Sixty Golden Minutes: A Regional Quality Improvement Initiative Paul Cawley & Nilesh Agrawal Specialty Paediatric Registrars, East of England Acknowledge: First Hour of Care Working Group, I. Long, C. O’Mara, M. Dyke & all the participating neonatal staff within the East of England EOE Neonatal ODN 22 September 2018

Background: Management of unwell neonates in the first hour after birth has far reaching consequences beyond the immediate neonatal period In recent years an increasing number of national and international guidelines have addressed the immediate care of the preterm and sick term infant The recommendations made within these guidelines are increasingly being substantiated with grade A & B studies Standardisation of care in line with current evidence may improve neonatal outcomes EOE Neonatal ODN 22 September 2018

Aim: In October 2014 the East of England First Hour of Care (FHOC) working group was created with the specific aims of: 1) Identifying key evidence on standards of early newborn care 2) Developing an unified region-wide FHOC admission booklet to capture key performance indicators and guide first hour care 3) Improve neonatal outcomes through improvement in standards of care across 4 related bundles of care: Antenatal Thermoregulation Respiratory Fluids & Medications EOE Neonatal ODN 22 September 2018

Setting: East of England Neonatal Operational Delivery Network The East of England Neonatal Network thus provides an ideal vehicle for positive service improvement over an entire region All units work closely together and share clinical and research expertise By standardising care to evidence-based gold standards across an entire region there is a potential for improvement in neonatal outcomes in a significant number of infants 17 neonatal units spanning 6 counties 3 tertiary Neonatal Intensive Care Units (2 paediatric surgical centres) Acute neonatal transfer service (ANTS) Regional birth rate: 70,000 per annum >3,500 premature births 800 very premature. >200 are extremely low birth weight/extremely premature EOE Neonatal ODN 22 September 2018

Methods & Mechanisms for Change: Sixty Golden Minutes: A Regional Quality Improvement Initiative Methods & Mechanisms for Change: EOE Neonatal ODN 22 September 2018

Mechanisms & Drivers of Change: Primary Goals Primary Drivers Secondary Drivers ‘Level A’ evidence; meta-analysis and international guidance relating to early newborn care Develop a unified region-wide FHOC admission booklet to capture key performance indicators and guide first hour care Standardise first hour care in line with current evidence Staff want clarity on best practice They may witness inconsistency or variation in everyday practice The 2014 region-wide scoping survey identified significant variation in standards of care from consensus guidelines Variation was seen between all 17 neonatal units; Level 1, Level 2 & Level 3 This provided compelling motivation for taking region-wide action; All units motivated to studying their actual practice in detail & to conform to best practice Uniformity in practice across a network - consistency for rotating nursing and medical staff Maximise neonatal survival Reduce the burden of neonatal co-morbidity ) Identifying key evidence on standards of early newborn care 2) Developing an unified region-wide FHOC admission booklet to capture key performance indicators and guide first hour care 3) Improve neonatal outcomes through improvement in standards of care across 4 related bundles of care: Antenatal Thermoregulation Respiratory Fluids & Medications Highly motivated staff want to improve their patient’s outcomes & provide consistent support for parents Staff regularly rotate between units Uniformity in practice – reassurance for parents transferring between units EOE Neonatal ODN 22 September 2018

Cycle of Change Management: EOE Neonatal ODN 22 September 2018

Plan Do Study Act What [small] changes will we make [& how]? 1st Phase Assessment & Interim Analysis 2nd Phase Plan What [small] changes will we make [& how]? What data is needed to test outcome? Do Put plan into action Study Analyse data [frequent feedback] Act Adopt, modify or reject plan Region-wide ‘scoping’ survey of practice Creation of working group to undertake full literature review and develop evidence-based guidance Pre-implementation Audit Results analysed & areas for improvement agreed Creation & implementation of admission booklet and care pathway Implementation supported by: Local dissemination by FHOC champions Regional launch day with practical demonstrations and video lectures All units offered education visits by FHOC team EOE Neonatal ODN 22 September 2018

