Quality Improvement Abstracts

NeoPremQI:An 18 month review following the introduction of a package

of evidence-based interventions for premature babies born at <32weeks

gestation at the Great Western Hospital, Swindon.

Dr Joanna Gumley, Dr Sarah Bates, Dr Thomas Isaac, Dr Charlotte Sullivan, Ms Victoria Norman, Ms Tanya Miles, Ms Janet Peart, Ms Toni Starr, Ms Lucie Edwards, Ms Rosalind Freestone, Dr Thomas Woodland 1Great Western Hospital, Swindon, United Kingdom

Biography: A multidisciplinary team of doctors,midwives,nurses and pharmacists at the Great Western Hospital launched the #NeoPremQI project at the start of 2017 with the aim of improving care for neonates born at <32 weeks gestation.

Introduction:

An MDT of paediatricians, neonatal nurses, midwives, obstetricians and pharmacists launched the

#NeoPremQI project in January 2017.A literature review identified 10 evidence-based perinatal

interventions to optimise long term outcomes for preterm babies. The project was introduced following an

audit of babies born <32 weeks in our unit in 2015. We identified some babies were not receiving these key

interventions in a timely manner if at all. We hypothesised that the use of champions to create change

could improve the proportion of babies receiving these key interventions, and ultimately improve health

outcomes for these babies1,2.

Methods:

The 10 identified interventions for improvement were:

- antenatal steroids3

- antenatal magnesium sulphate4

- early breast milk4,5,6,7

- delayed cord clamping8

- thermal care9

- respiratory management10,11,12

- vitamin K13

- caffeine14,15

- nutrition/glucose16,17

- probiotics18,19

Education and simulation was provided and funding for equipment was sourced. A sheet of the

interventions was put in the mother’s antenatal notes in order to provide a visual prompt for their delivery

and to promote accurate data collection by various members of staff. Within the multi-disciplinary team

there were champions for each intervention which enabled focused promotion of both delivery and

documentation.

Results:

Baseline data was collected on all in-born <32 week babies at GWH in 2015(n=32).Since the introduction of

this QI project, data has been collected on all in-born <32 week babies at GWH in 2017 (n=31).

A statistically significant improvement in:

- early breast milk advice

- antenatal attempt to express EBM

- time to colostrum given

- delivery of delayed cord clamping with airway, breathing and thermal care support

- early surfactant administration

- TPN and lipid administration

- Hypoglycaemia correction

has been achieved since the introduction of this quality improvement project. For example, delivery of

delayed cord clamping has risen from a baseline of 15% to a mean rate of 90% (p<0.0001).

In addition to data on the delivery of interventions, we have monitored the occurrence of 7 long term

outcome measures; survival to discharge, breast milk at discharge, BPD, NEC, Late onset sepsis, ROP and

Severe perinatal brain injury .Due to the relatively low incidence of negative outcomes including death,

statistical significance with our current sample size is difficult to prove. Encouragingly, positive trends are

being demonstrated. Survival to discharge has improved from 90% to 97%, NEC has reduced from 4% to 3%,

breast milk at discharge has improved from 59% to 67% and severe perinatal brain injury has reduced from

16% to 13%, severe ROP from has reduced from 6% to 0% and NEC reduced from 4% to 3%.

Conclusion:

We have demonstrated through multidisciplinary quality improvement a statistically significant

improvement in the delivery of evidence- based early care interventions, in turn optimising perinatal care.

We are also starting seeing promising trends in long term outcomes; survival to discharge increased by 7%,

severe perinatal brain injury reduced 3% and severe ROP reduced by 6%. The next step is to continue

collecting outcome data, including 2 year follow up neurodevelopmental data.

Family Integrated Care on the Neonatal Unit: The Leeds Way

Liz McKechnie2 Miss Katherine Dewhurst1 1Leeds Teaching Hospitals, Leeds, United Kingdom, 2Leeds General Infirmary

Biography: Katherine Dewhurst. RN BSc (Hons) RM BHSc (Hons) M.Ed

Kathy is a Registered Nurse, Qualified in Speciality for neonatal care and a Midwife, as well as having a Master’s Degree in Clinical Education. She has specialised in the care of preterm and vulnerable neonates on Transitional Care for more than 12 years. Over the past 7 years she has moved increasingly towards a role as breast-feeding advisor, educator and co-ordinator within Leeds Centre for Newborn Care and now works strategically as a Senior Project Nurse. Her input has been pivotal in the Maternity and Neonatal Service gaining Baby Friendly accreditation. She has taken on many challenges of change management as the neonatal service has awoken to the concept of Family Integrated Care.

