systems. This evaluation includes a:
  1. Structured survey and semi-structured interviews to explore existing maternity systems with expectant mothers and clinicians.
  2. Structured survey and semi-structured interviews to explore the experience of expectant mothers and clinicians using MiApp. This will include using the principles of user testing to evaluate the mother’s ability to retain and assimilate information held on MiApp.
  3. Economic evaluation of MiApp in relation to time spent on administration in comparison to current systems
Key Deliverables
  • Report on current range of systems available in the West Midlands and their perceived effectiveness in providing mothers and clinicians the information needed for safe maternity care
  • Qualitative and quantitative assessment of user experience of current systems and MiApp.
  • Cost benefit analysis with implications for service delivery in the West Midlands and nationally
  • MiApp is in the process of being rolled out at two sites in the UK but to date there has been no formal evaluation of the effectiveness of MiApp for clinicians and mothers.
  • Proposed outcome measures for women include:
  • Satisfaction with care
  • Retention and assimilation of information
  • Engagement in pregnancy
Inclusion criteria
A number of characteristics can influence the ability to find and understand information in an IT application (including age, educational attainment, inability to speak/read English and deprivation). To help ensure that our cohort reflects this range of characteristics, we will purposively select women from a variety of backgrounds and ensuring the survey is available in multiple languages. 
Adoption target:
The conduct of an evaluation is predicated on the adoption of the device within selected settings. This would be the the first stage of a controlled roll-out, one where we will precisely measure the benefits it provides to encourage its adoption across the region and beyond. 
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Innovation 'Elevator Pitch':
Our online workshop helps women from all backgrounds in all demographic areas to access positive, factual information to support their birth choices using evidence-based information that can be updated as and when new guidance is released.
Overview of Innovation:
The Real Birth Company’s mission statements are ‘to provide relevant, up to date, evidence based antenatal information that is delivered with a positive attitude’ and ‘to impart our knowledge with confidence to empower women and their birth partners at this very special time’.
We have achieved this with our RCM accredited antenatal education training programme that has been developed into an online e-learning antenatal resource for women birthing in the UK & is available in several languages. This e-learning resource is a birth physiology workshop full of important information that supports UK practice & enables women to understand the reasons behind their care, whilst supporting them to make informed choices in labour.

Antenatal education is essential to helping women form opinions & make choices in regard to their pregnancy & birth. There are various types of antenatal education. Hospital accessible antenatal education is dependant on resources, demographics & availability of staff to name a few. Lots of these classes use traditional methods of teaching with limited time to discuss at length the physiology.
The Real Birth online workshop is easily updated & uses evidence-based information from NICE, WHO, RCM, RCOG & others. It is holistic, culturally sensitive & can be accessed from anywhere by computer, tablet or mobile phone.
The innovation of creating a multi-lingual online e-learning workshop came from the positive birth results that were consistent with women & their partners who had attended a specifically designed positive birth workshop.
The workshop was created using techniques that help graduate students revise for exams, this learning technique has been integrated into the imparting of positive birth physiology. The use of non-threatening language & positive birth information helps to normalise birth & reduce fear. When fear is reduced in labour the benefits for both mother & baby are both psychological & physiological.
Barriers to effective antenatal education can include:
  • time pressures for antenatal classes
  • finding midwives who feel comfortable giving antenatal education
  • update & training costs
  • availability of classes
  • limited spaces for face to face classes
  • cost of interpreting services/availability of interpreters
  • birth terminology used
  • women being unable to attend for social or demographic reasons
Our online workshop works to address these barriers to help women from all backgrounds in all demographic areas to access positive, factual information.

Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Digital health / Innovation and adoption
Benefit to NHS:
The Real Birth online workshop is an easily accessible form of evidence-based antenatal education (updated as evidence changes) that is interactive, informative & fun to use.
The Better Births Maternity Review says that all women should have access to information to enable them to make an informed, non-bias choice.

Making Normal Birth a Reality states ‘evidence-based information for women about factors that make a normal birth with good outcomes for the mother & baby more or less likely, presented in a format which they understand so that they can plan for the kind of birth they want & make informed decisions’ is an essential part of birth preparation.

