HSIB: Suitability of equipment and technology used for continuous fetal heart rate monitoring (July 2021)

Summary

Healthcare Safety Investigation Branch (HSIB) looked into the suitability of equipment and technology used within maternity departments to conduct continuous fetal heart rate monitoring during labour and birth. Although there are multiple methods used to monitor fetal heart rate, the main equipment used is a continuous fetal heart rate monitoring is the cardiotocograph (CTG) machine.

There has been some common safety issues identified with availability of equipment and functionality, staff understanding of the equipment and its purpose and an inability to understand and interpret the fetal heart rate. HSIB conducted an investigation into how cardiograph machines are used, any problems staff experienced while using them and problems that staff using them and how the equipment was purchased experienced, and how staff are trained and assessed as being competent to use them.

Content

Safety recommendations

• HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to enhance the role of the ‘fetal monitoring lead’ to include, training and competency checks of all maternity staff on the use and functionality of cardiotocograph (CTG) equipment.
• HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to remove specific references to DawesRedman and instead use a generic term such as ‘computerised cardiotocograph (CTG) analysis’.
• HSIB recommends that the National Institute for Health and Care Excellence considers reviewing its telemetry recommendation as part of the current update of clinical guideline CG190, taking into account the existing evidence and the findings of this report.

Safety observations

• It may be beneficial for trusts to ensure that when procuring new equipment, they form a multidisciplinary team, which incorporates staff with the requisite skills in procurement and the clinical environment in which the new equipment will be used. If the new equipment has additional functionality, then stakeholders from these areas should be included – for example, if the equipment is to be networked the IT department should be included.
• It may be beneficial if a single procurement guidance document were produced for trusts to use when purchasing clinical equipment, with all relevant information included.
• It may be beneficial for trusts to use a change management system when implementing new systems or introducing new equipment.