When babies are admitted to a Neonatal Unit (NNU), parents have traditionally handed their baby over to

the nursing and medical staff to allow treatment to be delivered, and become a passive onlooker in their

baby’s care. Research now suggests that this practice is detrimental to clinical and developmental

outcomes. The Family Integrated Care (FIC) model is an innovative method of increasing the involvement of

parents in the care of premature or unwell newborn. A small pilot study of FIC was initiated at a Canadian

tertiary NNU and demonstrated significantly improved neonatal outcomes and parental wellbeing.

FIC was introduced as a Quality Improvement Project, on the NNU at Leeds. The primary aim was to

improve breast-feeding rates, with secondary outcomes monitoring length of stay, necrotising enterocolitis,

infection rates and parental anxiety after discharge.

A staff education programme was delivered and improvements made to parent facilities on the NNU.

Parents were asked to spend at least 6 hours of the day with their baby, with developmentally responsive

care encouraged at the earliest opportunity. Nursing skills such as nasogastric feeding, weighing,

temperature taking were taught to parents, and formal education sessions delivered daily.

Where parents participated in FIC there were increased breastfeeding rates(p=0.008)a reduction in length

of stay, improved parent experience and a reduction in non-routine G.P visits in the first 3 months after

discharge(p=0.016)

As the first unit in the UK to embed FIC, there has been great interest in this low-cost, high impact project as

a national role model.

“Outlier Neonates” under shared care with Maternity- how well do we

communicate between healthcare professionals on discharge?

Dr Hannah Smoker1, Dr Vennila Ponnusamy1

1Ashford And St Peters Nhs Trust, London, United Kingdom

Biography: Hannah Is an FY2 Doctor. She graduated from St Georges University of London in 2016 with MBBS and distinction in "Clinical Science." She has a keen interest in anaesthetics and ICU and has recently completed a rotation in NICU at St Peters Hospital, Chertsey.

Background: At St. Peters Hospital babies identified as high risk of or showing signs of sepsis are managed

on Labour Ward or Postnatal Ward and are referred to as "Outlier neonates". It was noted that on

discharge, these babies often did not have a discharge summary completed due to their short stay under a

"well babies" category. We hypothesised that a simple clear discharge summary provided for these well

outlier babies about their course of antibiotics will be useful to improve communication with other medical

professionals, especially if the baby becomes unwell following discharge.

Aim: To implement improvement measures and reassess the performance of the uptake of completed

discharge summaries for neonatal outliers on antibiotics.

Setting: Well babies with minor medical issues, and those on antibiotics are managed on the Labour Ward,

Postnatal Ward and Maternity led Birth Centre. These wards make up 56 cots in total. These babies are

reviewed daily by a neonatal doctor and have regular 4 hourly observations.

Mechanisms: All babies identified as at risk of sepsis, should follow the pathway as shown in Figure 1. Once

identified, screened for sepsis, and completed their course of antibiotics these babies would either be

discharged home or back to midwifery team to establish feeding prior to discharge home. Often a discharge

summary was not completed for a number of reasons, for example, not being admitted in the neonatal

BADGER system and complexity with multiprofesssional involvement and setting. Table1 divides these

mechanisms into the following categories: system failures, human behaviours and lack of knowledge.

Drivers of Change: Figure2 demonstrates how interventions were carried out to target specific challenges in

the department. Interventions were mainly educational, system and prompt based.

Methods/measures: Neonatal outliers treated for sepsis were identified from the "outlier diary." Outcome

measure on presence or absence of a discharge summary was collected quantitatively through electronic

records for each month between December 2017 and March 2018.

Results: By implementing various interventions, namely education, team working, encouraging and

reminding midwives and nurses to involve doctors in discharge process, checklist using the sepsis

whiteboard during daily board review and highlighting the responsibility of a doctor to complete a discharge

summary for babies screened and treated for sepsis, we have been successful at increasing the number of

completed discharge summaries. Figures 3a and 3b demonstrate an increase in uptake of discharge

summary from 20% to 85% with 2 cycles of intervention, as highlighted at stages A and B.

Discussion: Overall interventions improved uptake of discharge summaries for outlier neonates. There is still

room for improvement as not 100% of neonates screened and treated for sepsis received a discharge

summary in March 2018. This highlights the ongoing need for education and fostering good working

relationships in a challenging multiprofesssional environment. The next step would be to update the

Neonatal team “Post Natal Wards Handbook₁” in line with current computer software and departmental

standards, and introduce a quarterly champion to lead this QIP.

References:

1.ASPH Postnatal wards Handbook. March 2017. http://www.asph.mobi/neonatal.html

(Acessed:24/01/2018)

1

Milk As Medicine (MAM) Project: A QI initiative to improve early

delivery of enteral expressed milk to preterm infants

Dr Samantha Stiles1, Dr Laura de Rooy1

1Neonatal Unit, St George's Hospital, London, United Kingdom

Biography: Neonatal GRID trainee with an interest in neonatal nutrition.