Plan Do Study Act What [small] changes will we make [& how]? 1st Phase Assessment & Interim Analysis 2nd Phase Plan What [small] changes will we make [& how]? What data is needed to test outcome? Do Put plan into action Study Analyse data [frequent feedback] Act Adopt, modify or reject plan Region-wide ‘scoping’ survey of practice Staff views of 1st phase admission booklet/pathway surveyed Creation of working group to undertake full literature review and develop evidence-based guidance Re-audit of FHOC practice every month for 6 months Pre-implementation Audit Results analysed & areas for improvement agreed Interim Analysis half-way through 6 month audit cycle Creation & implementation of admission booklet and care pathway Implementation supported by: Local dissemination by FHOC champions Regional launch day with practical demonstrations and video lectures All units offered education visits by FHOC team 2nd phase booklet (see Fig. 3) is designed based on feedback on 1st phase booklet EOE Neonatal ODN 22 September 2018

First Hour of Care Pathway BACK PAGE MIDDLE PAGE SPREAD FRONT PAGE First Hour of Care Pathway Admission Booklet EOE Neonatal ODN

Sixty Golden Minutes: A Regional Quality Improvement Initiative Measures of Change: EOE Neonatal ODN 22 September 2018

Pre-implementation Audit (Baseline) In March 2015 351 infants were randomly selected using anonymous ‘Badgernet’ IDs – all gestational groups audited All 17 units participated: Local audit champions led data collection with intense support from a central project team and fortnightly reminders Data were collected via electronic spreadsheets with automatic data validation Amazing response!!! (351 responses : 100%) Prior to the implementation of our first hour of care admission booklet, we audited region-wide clinical practice >34+6 weeks 31+0 to 34+6 weeks <31+0 weeks <26 weeks EOE Neonatal ODN 22 September 2018

Electronic Audit Proforma: EOE Neonatal ODN 22 September 2018

Post-implementation Audit Following the implementation of our regional FHOC admission pathway, and the regional study day, we re-audited clinical practice Monthly audit took place between August 2015 to January 2016 Infants randomly selected, HOWEVER, all infants <26 weeks included Over the 6 months, a total of 556 infants were audited Amazing response yet again: 100% compliance Across the pre and post-implementation audits a total of 907 infants were selected and assessed for standards of care in all 4 defined care bundles. Gestational range: 23 to 42+ weeks EOE Neonatal ODN 22 September 2018

Study Post implementation audit month number

Antenatal Care Bundle Percentage receiving antenatal counselling; Infant’s < 26 weeks gestation Percentage receiving magnesium sulphate; Infant’s < 26 weeks gestation Percentage of infants shown to parents before leaving delivery room room/theatre

Fluids & Medications

Initial outcome measure: <26 weeks gestation Maximal Oxygen Requirement: 1st 72 Hours After Birth Initial outcome measure: <26 weeks gestation EOE Neonatal ODN 22 September 2018

Sixty Golden Minutes: A Regional Quality Improvement Initiative Close: EOE Neonatal ODN 22 September 2018

Improvements seen: Good uptake of standardised paperwork to improve documentation Standardised paperwork to includes prompts for organisation, prioritisation and gold standards of care which seems to have improved: Recorded/documented antenatal counselling Use of antenatal magnesium sulphate in tertiary units Documentation & use of oxygen/air blenders at delivery Documentation & use of PEEP at delivery Use of saturation monitors to guide assisted transition Optimised dose of curosurf Baby shown to parents after birth

However: Although improved, the time from birth to starting fluids and antibiotics could still improve Too early to determine further affect on outcomes, such as incidence of BPD, ROP and neurodevelopment Persistent concerns regarding thermoregulation and aspects of antenatal care EOE Neonatal ODN 22 September 2018

What’s Next? Plan Do Study Act 1st Phase Assessment & Interim Analysis 2nd Phase Plan What [small] changes will we make [& how]? What data is needed to test outcome? Do Put plan into action Study Analyse data [frequent feedback] Act Adopt, modify or reject plan Region-wide ‘scoping’ survey of practice Staff views of 1st phase admission booklet/pathway surveyed Creation of working group to undertake full literature review and develop evidence-based guidance Re-audit of FHOC practice every month for 6 months What’s Next? Pre-implementation Audit Results analysed & areas for improvement agreed Interim Analysis half-way through & at completion of 6 month audit cycle Creation & implementation of admission booklet and care pathway Implementation supported by: Local dissemination by FHOC champions Regional launch day with practical demonstrations and video lectures All units offered education visits by FHOC team 2nd phase booklet (see Fig. 3) is designed based on feedback on 1st phase booklet EOE Neonatal ODN 22 September 2018

