First Hour Care audit data Dr Nilesh Agrawal Dr Paul Cawley (on behalf of EoE First Hour Care Project Team) 14 April 2019 EOE Neonatal ODN

Audit Pillar of Clinical governance Compares current practice to known gold standards/ best evidence practice. Analyze and interpret results Make suggestions for change Re audit to measure and demonstrate change It’s a Cyclical process

Setting The East of England Neonatal Operational Delivery Network consists of 17 neonatal units spanning 6 counties. This collaboration includes 3 tertiary Neonatal Intensive Care Units with 2 specialist paediatric surgical centres, and an acute neonatal transfer service. 70,000 per annum 3,500 premature births 800 are born very premature. 200 are extremely low birth weight/extremely premature

Effective change management- PDSA 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

Plan

Giving high risk neonates best possible start Standardize care in line with current evidence Developing an unified region-wide FHOC admission booklet to capture key performance indicators and guide first hour care, Done appropriately – less lung injury/CLD, IVH, ROP and possibly better ND outcomes

TIME LINE Feb 15 – Apr 15 Pre-implementation audit

Pre-implementation audit Excel sheet with data validation Blind randomization using anonymous Badgernet IDs 20 babies from each LNU/SCBU, 25 from NICUs Local audit champions and data clean up by project team Amazing response!!! (351 responses : 100%)

Do

TIME LINE June 2015 Guideline + care bundle/pathway Feb 15 – Apr 15 Pre-implementation audit

First Hour Care Thermoregulation Teamwork and peripheral actions Initial respiratory suppoprt Saturation targetting

TIME LINE Aug 15 – Jan 16 June 2015 – Sep 2015 Post Implementation Audit June 2015 – Sep 2015 Impact assessment Education June 2015 Guideline + care bundle/pathway Feb 15 – Apr 15 Pre-implementation audit

Post-implementation audit Same proforma used 7-10 babies per month from each of the 17 units Similar range of gestations as pre audit Logistically challenging as more engagement needed from local champions Data collected from August 2015 to January 2016 available (556 babies)

100 % compliance again! 14 April 2019 EOE Neonatal ODN

Study

Post implementation audit month number

Care bundle: Teamwork and peripheral actions

Antenatal counselling

Antenatal counselling

Antenatal steroids (full course) (%)

Antenatal steroids (full course) (%)

Antenatal steroids (full course) (%)

Antenatal magnesium sulphate (%)

Antenatal magnesium sulphate (%)

Baby shown to parents before leaving delivery room room/theatre? (%)

Baby shown to parents before leaving delivery room room/theatre?(%)

Baby shown to parents before leaving delivery room room/theatre? (%)

Care bundle: Thermoregulation

Hat applied (%)

Hat applied (%)

Hat applied (%)

Hat applied (%)

NLS guidance?

Care bundle: Saturation targeting

Resuscitation started in air (%)

Resuscitation started in air (%)

Care bundle: Initial respiratory support

PEEP from T0 (%)

PEEP from T0 (%)

Reason for intubation : InSurE

Reason for intubation : InSurE

Curosurf 200mg/kg used? (26-30+6 weeks: ~30%, no change)

Summarizing 14 April 2019 EOE Neonatal ODN

Doing well Antenatal counselling Availability of blenders Use of saturation monitors Antenatal steroids Antenatal magnesium sulphate in tertiary units PEEP from Time 0 Baby shown to parents after birth Dose of curosurf

14 April 2019 EOE Neonatal ODN

Not so well Delaying cord clamping (under 10 %) Magnesium sulphate in LNUs/SCBUs ‘Documenting’ the use of a hat (we all do it!) Admission temperatures (main focus of 2015 NLS guidelines) Reasons for intubation? Be Smart, InSurE ! Time from birth fluids and antibiotics are administered. Delay in writing prescriptions

Act

Moving ahead Good mix of positive feedback and constructive criticism from the region re: paperwork We have had regular meetings of the core working group to discuss this feedback Lots of positives from audit cycle! Revised paperwork and guidelines have been circulated Continue auditing to measure change Continue addressing the human factors of change!

TIME LINE June 16 Aug 15 – Jan 16 June 2015 – Sep 2015 Post Implementation Audit June 16 Improved guidance and paperwork implemented June 2015 – Sep 2015 Impact assessment Education Implementation date Sep 2015 June 2015 Guideline + care bundle/pathway Feb 15 – Apr 15 Pre-implementation audit

14 April 2019 EOE Neonatal ODN

14 April 2019 EOE Neonatal ODN