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Re: Re: Project 27/28

Dear Editor

A Jain and P Fleming’s annotation paper [1] on the Project 27/28 Report highlights some of the report’s findings. However, there are some inaccuracies in this publication, which we wish to clarify.

The original development of the standards of care to be used by panel assessors is described fully in a previous report (CESDI 6th Annual Report) [2]. The standards were compiled by the Project 27/28 Working Group, a multidisciplinary group of experts in this field, using the national guidelines available at that time [3]. These standards of care are included in the Project 27/28 Report together with the levels of evidence used, and were not based on more recent standards as suggested by the authors [4].

The authors have attempted to evaluate Project 27/28 as a guideline. It must be re-emphasised that the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) was not a guideline-producing organisation using systematic reviews of the literature to grade the quality of evidence but a National Confidential Enquiry, which used enquiry findings to make recommendations for future practice. CESDI’s recommendations have historically been used by other national organisations in the development of guidelines and standards of care [5,6].

In their paper, the authors include a discussion about the use of the polyethylene bag in thermal care. We wish to clarify that this was not a recommendation made by CESDI in the Project 27/28 Report. This was primarily due to the fact that the enquiry did not address the role of this technique, and conclusions could not therefore be made about its usefulness in the context of the enquiry findings.

We agree with the authors that the recommendation-deriving process used in Project 27/28 was not fully described in the report due to constraints of length. However, the use of the Delphi technique was mentioned in the report. This is a recognised method of achieving consensus and is fully described elsewhere in the literature [7]. In response to the authors’ concerns, the process used to derive recommendations for Project 27/28 will soon be available on the CEMACH (Confidential Enquiry into Maternal and Child Health) website (www.cemach.org.uk) and should reassure the authors about the process.

Only 31 out of 243 initial neonatal recommendations were discarded (12.3%), if the weighted score for relevance and/or validity was < 50%. Using mean and standard deviation reached the same agreement. The authors’ hypothesis, that rejecting recommendations, which are not agreed by a consensus group, does not allow primary research issues to be raised, is an interesting one. It does not fit with the “democratic” consensus process of the Delphi technique but does raise questions for the process of future enquiry recommendations. CESDI’s role has traditionally been to derive “pure” healthcare recommendations from its enquiry findings. These have sometimes been criticised in the past [8] and these issues will continue to be addressed by its successor organisation CEMACH.

The quality of the data in Project 27/28 is not disputed by A Jain and P Fleming. This was the first time a case-control approach was carried out by a National Confidential Enquiry and represented a significant and valued investment of time by health professionals in England, Wales and Northern Ireland. The process of disseminating the findings of this major work to NHS trusts is continuing under the auspices of CEMACH.

References

1. A Jain, P Fleming. Project 27/28. Arch Dis Child Fetal Neonatal Ed. 2004; 89: F14-F16.

2. CESDI (1999) Confidential Enquiry into Stillbirths and Deaths in Infancy: 6th Annual Report, 1 January-31st December 1997, London: Maternal and Child Health Research Consortium.

3. Report of a working group of the British Association of Perinatal Medicine and the Research Unit of the Royal College of Physicians. Development of audit measures and guidelines for good practice in the management of neonatal respiratory distress syndrome. Arch Dis Child 1992; 67:1221-1227.

4. RCPCH (2001) Standards for development of clinical guidelines in Paediatrics and Child Health, 2nd edn. London: Royal College of Paediatrics and Child Health.

5. RCOG Clinical Effectiveness Support Unit (2001) The Use of Electronic Fetal Monitoring: Evidence-based Clinical Guideline Number 8. London: RCOG Press.

6. RCOG/RCM (1999) Towards Safer Childbirth: Minimum Standards of the Organisation of Labour Wards. Report of a Joint Working Party, London: Royal College of Obstetricians and Gynaecologists and Royal College of Midwives.

7. Elwyn G, Greenhalgh T, MacFarlane F. Consensus research. In: Groups: a guide to small group work in health care education, management and research. Radcliffe: 2000.

8. Research into the Dissemination of CESDI information (July 1998) London: Office for Public Management