Background

There is increasing evidence that feeding preterm babies confers benefit, and that conversely delaying feeds

can lead to longer hospitalization and increased incidence of late onset sepsis1-3

. It was identified in our unit that enteral feeding was often being delayed while waiting for maternal milk,

with an average time to first enteral of 29 hours, significantly longer than desirable.

Aim

To improve the timely delivery of expressed breast milk to preterm infants less than 32+6 weeks gestation.

Setting

A tertiary neonatal intensive care unit and regional surgical referral center in London. In 2017 there were

675 admissions to the neonatal unit with 3963 (HRG1) intensive care days. Of these there were 185

admissions of preterm infants less than 33 weeks. The unit has access to an onsite milk bank.

Mechanisms

Current guidance from the Baby Friendly Initiative (UK) is that all mothers whose babies are admitted to the

neonatal unit are encouraged to start hand expression within 2 hours after birth. This quality improvement

project was undertaken as part of the unit’s progress towards attaining full Baby Friendly accreditation. We

identified drivers for change as well as likely obstacles (see figure 1). The important role of the neonatal

nurses as advocates of feeding practices is clear. The main concern was perception of increased time

necessary to seek expressed milk at admission, when this is not felt to be a priority. Additionally there were

concerns expressed about the infant’s ability to tolerate milk very early on; and reluctance to use donor

milk. We identified that nutrition was rarely featured in the admission ‘plan’ by the medical team; with

limited documentation that conversations about expressing and the importance of breast milk were taking

place.

Methods

We began discussing the project and setting up education sessions 3 months prior to implementation. We

undertook the project in several steps: • Meeting with nursing team leaders to explain the purpose of the project and to identify and

directly address concerns

• Recruitment of nurse champions

• Education of medical and nursing staff

• Displayed posters about the project on the unit

• Establishment of equal sharing of responsibility between medical and nursing teams to prioritise

enteral feeding

• Decision making regarding contents and design of expressing pack to encourage use

• Charity appeal for a camera to obtain instant photos of baby to share with parents after birth

Following these steps we set an ambitious target of first feed within 6 hours, having delivered an expressing

pack and photo of baby to the mother within 2 hours of admission. This target was chosen as it is in line

with current evidence. Additionally as the target is very different from practice on the unit this would help

highlight the magnitude and importance of the change required. The name of the project – Milk as

Medicine – was deliberately chosen to remind everybody, including expressing mothers, of the importance

of breast milk for preterm infants.

It was important that the expressing packs were user friendly and attractive. Previously parents were not

given a ‘pack’ but syringes and poorly photocopied information. A secondary aspiration of our project was

to improve parent involvement in care and satisfaction following the unexpected trauma of preterm birth.

Measures

Our primary outcome measurement was hours to first feed; however the following were also audited:

• Time to obtain full enteral feeds (150ml/kg/day)

• Type of first feed (maternal/donor/artificial)

• Documented feed tolerance problems

• Documentation of delivery of expressing (MAM) pack

Infants with surgical pathology, and those transferred in after 12 hours of age were excluded from data

collection.

Data

Following introduction of the MAM project there is significant improvement in the time to first enteral feed

from 29.5 to 16.4 hours (p= 0.0012). There is a trend towards earlier feeding where documented evidence

of a MAM pack being given (MAM pack 14.1 hours (n=16), no MAM pack 21.2 hours (n=16), p = 0.11). There

was a trend towards the earlier attainment of full enteral feeds after initiation of the project, but this was

not significant. There was an improvement in earlier use of bank milk whilst awaiting maternal milk from

26% to 41%. There was no increase in the type or severity of documented feeding problems –which

consistently across both groups was related to early feed tolerance and aspirate size. There was one

episode of medically managed suspected NEC amongst the post-intervention cohort. Results and

demographics are displayed in table 1.

Discussion

Carrying out the MAM project has improved the time to first enteral feed amongst our cohort of preterm

infants. In doing so we have increased the confidence of medical and nursing staff in the early use of

enteral feeds, and particularly donor milk to supplement maternal milk. These results are encouraging. To

advance the project we will continue education amongst nursing and medical staff to prioritise early

nutrition. We aim to undertake a qualitative review of the packs to discover how parents’ perceive the pack

and the intervention, and thus how they can be improved. We continue to work towards the full Baby

Friendly accreditation. We aim to investigate the impact of our early enteral feed initiation strategy on late

onset sepsis rates, days of parenteral nutrition, and breastfeeding at discharge.

Team Acknowledgement

Our thanks to all our neonatal nurses who shared our enthusiasm for the project. A special thanks to

Theresa Alexander (infant feeding advisor) for her ongoing encouragement; and to the unit charity First

Touch for their support of the project.

References

1. Oddie SJ, Young L, McGuire W. Slow advancement of enteral feed volumes to prevent necrotising

enterocolitis in very low birth weight infants. Cochrane Database of Systematic Reviews 2017, Issue 8.