Assessment & Interim Analysis 2nd Phase 1st Phase Assessment & Interim Analysis 2nd Phase Region-wide ‘scoping’ survey of practice Staff views of 1st phase admission booklet/pathway surveyed Target areas for improvement: Full evidence based guideline commissioned to complement FHOC admission booklet Implementation of 2nd Phase admission booklet Consolidate & Educate: Regional study day organised to consolidate practice development in permanent staff across all 17 units Regional education session for all new paediatric trainees joining the region Creation of working group to undertake full literature review and develop evidence-based guidance Re-audit of FHOC practice every month for 6 months Pre-implementation Audit Results analysed & areas for improvement agreed Interim Analysis half-way through & at completion of 6 month audit cycle (1) Regional survey of practice to assess need. (2) Creation of working group to undertake full literature review, develop unified admission booklet and develop interim evidence-based guidance. (3) Pre-implementation audit of our 4 key bundles of care (see aim) took place in March 2015; 351 infants were randomly selected from all gestations across all 17 units. (4) The 1st phase admission booklet/care pathway was implemented in July 2015, implementing evidence-based practice and specifically targeting areas for improvement identified in step (3). Units lead dissemination of interim guidance locally, as well as regional launch day with practical demonstrations and video lectures. (5) Staff views on 1st phase admission booklet/pathway are surveyed and FHOC practice across the 4 key bundles of care are re-audited every month for 6 months; between August 2016 through to January 2016. A total of 556 infants are audited from all units. (6) Interim analysis half-way through 6 month audit cycle; 2nd phase booklet (see Fig. 2) is designed based on feedback on 1st phase booklet. (7) Following completion of 6 month audit cycle, full standards of care analysed; full evidence based guideline commissioned to complement FHOC admission booklet/pathway & 2 further regional study days organised to consolidate practice & target further areas for improvement. Study sessions target development in permanent staff across all 17 units, as well as an education session for all new paediatric trainees joining the region. (8) Ongoing audit following 6-month consolidation. Creation & implementation of admission booklet and care pathway Implementation supported by: Local dissemination by FHOC champions Regional launch day with practical demonstrations and video lectures All units offered education visits by FHOC team 2nd phase booklet (see Fig. 3) is designed based on feedback on 1st phase booklet Ongoing audit planned following 6-month consolidation EOE Neonatal ODN 22 September 2018

Quick Reference Guideline: The concept: A4 Landscape laminated (wipe clean!) & bound One to two printed copies available to each unit Online version with indexed ‘hyperlinks’ EOE Neonatal ODN 22 September 2018

Learning points: Strong drivers for change and enthusiastic neonatal staff facilitated rapid uptake of our quality improvement drive Use of data validation and intense support during audit phases meant 100% compliance was reached across the region Involvement of all involved stakeholders is paramount to full regional engagement and improvement Further engagement of our midwifery and nursing teams is necessary to optimise antenatal care EOE Neonatal ODN 22 September 2018

Dissemination to other trusts: Although the clinical context of this project is neonatal-specific, there are many learning points which may be generalised and disseminated to others The model of regional directed standards of care is effective where areas of expertise are replicated over multiple sites Successful audit is possible on a region-wide scale, with high levels of compliance Success pivots on: Available and willing support staff Easy to use proformas – which collect essential information EOE Neonatal ODN 22 September 2018

Timeline: July – September 2015 Implementation of FHOC admission booklet Ongoing impact assessment Staff surveys: feedback on pathway Local education and local dissemination of FHOC practice February – April 2015 Pre-implementation audit Creation of FHOC care pathway/admission booklet August 2015 – January 2016 Post -Implementation Audit June 2015 Regional study day & launch day Video lectures & demonstrations Release of care pathway June 16 Implementation of revised FHOC Care pathway First preview of FHOC guideline Regional study day to consolidate learning 2014 Region-wide scoping survey confirms variation in clinical practice Creation of FHOC working group to lead project to help address this 22 September 2018

EOE Neonatal ODN 22 September 2018