WHOs new recommendations on reducing unnecessary births by C-section recommended ‘Health education for women is an essential component of antenatal care’ by using childbirth education workshops that include partners to support women & address fear of birth with methods such as understanding birth physiology, our workshop helps to address unnecessary interventions in labour.

Women with access to antenatal education have a higher chance of normal birth & a more positive birth experience that can help in the postpartum period.
The workshop follows a researched learning technique. Written in a style that enables users to learn & retain the information more effectively leading to confidence & understanding of birth.
Accessed from 25 weeks of pregnancy via a unique coded card issued by the healthcare provider, users work through 1 module at a time before accessing the next to ensure the workshop is comprehensible. Within the modules are questions, diagrams & carefully designed non-threatening animations.
Each language has been translated by first language speakers to ensure the terminology is understandable & animations are culturally respectful whilst explaining a journey of birth. NICE Pregnancy & Complex Social Factors list barriers for women who speak no or little English that include lack of interpreters & knowledge of the maternity service. Our workshop helps address such barriers. NICE also say that with this group of women other methods such as online video clips & audio information should be used.

Our workshop is factually based giving true & correct information & techniques to practice for labour along with the best positions & why. It addresses subjects like the reasoning behind recommendations for skin to skin & looks at how this can help aid mental health for both parents in the postnatal period.
Initial Review Rating
5.00 (1 ratings)
Benefit to WM population:
Antenatal education has a role to play in improving knowledge of, and preparation for parenthood and can lead parents to be, to adopt a range of healthy behaviours that affect pregnancy and birth, improving outcomes and the mother’s experience of birth.
The Real Birth Company is committed to supporting all women to access up to date and evidence-based information relating to their birth. We believe that all women should have access to this information and have produced the e-learning modules in several languages to help tackle health inequalities.
Tackling health inequalities in infant mortality and infant and maternal health, will not just improve health outcomes today, but lay the foundations for sustainable, long-term improvements in health.
At 5.5 deaths per 1,000 live births, the West Midlands has the poorest infant mortality rate in England [2014 data].  The infant mortality rate takes into account the total number of live births and so provides a more accurate indication of trends than just analysing the number of deaths in infancy over time. The West Midlands rates are significantly higher than the England average. (source)
Poorer mothers-to-be often do not attend antenatal classes. Almost three-quarters of pregnant women on low incomes do not attend antenatal classes according to new figures. Nearly half are not even offered them on the NHS. (source)
The Real Birth Workshop was created because we believe that all expectant parents should have access to positive birth information. It is beneficial for pregnant mums and their birth partners to have positive help with their birth preparation. We support all birthing choices because we believe in empowering women with the right information when they need it.
A report by the National Childbirth Trust (NCT) Preparing for birth and parenthood report surveyed 928 expectant parents (first-time mothers and fathers) attending antenatal courses. The research found that while only 3% of women said they felt confident about birth before attending an antenatal course, afterwards 98% said they felt confident or fairly confident. Similarly, among fathers-to-be surveyed, just 1% said they felt confident about birth before their course; afterward 97% felt confident or fairly confident.
The Real Birth Online Workshop provides parents to be with the education they need to manage and reduce maternal anxiety leading to improved coping strategies, greater partner support and a better birth experience.
Current and planned activity: 
We believe the workshop shows decreased admission in the latent phase, decreased use of analgesia & an increase in women having a positive birth experience.

We need champions who can apply for NIHR funding with us to pilot The Real Birth Online Workshop with women using their NHS maternity services.  
A number of languages are currently active, we want to include more to help all women access valuable antenatal education. Being able to access our online workshop provides antenatal education to women who may otherwise be unable to attend classes for various reasons including social, cultural & demographic.
Many proactive measures are being taken to address perinatal mental health. We believe a positive birth experience doesn't depend on mode of birth but choice, understanding & involvement in decision making & empowerment in pregnancy & labour.
Our programme can have a positive effect on women’s birth experiences & her birth partners & assist with informed choice & understanding of birth.  
What is the intellectual property status of your innovation?:
100% IPO The Real Birth Company Limited
Return on Investment (£ Value): 
Return on Investment (Timescale): 
Ease of scalability: 
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