Art. No.: CD001241. DOI: 10.1002/14651858.CD001241.pub7

2. Konnikova Y, Zaman MM, Makda M, D’Onofrio D, Freedman SD, Martin CR (2015) Late Enteral

Feedings Are Associated with Intestinal Inflammation and Adverse Neonatal Outcomes. PLoS ONE

10(7): e0132924. doi:10.1371/journal.

3. Sallakh-Niknezhad, A., Bashar-Hashemi, F., Satarzadeh, N., Ghojazadeh, M., & Sahnazarli, G. (2012).

Early versus Late Trophic Feeding in Very Low Birth Weight Preterm Infants. Iranian Journal of Pediatrics, 22(2), 171–176.

2

Increasing provision of Delayed cord clamping at pre-term delivery to

optimise outcome using a novel protocol for caesarean section delivery-

An Update on NeoPremQI

Dr Joanna Gumley1, Dr Sarah Bates1, Dr Charlotte O'Sullivan1, Dr Thomas Isaac1, Ms Victoria Norman1, Ms Toni Starr1, Ms Tanya Miles1, Ms Janet Peart1, Ms Rosalind Freestone1

1Great Western Hospital, Swindon, United Kingdom

Biography: I graduated from the University of Nottingham in 2014 and completed my foundation training in the Severn Deanery. After working in an Emergency Department in Australia for a year I returned to work at the Great Western Hospital in Swindon. I started my role as a Clinical Innovation Fellow in Paediatrics in September 2017. This job has allowed me to combine clinical practice with academic time to devote to quality improvement work.

Introduction:

Compared to immediate clamping of the umbilical cord after preterm delivery, delayed cord clamping (DCC)

by 60-120 seconds significantly reduces the risk of intraventricular haemorrhage, necrotising enterocolitis

and anaemia requiring transfusion by 61%1. European and international consensus and 2015 newborn life

support guidelines, recommend that “uncompromised preterm infants” receive “a delay in cord clamping of

at least one minute”2. As part of the NeoPremQi project the team developed a procedure for premature

infants born by caesarean which is inexpensive and easily applicable, compared to other developing

methods, which enables the most compromised preterm infants to receive thermal care and DCC alongside

immediate airway support.

Materials and methods:

Data collected from our unit suggests babies were missing out on DCC, especially those born by caesarean.

A multidisciplinary QI project began including neonatologists, obstetricians, midwives, resuscitation officers

and neonatal nursing, with champions identified for DCC.

The team worked together to overcome barriers of providing thermal care and airway support in a sterile

environment. The team demonstrated and recorded the procedure in a training video which the midwifery

champion disseminated to midwifery and obstetric staff, this was posted on the hospital intranet for

viewing.

Results:

A sustained increase in both provision of delayed cord clamping and provision of airway and breathing

management during delayed cord clamping has been observed to neonates born at <32 weeks. Compared

to retrospective data from 2015 there has been a rise from a mean of 15% to 88% (p< 0.001, Fishers Exact).

Conclusions:

Through multidisciplinary work, championship of key interventions and our novel protocol for airway and

breathing in management during DCC as sustained increased in DCC has been seen.

References:

1.Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at

preterm birth on maternal and infant outcomes, 2012, Heike Rabe, Jose Luis Diaz-Rossello, Lelia Duley,

Therese Dowswell, The Cochrane Collaboration, John Wiley and Sons, LTD

2.Resuscitation and support of transition of babies at birth, 2015, J Wyllie, S Ainsworth, R Tinnion, on line,

Resuscitation Council UK

3

Using weekly multidisciplinary team presentations and social media to

improve the learning from risk incidents

Dr Charlotte Ashton1, Dr Caroline Fraser1, Dr Sunita Seal1, Carol Hudson1

1Bradford Teaching Hospitals, Bradford, United Kingdom

Biography: I am an ST5 Paediatric Doctor currently working in Bradford.

· Background

Bradford Neonatal Unit prioritises reporting risk incidents. Incidents are investigated and changes are

implemented accordingly to improve practice and patient care. Previously this was disseminated to the

department using a monthly newsletter via email. Copies were dis-played around the department. These

were time consuming to compile and as a result were often sent out every 2-3 months.

· “SMART” Aim

To consistently improve communication, discussion, feedback and learning from risk incidents reported

within the department for the multidisciplinary team.

· Setting

Bradford Neonatal Unit, tertiary care centre, 29 cots.

· Mechanism

(see diagram)

· Drivers for Change

Incident forms were frequently completed but there was a delay in hearing the outcomes from them. The

learning was often confined to those working when the incident occurred.

· Methods

Reported incidents are reviewed on a weekly basis and action plans established. A poster is created with

these points. Lessons from other sources such as morbidity and mortality meetings and patient safety alerts

are also used.

