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Objective: To evaluate the effectiveness and cost-effectiveness of the National PReCePT Programme (NPP) in increasing use of magnesium sulfate (MgSO 4 ) in preterm births., Design: Before-and-after study., Setting: Maternity units (N=137) within NHS England and the Academic Health Science Network (AHSN) in 2018., Participants: Babies born ≤30 weeks' gestation admitted to neonatal units in England., Interventions: The NPP was a quality improvement (QI) intervention including the PReCePT (Preventing Cerebral Palsy in Pre Term labour) QI toolkit and materials (preterm labour proforma, staff training presentations, parent leaflet, posters for the unit and learning log), regional AHSN-level support, and up to 90 hours funded backfill for a midwife 'champion' to lead implementation., Main Outcome Measures: MgSO 4 uptake post implementation was compared with pre-NPP implementation uptake. Implementation and lifetime costs were estimated., Results: Compared with pre-implementation estimates, the average MgSO 4 uptake for babies born ≤30 weeks' gestation, in 137 maternity units in England, increased by 6.3 percentage points (95% CI 2.6 to 10.0 percentage points) to 83.1% post implementation, accounting for unit size, maternal, baby and maternity unit factors, time trends, and AHSN. Further adjustment for early/late initiation of NPP activities increased the estimate to 9.5 percentage points (95% CI 4.3 to 14.7 percentage points). From a societal and lifetime perspective, the health gains and cost savings associated with the NPP effectiveness generated a net monetary benefit of £866 per preterm baby and the probability of the NPP being cost-effective was greater than 95%., Conclusion: This national QI programme was effective and cost-effective. National programmes delivered via coordinated regional clinical networks can accelerate uptake of evidence-based therapies in perinatal care., Competing Interests: Competing interests: GAF received grant funding from the NIHR and the British Heart Foundation and is a party to partnership agreements with industry partners as CEO of the Oxford Academic Health Science Network. He is chair of the Buckinghamshire, Oxfordshire and West Berkshire Integrated Stroke Delivery Network, the Academic Health Science Network, the European Stroke Organisation Council of Fellows and the Academy of Medical Sciences Fellowship Sectional Committee 7. He is Director of the Cogentis and Accelerate companies and Non-Executive Director of the National Institute for Health and Care Excellence, and serves on the Board of Trustees of the Picker Institute and Health Services Research UK, and the governing body of Green Templeton College, Oxford University. He is data monitoring committee member for the PREVENT-SVD study, trial steering group member for OPTIMAS, R4VaD, ATTEST-2 and SENIOR-RITA trials, grants review panel member for Pfizer/Bristol Myers Squibb, and round table member for the Bristol Myers Squibb/Price Waterhouse Cooper Life Sciences 2030 Cancer Moonshot and Astellas Company Conference. KT acted as expert witness to the High Court in England, called by the UK MHRA, defendant in a case on hormonal pregnancy tests and congenital anomalies in 2021/2022. All other authors in this manuscript have no conflict of interest to declare aside from funding from NIHR ARC West, AHSN, NHS England and Health Foundation. The authors declare that the study management group has no competing financial, professional or personal interests that might have influenced the study design or conduct., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: A quality improvement strategy (PReCePT) was used in a standard and enhanced format to scale up a clinical intervention (administering magnesium sulphate to women in preterm labour) across all maternity units in England to protect prematurely born infants from neurodevelopmental disabilities. Formal evaluations reported the effectiveness of the standard package alone in increasing the administration of magnesium sulphate. In this paper, we focus on the findings of the process evaluations, using normalisation process theory to explain how different implementation contexts generated the observed outcomes relating to normative and relational restructuring and sustainment., Methods: Interviews were conducted with key individuals in implementation of leadership positions nationally and locally. Interviews were analysed initially using the framework method. We then engaged recursively with NPT constructs to generate generalisable insights with pragmatic applicability in other settings., Results: In total, 72 interviews were conducted with good representation from units across England and staff from the National Academic Health Science Network. We found that all units irrespective of whether they received a standard or enhanced QI package were successful in the 'normative restructuring' of their setting to enable magnesium sulphate to be administered. This suggests that this implementation outcome is necessary to achieve improvements. However, it may not be sufficient to sustain the changes once additional resources have been withdrawn. Sustainment, our findings suggest, required 'relational restructuring' to accommodate altered workflows and facilitate the sharing of responsibilities and tasks in daily practice. Relational restructuring was more likely to have been achieved units receiving enhanced QI support but also happened in units with standard QI support, especially in those where perinatal team working was already well established., Conclusion: Unlike other large QI-focused spread-and-scale programmes which failed to show any impact on outcomes, the PReCePT programme in both the enhanced and standard support packages led to improvements in the uptake of magnesium sulphate. The findings suggest that QI programmes interact with the enabling factors, such as strong interprofessional team working, already present in the setting. A standard package with minimal support was therefore sufficient in settings with enabling factors, but enhanced support was required in units where these were absent., (© 2023. The Author(s).)

