Implementing the Quick Reference Handbook for Obstetric Emergencies (Obs QRH)

• Assemble a team and a team leader. The team will include representation from obstetric, anaesthetic, midwifery, neonatology and theatres. It is important that all groups are represented. The team leader could be any team member. It maybe that an anaesthetist takes the lead, as they are likely to have existing knowledge of the AoA QRH used in theatres.
• Get the support and co-operation of the leads from all the aforementioned clinical areas.
• Secretarial and/or admin support can be useful, especially initially when the Obs QRH needs to be printed and assembled
• Other useful members to have in the implementation team are:
  • Colleagues experienced in training and/or simulation
  • The College Tutors from the different clinical specialties
  • Practice educators
  • Trainee representatives
  • Risk manager
  • Other educators

• The Obs QRH should be immediately available in all locations where care of a birthing person takes place; this may mean one copy per triage room, birthing room, theatre, emergency department, intensive care unit. This list is a suggestion only. Consideration must be given to all locations in which birthing persons are cared for. 
• Departments should make sure the Obs QRH is available in remote locations, such as CT or MRI suites and emergency departments. If care is only occasionally provided in these locations, it may be more appropriate to take an Obs QRH along each time (for instance with the emergency 'grab bag') rather than leaving one there all the time. Be aware it's harder to police QRHs in such locations and they are more likely to disappear
• Print extra copies for training and for simulation, as appropriate to your unit

• The Obs QRH should have a highly visible and dedicated storage point in each location
• The Obs QRH should ideally be displayed in a wall mounted holder, marked clearly with a sign as the location for the Obs QRH. You can download a ready-made template sign for the Obs QRH holder
• The locations of the Obs QRH needs to be decided for each clinical area in which the guides will be used

• Print the Obs QRH in colour if possible
• Individual guidelines will change over time and will need to be removed and substituted. Guidelines may also be added or removed. The Obs QRH needs to be assembled in a way which anticipates this
• The simplest way to assemble the Obs QRH is to use A4 hole-punched polypockets in a simple clear-fronted plastic prong folder
• The guidelines can also be professionally printed, for example on laminated paper. Individual departments can evaluate the cost vs benefit of this
• We don't recommend spiral binding or other more elaborate binding methods, unless they allow removal and substitution of individual guidelines

• The PDF version of the Obs QRH has been designed to be printed off, assembled and implemented right away
• Some units will wish to modify some or several of the guidelines by downloading the Word version
• While we support this, there are caveats:

i. You must understand and accept the licensing terms
ii. You are responsible for checking the entirety of any guideline once you begin to modify it, not just the portions you modify

• Make sure everyone knows the Obs QRH is being implemented
• Make sure colleagues understand the intent, extent and limitations of the Obs QRH
• Use departmental and clinical governance meetings to preview the Obs QRH
• Make sure your risk managers, Trust Board and CEO know about it!

• Regular multi-disciplinary practice of crisis management should take place
• In remote locations, regular multi-disciplinary practice of crisis management should take place and should include special focus on any location-specific limitations or impediments that exist
• The mere presence of an Obs QRH won't help in a crisis; it's a tool like any other and teams must practice using it
• The Obs QRH is not a substitute for learning and practicing the skills required to manage a crisis
• Effective practice doesn’t need high fidelity simulation; simpler forms of simulation can be more effective
• 'Table top' practice can be just as effective at familiarising users with the guidelines. This simply involves an informal 'walk through' of the guidelines with the relevant team members, but in a non-immersive environment, i.e. without simulation of any kind. It can be undertaken anywhere
• Having a timetable for 'crisis of the day' can be a useful way of stimulating multidisciplinary discussion (e.g. on labour wards) and informal practice. Each day or week has a nominated crisis (rotated daily or weekly) and during any down time, at their convenience, multidisciplinary obstetric and neonatal teams can work their response to that crisis and refresh their knowledge. This retains team familiarity with the Obs QRH.
• Alternatively, clinical concerns regarding birthing people currently in your clinical area can act as a stimulus for reviewing Obs QRH guidance. This allows for familiarisation, rehearsal and a feeling of being better prepared.

• Local circumstances will dictate exactly where, when and how the practice takes place
• Remember: Clinicians should be familiar with what's in the Obs QRH and be practiced in its use. Reaching for it in a crisis should be automatic.

• Ensure you have the most up to date version
• Periodically check the presence, integrity and completeness of all the handbooks
• Replace any missing handbooks promptly