The poster is presented at the Friday grand round, involving the multidisciplinary team, and amended after

discussions. The slide is sent out to the doctors WhatsApp group and nursing Facebook group. Posters are

printed, placed around the department and discussed at nursing handover. Information Governance have

approved the project.

A summary presentation is given to each new rotation of doctors.

· Measures

The increase in the number of incidents communicated to the team compared to previous practice.

A qualitative survey to assess staff satisfaction and learning.

· Data/Results

Between April 2016 and March 2017 15 incident ‘themes’ were communicated to the team via newsletters.

Between April 2017 and March 2018 233 incidents were communicated, a 15.5 fold increase on the

previous year. Between August 2017 and March 2018 202 incident reports were filed of which 159 (78.7%)

were discussed using this platform.

A staff survey one year after starting this project revealed that 96% of staff ‘agreed’ or ‘strongly agreed’ that

this was a useful learning tool. 79% of staff ‘agreed’ or ‘strongly agreed’ that it changed clinical practice.

Frequent errors with gentamicin use on the postnatal wards were highlighted, and as a result the postnatal

antibiotic guidelines have changed. Cefotaxime is now used after 36 hours and midwives are happy to

administer this, therefore not requiring medical staff to anymore.

· Discussion

The weekly presentation of risk incidents on the neonatal unit has encouraged multidisciplinary

engagement in risk awareness and management. The multi-platform approach to disseminate learning has

improved access for all staff members. Recommendations are implemented timely and efficiently, including

changes in clinical practice and guidelines. We have categorised the incidents filed and will investigate if

there is a decrease in each group as a result of this project.

· Team Acknowledgement

Dr Charlotte Ashton ST5, Dr Caroline Fraser ST4, Carol Hudson ANNP, Dr Sunita Seal Consultant.

Reference https://qi.elft.nhs.uk/resource/driver-diagrams/ accessed 27/04/2018

4

'Learning from Excellence' initiative in a Neonatal Intensive Care Unit

Fateh Singh2, Dr Matthew James Cawsey1, Dr Anju Singh1

1Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom, 2Newcastle University , , United Kingdom

Biography: Dr Anju Singh is the Clinical Director of the Neonatal directorate at Birmingham Women's and Children's NHS Foundation Trust. She is the Respiratory lead of the department. Her research interests are pulse oximetry screening and tissue doppler imaging. She is the training programme director for ST1-3 Paediatrics in Health Education West Midlands.

Background:

The Learning from Excellence (LFE) initiative was conceived and successfully implemented at Birmingham

Children’s Paediatric Intensive care unit (PICU) with the aim to identify and learn from peer-reported

episodes of excellence (1). The LFE system was launched in November 2016 at Birmingham Women's

Hospital (2). The IR 2 (Incident Report 2) form on the trust intranet was made available for staff to report

the 'excellent episodes' with no specific guidance on the definition of excellence. Following analysis, themes

of good practice were identified and disseminated to the involved individuals and the wider teams. The

learning was further explored in IRIS meetings (Improved Resilience, Inspiring Success) using appreciative

inquiry approach. LFE episodes were also reported to the Trust Governance meetings.

Aim:

The aim of this study was to study the engagement of the Neonatal team with the LFE initiative.

Methods:

All LFE reports were analysed over a period of November 2017 to March 2018

Results:

There were 28 LFE episodes reported during the study period. They were reported by a wide range of

professionals including 8 nurses, 13 consultants and 7 junior doctors. The majority of these episodes were

appreciative of individual contributions (16 out of 28). There were various themes of excellence: individual

and/ or team management of a sick neonate, multi-professional coordinated clinical care, initiative in staff

training and service improvement, management of bereavement process and family integrated care

initiative. 1-4 episodes were reported every month; this rate remained steady over the study period.

Conclusions:

The engagement with the LFE initiative shows that it has become embedded within the multi-professional

team in the Neonatal intensive care unit. The identified themes highlighted a broad range of areas of

excellence.

References:

1. Kelly N, Blake S, Plunkett A Learning from excellence in healthcare: a new approach to incident reporting

Archives of Disease in Childhood 2016;101: 788-791.

2. Cawsey MJ, Ross M, Ghafoor A, et al Implementation of Learning from Excellence initiative in a neonatal

intensive care unit Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 22

March 2018. doi: 10.1136/archdischild-2017-314737.

5

Improving the Stabilisation of Preterm Babies at Delivery - Encouraging

Routine Use of Non-Invasive Respiratory Support

University Hospital Southampton NHS Foundation Trust, Southampton, UK.

Dr D Winderbank-Scott MBBS,BSc, MRCPCH

Dr Sarah Lodge, BM, MRCPCH

Dr Donna Winderbank-scott1, Dr Sarah Lodge1

1University Hospitals Southampton NHS Trust , Southampton, United Kingdom

Biography: Donna Winderbank-Scott is a Consultant Neonatologist at University Hospitals Southampton NHS Trust, working in the Neonatal Unit at Princess Anne Hospital, Southampton. She holds lead roles including Quality Improvement, Clinical Guidelines and Neonatal Simulation and has been working with the Southampton Maternity and Neonatal Health Safety Collaborative Team and the Wessex Community of Practice to create a culture of Continuous Learning and Improvement.