The UK's National Institute for Health and Care Excellence Preterm labour and birth guideline recommends use of magnesium sulfate (MgSO 4 ) in deliveries below 30 weeks' gestation to prevent cerebral palsy and other neurological problems associated with preterm delivery. Despite national guidance, the uptake of MgSO 4 administration in eligible women has been slow. National Health Service England has rolled out the PReCePT (PRevention of Cerebral Palsy in Pre-Term labour) quality improvement (QI) toolkit to increase uptake of MgSO 4 in preterm deliveries. The toolkit is designed to increase maternity staff knowledge about MgSO 4 and provides training and practical tools to help staff consider use in eligible women. The PReCePT trial compares the effectiveness of two different methods of implementing the QI toolkit (standard versus enhanced support). The standard support arm (control) receives the QI toolkit and regional-level support for a midwife/obstetric 'champion'. The enhanced support arm (intervention) receives this plus additional clinical backfill funding and unit-level QI microcoaching. It is funded by The Health Foundation. This is a cluster randomised controlled trial designed to include 48 maternity units randomised (2:1 ratio) to standard or enhanced support. Units are eligible for inclusion if they have 10 or more preterm (<30 weeks' gestation) deliveries annually and MgSO 4 uptake of 70% or less. Randomisation is stratified by previous level of MgSO 4 uptake. The QI intervention is implemented over 9 months. All units are followed up for a further 9 months. Blinding is not possible due to the nature of the intervention. The primary outcome is the proportion of MgSO 4 uptake among eligible women at follow-up, adjusting for uptake before implementation of the toolkit. The effectiveness of the intervention will be assessed using weighted linear regression on data from the National Neonatal Research Database. Semistructured qualitative staff interviews will inform understanding of the process and outcomes. Economic evaluation will describe total costs and cost-effectiveness. Trial registration number SRCTN 40938673., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare two quality improvement (QI) interventions to improve antenatal magnesium sulphate (MgSO4) uptake in preterm births for the prevention of cerebral palsy. Design: Unblinded cluster randomised controlled trial. Setting: Academic Health Sciences Network, England, 2018. Sample: Maternity units with ≥10 preterm deliveries annually and MgSO4 uptake of ≤70%; 40 (27 NPP, 13 enhanced support) were included (randomisation stratified by MgSO4 uptake). Methods: The National PReCePT Programme (NPP) gave maternity units QI materials (clinical guidance, training), regional support, and midwife backfill funding. Enhanced support units received this plus extra backfill funding and unit‐level QI coaching. Main outcome measures: MgSO4 uptake was compared using routine data and multivariable linear regression. Net monetary benefit was estimated, based on implementation costs, lifetime quality‐adjusted life‐years and societal costs. The implementation process was assessed through qualitative interviews. Results: MgSO4 uptake increased in all units, with no evidence of any difference between groups (0.84 percentage points lower uptake in the enhanced group, 95% CI −5.03 to 3.35). The probability of enhanced support being cost‐effective was <30%. NPP midwives gave more than their funded hours for implementation. Units varied in their support needs. Enhanced support units reported better understanding, engagement and perinatal teamwork. Conclusions: PReCePT improved MgSO4 uptake in all maternity units. Enhanced support did not further improve uptake but may improve teamwork, and more accurately represented the time needed for implementation. Targeted enhanced support, sustainability of improvements and the possible indirect benefits of stronger teamwork associated with enhanced support should be explored further. [ABSTRACT FROM AUTHOR]