nihr southampton biomedical research centre the southampton biomedical research centre is funded by...

NIHR SouthamptonBiomedical Research Centre

The Southampton Biomedical Research Centre is funded by the National Institute for Health Research (NIHR) and is a partnership between University Hospital Southampton NHS Foundation Trust and the University of Southampton

What can data do to improve quality of care in the NNU?

Dr Alison Leaf

Academic Neonatologist

NIHR Nutrition BRC Southampton

Examples from Vermont Oxford and SPIN Study


Improvement….• im·prove (m-prv) v. im·proved, im·prov·ing, im·proves • v.tr. • 1. To raise to a more desirable or more excellent quality

or condition; make better.• 2. To increase the productivity or value of (land or

property).• 3. To put to good use; use profitably.


The Model for Improvement

What are we trying to accomplish?

How will we know that a changeis an improvement?

What changes can we makethat will result in an improvement?

Aim

Measurement

Cycle forLearning

andImprovement

PLAN

DOSTUDY

ACT

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. Sa Francisco, CA. 1996.


Habit for Change Habit for Change

Four key habits

BETTER PRACTICES Clinical

OrganizationalOperational

Habit for Systems Thinking

Habit for Evidence-BasedPractice

Habit for Collaborative Learning


If you want to IMPROVE…You need to MEASURE…

So need accurate and robust DATA


VON - beginningsStarted in 1991 by Dr Jerry Lucey

Professor of Neonatal Medicine, Burlington, Vermont Editor of Pediatrics

50 neonatal units in USALow Birth-weight database

All units collect standardised data on babies <1500g (paper forms)Clear definitions in ‘Manual of Operations’

Data collected at 28 days and discharge Received quarterly and annual reports

Developed to foster research (RCTs) and standardisation of care


VON - evolution

• Recognition of the wide variation in clinical practice and in outcomes– Interest in bench-marking

• 1999 - Development of NIC/Q collaborative– NICU quality improvement programme

• 2000 - Expanded database (electronic data)– Optional data collection on all NICU admissions

• 2003 – iNIC/Q– Internet based QI programme

• Steady increase in membership– International Participation


Variability in outcomes


Variability….

• Is it due to case-mix??– Risk adjusted data / standardised mortality ratios– Look at inborn/outborn separately– Look at outcomes by birthweight or gestational age group

• Is it due to chance -natural variability in rare outcomes??– Summarised data over three years

• Is it due to differences in clinical management??


Addressing case-mix


Addressing natural variation


Habit for Change Habit for Change

Addressing Clinical Practice

BETTER PRACTICES Clinical

OrganizationalOperational

Habit for Systems Thinking

Habit for Evidence-BasedPractice

Habit for Collaborative Learning


‘Potentially better practices’

• Evidence-based guidelines• Not all tested by randomised controlled

trials, but best available info• ‘Potentially’ better – depends on how they

are implemented• Shown by NIC/Q-2000 teams to improve

achievement of clinical aims


“FBI” – fight bacterial infection8 aspects for potentially better practice

• Hand washing• Diagnosis of sepsis• Hub care• Lipid duration

• Line duration• Skin emollients• Skin punctures• Maximal barrier

precautions


iNIC/Q programme

• Series of internet learning collaboratives– Video and telephone links– Pre-work– Lectures– Discussion and project planning– Work on local QI initiatives

• Use on-going bench-marking to assess progress


iNIC/Q 2004: Sepsis

• 18/2 Introduction to iNIC/Q• 22/3 Nosocomial infection in NICU• 16/6 Potentially better practices to reduce

infection• 22/9 Antibiotic use and resistant

organisms• 17/11 Outbreaks and special

pathogens

Infection Rates (VON Babies) Southmead 2001-2006

Infection Rates at Southmead NICU

0

10

20

30

40

50

%Any lateinfectionCoag negstaphFungal


Key messages

• Change IS possible…• It requires a multifaceted approach…• Good teamwork is crucial…• You can’t take your eye of the ball…• Have some fun along the way…

• You need accurate data


Further Developments in VON

• ‘Nightingale’– Continuous on-line reporting – Increasing speed of data verification: now 30 minutes

• Increasing focus on safety and family communication• Regional and National Networks

– California– Italy– UK– Europe


Quality improvement in nutrition

• Potentially better practices in NIC nutrition– interventional study within VON ‘NIC/Q’ ; ‘potentially better practices’

with before and after data; earlier initiation of feeds; earlier full feeds; higher energy intake; lactation support: shorter LOS; better wt gain

• Kuzma-O’Reilly B, Duenas M, Greecher C et al. Pediatrics 2003;111:e461-70

• Impact of standardised feeding regimen on incidence of NEC– Systematic review; 6 observational studies with before and after data;

RR of 0.13 (95% CI 0.03-0.5)• Patole SK, de Klerk N. Arch Dis Chld F&N 2005;90:147-51