The quality of delivery room care has a significant impact on long term outcomes in premature babies.

Evidence is increasing that even extremely premature babies can be managed with non-invasive respiratory

support instead of routine intubation, avoiding complications from mechanical ventilation and improving

respiratory outcomes. Despite this, clinical practice in our unit was variable and dependent on individual

preferences.

Our aim is to improve the stabilisation of preterm infants by providing respiratory support along a

standardised pathway based on individualised assessment instead of gestational age stratification. We aim

to achieve 100% compliance with the pathway within 1 year, for all deliveries <35 weeks gestation.

Setting: Level 3 Regional Neonatal Unit with 15-20 admissions <35 weeks gestation each month.

Mechanism: We describe 4 PDSA cycles over 6 months. We theorised that variability in delivery room

management was due to differences in education and experience between clinicians which may be

amenable to modification.

Drivers of Change:

1. Improve standardisation of approach so that

- Every baby receives evidence-based care regardless of attending clinician,

- Teamwork is enhanced via shared expectations

2. Create cultural change so that

- Standardisation of approach becomes universally accepted

3. Remove barriers to implementation so that

- Anxiety and unfamiliarity does not prevent use of new equipment

- The pathway can be followed easily.

- Clinicians are reassured regarding concerns about complications which may cause reluctance to

follow the pathway.

Methods:

Change ideas were incorporated into 4 PDSA Cycles:

1: Simulation to practice implementation of the respiratory management flowchart

2: Simulation to test and practice with the new equipment in-situ.

3: Implementation in practice with ongoing data collection and qualitative feedback. Flowchart on all

Resucitaires for reference.

4: Development and use of educational videos to reach more staff than simulation sessions, and to target

senior clinicians.

Measures:

Outcome: Modality of respiratory support, percentage of cohort receiving primary CPAP (success and

failure) and intubated immediately.

Balancing: Rate of intubation after admission (ensuring we were not just delaying intubation),

pneumothorax and admission temperature data (it takes longer to stabilise on CPAP, concern this might

adversely affect thermoregulation).

Process : Qualitative feedback from simulation debriefs, and case based discussions.

Discussion: We did not show a dramatic improvement in numerical measures, possibly because simulation

did not involve senior clinicians who tended to lead the more extreme preterm stabilisations. Educational

videos may be more successful in this group and will form the basis of our 4th PDSA cycle. We did identify

important learning from simulations in situ, resulting in provision of longer tubing to enable CPAP delivery

in confined environments. We also observed better documentation of the reasoning behind intubation,

indicating clinicians were becoming more selective about intubation, even if this is not yet reflected in the

numbers. We did not see any increase in pneumothoraces, and believe if required, surfactant

administration is better performed in the controlled environment of NNU than in delivery suite. Therefore

we will continue to work towards improving non-invasive respiratory support following delivery into the

future.

6

CLABSI’s: “Reduce the rate”- two successes and one failure; an ongoing

project.

The Jessop Wing, Sheffield, England.

Dr Rebecca Lancaster, MBCHB

Dr Rebecca Lancaster1

1The Jessop Wing, Sheffield Teaching Hospitals, Sheffield, United Kingdom

Biography: Dr Rebecca Lancaster is a St6 paediatric trainee with a strong interest in neonatal outcomes. As such she is

currently clocking up many miles as she travels around the United Kingdom visiting 11 year olds as part of

her clinical research associate role with EPICure2.

The Jessop Wing, a tertiary neonatal unit has been working on a central line care bundle since 2010-

“Reduce the rate” campaign. A pre-implementation retrospective audit revealed that the rate of long line

(LL) infections was 44 per 1000-line days. The current aim is to reduce the rate of all CLABSIs to <10/1000-

line days.

The unit has 18 ITU, 8 HDU and 18 SCBU cots. Please see the driver diagram to review the methods used.

The definition used to define a CLABSI includes any positive blood culture after the first 72 hours of life in

association with the presence of a central line. Positive blood cultures are excluded if they have been taken

on the day of admission for a patient who has been transferred in from elsewhere, and those results where

the line is put in after the positive result as these do not reflect unit specific infection. Additionally, repeat

positive cultures within 48 hours whilst the patient is still receiving treatment for the infection were classed

as being within the same episode.

Monthly data collection facilitates constant monitoring of rates and the outcomes are illustrated on the flow

chart. The named infection neonatal consultant receives monthly e-mails from microbiology and ensures all

data is entered.

A summary of the findings so far:

Introduction of 2% alcoholic chlorhexidine for site cleaning prior to line insertion saw LL infection rates

halve (44-24 per 1000-line days). The use of this solution for all line insertions (including cannulas and pre-

blood culture collection) has resulted in a sustained reduced rate (around 20/1000line days) of all CLABSIs.

The introduction of an early feeding guideline and the promotion of buccal colostrum (April 2017) saw the

median rate of CLABSIs almost halve (21.4 -10.9 per 1000-line days).

This has been a sustained trend over nearly a year. Interestingly, the overall number of line days has not

reduced significantly and as such would support the immunological theory associated with early initiation of

enteral feeding in preterm or low birth weight infants and reducing rates of late onset sepsis.

The data collection facilitated recognition that the well-intentioned use of alcoholic impregnated port

protectors(AIPP) was having the opposite effect on our infection rates. The median rate per 1000-line days

increased from 21.3 to 27.5. Therefore, use was discontinued, and usual practice resumed. Following this

the rate of CLABSIs correspondingly reduced back to baseline (21.4).

Moving forward:

We are approaching our aim of achieving a CLABSI rate of <10/1000-line days however there is still room for

improvement. Our next steps are, more intensive training around line care and increasing nursing levels to

get closer to the BAPM standards of 1:1 nursing in an attempt to further reduce line infection rates.

Team Acknowledgement:

Elizabeth Pilling(Consultant neonatologist &infection lead),

Liz McLellan(Consultant microbiologist, helped with action plan, AIPP plan)

Jessop Wing Neonatal infection control link nursing team: Sandra Brown, Lisa Parkin, Nicky Recknell, Claire

Howard(JW matron)-supporting implementation

Chris Forster and Sharron English (Consultant Neonatologists, Leeds; feeding/skin prep guideline)

7

Reducing the rate of Unplanned Extubation in a Tertiary Neonatal Unit.

Dr Affi-Anne Anosike1, Dr Simon Power2

1Royal Manchester Childrens Hospital, Stalybridge, United Kingdom, 2Royal Bolton Hospital, Bolton, United Kingdom

Biography: A Paediatric trainee of the Northwest region with a Specialist Interest in Neonatology. She is at level 8 of her training. She has had more than 3 years experience in tertiary neonatology and has worked with Consultants whose special interest and role is within the Quality Improvement division of the department. She looks forward to a career in Tertiary Neonatology.

Introduction:

Mechanical ventilation through an endotracheal tube (ETT) is a routine procedure in a Neonatal Intensive

Care Unit (NICU). The Device A has been the traditional device for securing ETT for over 6 years in our

neonatal unit. A previous audit was done to assess the rate of Unplanned Extubation (UE) per 100

ventilation days. Due to concerns that there was increasing UE with the Device A, a comparison audit was

performed with Device B to review our practice.

Aims:

� To identify the rate of unplanned extubation on Device B.

� To compare this result with the result of a similar audit on Device A.

� To assess the views and perception of members of staff on both devices.

Setting:

This project was carried out on the intensive and high dependency care unit of the neonatal unit. The

qualitative study was carried out on medical and nursing staff who work in these areas.

Mechanism:

This project was carried out as an audit, a comparative audit and a qualitative study .

Subjects were patients as well as medical and nursing staff.

Drivers for Change:

� A desire to reduce the rate of unplanned extubation in our neonatal unit.

� The desatisfaction of medical and nursing staff with the rate at which unplanned extubation

occurred and the resulting effects on patients.

Method:

� Training of medical and nursing staff on using Device B was carried out over 1 month.

� The use of only Device B was implemented on the unit for 3 months.

� Episodes of unplanned extubation was recorded in a designated folder.

� A qualitative questionnaire was completed by all clinical staff.

Measures:

� The following measures were looked at : Gestational age, birth weight, day of life , reason for

unplanned extubation, and number of episodes of unplanned extubation.

Results:

Device A Device B

Episode of UE 17 19

Total patient ventilation days 298 325

Ratio of UE : ventilation days 1:20 1:17

Most frequent reasons for UE

-High ETT position

- ETT mobile

-ETT slipped through Device A

-Procedure or care related - -Agitated baby/self extubated

-Routine care/repositioning

-Opening ETT to suction

-Loose ties / hat

� Medical and nursing staff with longer years of experience, had used both

devices to secure ETT , but used Device B the most. The preferred device among all members of staff was

the Device A. Staff listed more disadvantages with Device B.

Discussion:

A higher ratio of unplanned extubation was shown with the use of Device B. However, it is recognised that

the rate of unplanned extubation with both devices are high. Implementing preventative measures , with

the foremost being educating and training staff, is paramount to reducing these incidences further.

Team Acknowledgement:

A special thank you to my Supervisor on this Project -Dr Power, and to all my medical and nursing staff who

contributed to the qualitative study in this project.

8

Waving goodbye to the baby train! How separation and drug errors were

reduced by training midwives to become second checkers of IV

antibiotics on the postnatal ward.