SPIN Study, SouthamptonStandardising Preterm Infant Nutrition

• 2009 (Jan-Dec) Baseline (SPIN 1)• ‘SENNAT’ to measure and display nutrition and growth

• 2011 (Jan-July) pre-intervention• 2011 (Aug-Dec) partial intervention• 2012 (Jan-Dec) prospective intervention group

– Guidelines for nutritional care– Screening tool for nutritional risk– Neonatal nutrition team– Nurse ‘champions for nutrition’

• 2013 (Jan-Jun) post-intervention group• Outcomes

– Neonatal: daily nutrition AND daily nutrient intakes throughout stay– Neonatal growth to discharge– Body composition and plasma micronutrients– Normalisation Process theory to assess embedding into ‘normal practice’


Normalization Process TheoryMay, C, et al. Sociology 2009;43(3):535-554

• Example of ‘implementation science’• Explains how new interventions become routinely embedded within

in their contexts• Explains routine embedding by 4 domains:

– Coherence• Understand difference from current practice

– Cognitive participation• Appreciate the relevance of new practice

– Collective action• Support and agreement of team members

– Reflexive monitoring• Effects of change seen to be positive

• Attempts to explain embedding of new behaviour through individual and collective work, as well as external influences

• Administered as on-line questionnaire: 16 questions


Summary of SPIN outcomes

• Complex intervention resulted in improvement in protein intakes and reduced EUGR

• The clinical team was already motivated to improve nutrition support (high NPT scores at start) however scores increased during study

• Despite this some interventions and outcomes did not improve

• Regular and constructive feedback is essential (‘reflexive monitoring’ in NPT) – and must be acted on


2014: 25 years of VON


Improved outcomes in VON


Improved outcomes in VON

But….only 30 units in UK


UK Neonatal Data Systems

BADGER

SEND

NNAP

NDAU

NNRD


BADGER ~ 2000

• Clinical database• Designed and managed by ‘Clevermed’

– Dr Andy Lyon, Peter Badger

• Recorded all admissions• Standardised entries• Admission and discharge summaries• Generated data for audit


SEND – early 2000sStandardised Electronic Neonatal Database

• Started as South-East Neonatal Database• Aimed to encompass all UK NICUs• Managed on ‘Clevermed’ platform• Provided bench-marking service

• www.neonatal.org.uk/Healthcare+Professionals/SEND/

• https://nww.neonatal.nhs.uk/nnn/• BUT lack of uniform definitions

http://www.neonatal.org.uk/Healthcare+Professionals/SEND/

http://www.neonatal.org.uk/Healthcare+Professionals/SEND/

https://nww.neonatal.nhs.uk/nnn/

https://nww.neonatal.nhs.uk/nnn/


NNAP ~ 2007 www.rcpch.ac.uk/nnap

• National Neonatal Audit Programme• UK based project to look at consistency of

IC/SC care for babies • Collaboration between DH and RCPCH• Funded by Healthcare Commission• Data collected electronically on

– Unit variables – size, staffing, facilities etc– Baby variables – gestation, gender, items of

care, transfer


NNAP - topics

• Do all babies 26-28 weeks receive surfactant?

• Do all<28wks have temp and BP in 1st h?• Do all <1250g have 1st ROP screen as

I/P?• Do all <33wks receive MBM while I/P?• Are parents seen by senior staff in 1st 24

h?• Are rates of normal survival at 2 years

comparable?


Temperature within 1 hour – level 3 NNUs 2011


Proportion of eligible babies receiving any MBM at discharge – Level 3


NNRD ~ 2012

• National Neonatal Research Database• Increased consensus and accuracy• Almost all UK NNUs participate

– Almost all VLBW infants recorded

• Generating large volume research data for UK studies– East of England Care Bundle– Growth study– NEC study


A regional care bundle aimed at increasing maternal breast milk use in preterm infants

Battersby, C et al. Arch Dis Child F&N 2014;99:F395-401

n= 3,680 EoEn= 29,492 UK

http://ezproxy-prd.bodleian.ox.ac.uk:3547/content/99/5/F395/F2.large.jpg


Mean growth curves of preterm infants 23-31 weeks gestation, born in UK 2006-11 (UK 1990 weight charts)

Cole T,J. et al ArchDisChildF&N, 2014;99:F34-40

• Data on 5009 infants• 103194 weight measures


Conclusions

• Neontatology has led the way in harnessing large data sets for QI and research

• Lessons adapted from industry – safety and QA• VON started as a research tool and evolved to practical

reporting and QI• UK systems started with practical reporting and evolved

to QI and research• Both systems provide extremely useful outputs• Both systems rely on accurate and consistent data input• Consistent data between large networks can enable

global comparison of outcomes


Thank you for listening!

nihr southampton biomedical research centre the southampton biomedical research centre is funded by...

Documents

health research nihr

standardised data

improvement guide

evidencebasedpractice

good use use

quality of care

excellent quality

vermont oxford