Mrs Sarah Quinton-Shapcott1

1Colchester Hospital University Nhs Foundation Trust. , Essex, United Kingdom

Waving goodbye to the baby train! How separation and drug errors were reduced by training midwives to

become second checkers of IV antibiotics on the postnatal ward.

Neonatal sepsis is a common cause of morbidity and mortality (Muller-Peabody et al 2011) but due to its

nonspecific presentation infants are often commenced on empirical antibiotics even if clinically well

(Bohnhorst et al 2011). This practice is fraught with issues which became drivers for changing practice

within the authors hospital where babies were transferred to the neonatal unit to receive their antibiotics.

They include:

⦁ Separation of mother and infant

⦁ Drug errors, mostly missed and delayed doses

⦁ Patient safety- transferring infants though the hospital resulting in infection control issues.

⦁ Workload- increase presence of infants on NNU- distracted NNU from caring for their infants. MSW

missing in action as they accompanied infants to NNU.

In light of these concerns a new practice initiation was designed whereby midwives would become second

checkers and would, alongside the neonatal nurse administer antibiotics on the postnatal at the mother's

bedside.

It was acknowledge from an early point in the quality improvement initiative that traditional teaching

methods of a study day was not a possibility. To train midwives en mass was ruled out due to workload and

staffing shortages so we were required to think outside the box- or rather inside the box!

A training package of Bite size teaching boxes were developed to facilitate adhoc teaching on the ward.

These had all the necessary resources to teach each topic, each session lasted around 15 to 20 minutes.

There are 4 topics included were:

1. Understanding neonatal sepsis

2. Checking the drug chart

3. Drawing up drugs

4. Administration and cannula assessment

Each box contains a training manual detailing what is required of the key trainer to run the session and

background information on the specific box theory. There is a flip chart containing theory for each session

and simulation/training materials of equipment used in each session.

There was an initial reticence’s by midwives to increase their workload, many expressed an understandable

anxiety about drug calculations in newborn infants.

Improved working relations between PNW and NNU has been a consistent response from both teams and

going forward will foster a better culture of collaborative working.

A reduction in drug errors is evident from the reduction in incident reports- although this process always

relies upon an openness to report errors.

The project was presented at the East of England ODN clinical oversight group and received lots of support

and positive feedback. There was encouragement from the lead nurse for others to consider such projects

in their own trusts and subsequently the authors have been contacted to share their resources. The bite size

boxes have been key to the successful implementation, by being able to train midwives on an ad hoc basis

has facilitated more staff to be trained.

9

A Multi-disciplinary approach to improving the time taken to administer

vitamin K in babies born <32 weeks as part of NeoPremQI

Dr Joanna Gumley, Dr Sarah Bates, Ms Cathy Dewdney, Dr Thomas Isaac, Dr Charlotte O'Sullivan, Ms Janet Peart, Ms Toni Starr, Ms Tanya Miles, Dr Thomas Woodland 1Great Western Hospital, Swindon, United Kingdom

Biography: I graduated from the University of Nottingham in 2014 and completed my foundation training in the Severn Deanery. After working in an Emergency Department in Australia for a year I returned to work at the Great Western Hospital in Swindon. I started my role as a Clinical Innovation Fellow in Paediatrics in September 2017. This job has allowed me to combine clinical practice with academic time to devote to quality improvement work

Introduction:

The NeoPremQI project was launched at the GWH, Swindon in 2017. The aim of the project was to ensure

the delivery of 10 evidenced based interventions with the aim to improving long term outcomes in

premature babies born <32weeks. Vitamin K administration is essential in neonates due to their vitamin K

deficiency at birth. Administration is proven to reduce the risk of intraventricular haemorrhage¹. Premature

babies are at a higher risk of IVH and often due to their low birth weight and potential complications at birth

its administration can be delayed.

Materials and methods:

The NeoPremQI proforma was placed in the antenatal notes to prompt the prescription of vitamin K. A

multidisciplinary team were involved with the QI project with specific champions for the vitamin K

intervention. During the project we felt that time to administration could be further improved. A pharmacist

at the trust developed evidenced-based doses based on estimated weight for gestational age, these were

used to produce a modified prescription chart to improve timely administration when a weight is not

immediately available.

Results:

There was a statistically significant reduction in the time to vitamin K administration (p=0.000225) with the

introduction of the NeoPremQI. The revised vitamin K prescription has now been approved by the trust and

will be introduced over the coming weeks. A poster detailing the importance of vitamin K administration will

be distributed among staff.

Conclusion:

Through multi-disciplinary quality improvement work we are seeing marked improvement in time to vitamin

K administration and in turn hope to see improved long-term outcomes.

References:

1.Puckett RM, Offringa M. (2000) Prophylactic vitamin K for vitamin K deficiency bleeding in neonates.

Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD00