NNAP Collaborators Meeting – 16 th March NNAP Update Sam Oddie, NNAP Clinical Lead Birmingham

NNAP Collaborators Meeting – 16 th March Background 2013 data report Parents and carers Survey Monkey Widening clinical input Changes in NNAP reporting Changes in data flow Mortality

National Neonatal Audit Programme (NNAP) Commissioned - HQIP (NCAPOP). Funding - NHS England and the Welsh Government. Delivered RCPCH – 2015 (contract extension) Wales since 2012 data

NNAP PB supports inclusion of Scottish NNUs Logistics – no barrier Next steps HQIP/ RCPCH, Scottish National Neonatal Project, Scottish Clinical Outcomes and Measures for Quality Improvement (COMQI) Inclusion of Scottish Neonatal Units

National Neonatal Audit Programme (NNAP) Aims: i.assess whether babies admitted to NNU in England and Wales receive consistent care in relation to the audit questions; ii.identify areas for quality improvement in NNUs in relation to delivery and outcomes of care.

Audit Questions Results: Temperature Do all babies of less than or equal to 28+6 weeks have their temperature taken within an hour after birth? NNAP data year Number of eligible NNU Number of Eligible babies % with T taken within an hour of birth % % % % % %

Audit Questions Results: Temperature Do all babies of less than or equal to 28+6 weeks have their temperature taken within an hour after birth? n< ≥37.5 Other (56%)4 (15%)5 (19%) 2 (7.4%) SCU (10%)38 (26%)74 (51%) 17 (12%) LNU (16%)224 (30%)336 (45%) 72 (9.6%) NICU (11%)505 (28%)852 (48%) 234 (13%) Total (19%) 325 (12%)

Audit Questions Results: ANS Are all mothers who deliver their babies between 24+0 and 34+6 weeks gestation given any dose of antenatal steroids? NNAP reporting year Number of eligible NNU Number of eligible mothers Percentage with any antenatal steroids given % % % % % %

Audit Questions Results: Consultation Is there are documented consultation with parents by a senior member of the neonatal team? NNAP data year Number of eligible NNU Number of eligible episodesWithin 24 hours % % % % % %

Audit Questions Results: ROP Do babies <1501g or 32/40 undego the first ROP screen in accordance with the current guideline recommendations? NNAP data year Number of eligible NNU Number of eligible babies Screened on time % % % % % (87%)

2014 Annual Report on 2013 Data completeness: Feeding and T - very good ROP is much better 44% had FU data Infection – still poor ROP – big babies not always screened Non participants and outliers

Developing engagement with Parents & Carers Existing strong partnership with BLISS Under ToR, add further representation to PB Parent & Carer version of 2013 data report PREM development work

Patient Reported Experience Measures (PREM) RCPCH and Partners BLISS Neonatal networks

Patient Reported Experience Measures (PREM) RCPCH and Partners BLISS Neonatal networks

Engagement with NNUs – Survey Monkey June 2014: ‘Developing the future of the NNAP' Objectives: Help PB better understand the views of clinicians Develop work of NNAP in responsive manner including whole of the neonatal community. 182 responses from 166 units. “I think measuring (temperature) is important AND ensuring it is in (the) normal range” ROP “I am glad this question was audited……..no one listened……. we are making progress!! Finally!!” BrMilk: “The aim is laudable - the attempt to shame is not”

Wider clinical input - CRAG C linical R eference and A dvisory G roup Purpose: Represent full range of NNUs by geography and unit size Broaden base of clinical representation into NNAP Reconsider existing questions and analyses Suggest and refine new questions Meetings by teleconference/ face to face meeting

What has NNAP changed? – Infection questions LOI – hopefully preventable Current measures in NNAP relate to EOI + LOI Most quality improvement work focussing on blood cultures taken >72 hours NB views of CRAG

What has NNAP changed? – ROP NNAP interpretation of RCOPhth guidance ROP screen in window, but after discharge = “adherent” ROP in Badger Daily data Ad hoc forms PB agreed “daily data” OR “ad hoc forms” would count as evidence that an ROP screen had taken place Significant impact on data completeness (87% to 91% overall, Units <90% complete 84 to 66 ) Change to Badger system

What has NNAP changed? – Temperature Unrecordably low temperatures Now assumed to be low in analysis Values in report

What has NNAP changed? – parental consultation Short admissions (<12 hours) no longer included

What has NNAP decided to change? – BPD/ CLD Mild: resp support (ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) + air at 36/40 Significant: (mod+severe) resp support (ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) + resp support(ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) at 36/40 corrected. Eligible babies: <32/40 or <1500g, and alive at 36/60 Data sources and years Daily data entry form in the Badger systems. 3 year rolling averages (2012/2013/2014) Assigning BPD/ CLD to a neonatal unit BPD/ CLD is assigned to the unit of birth

What has NNAP considered changing? Infection Temperature Antenatal steroids for term El LSCS OFC growth Equity of access to care Breastmilk analysis Report format Reporting process Mortality

NNAP support for improved 2014 data quality Process for the 2014 data report Beginning of May - NNAP will notify all units with: provisional outlier status for particular questions current non-participant status (i.e. less than 90% data completeness for a particular question) Throughout June - All neonatal units will be offered the opportunity to review their data for accuracy before the final data download is taken for analysis and reporting at the end of June.

Process for 2015 data report Mini quarterly unit reports for all NNAP units to include: Data completeness reporting Adherence to audit standards Definitive 2015 NNAP dataset will be established after data quality window closes Publication in Summer rather than Autumn without the need to highlight provisional outlier status. Full details will be communicated to all NNAP units later in March 2015 NNAP reporting process for 2015 data

Work in progress - Mortality Competing analyses? MBRACE/ TNS/ Local analyses NNAP possible USP is gestationally limited denominator data to NNU discharge Challenges Non NNAP units (eg surgical) Small numbers (power) Need to aggregate years Unit of analysis Choice of model for risk adjustment Confidence in our approach Why?

Work in progress – Mortality (2) Expert group met Nov 2014 Recommendation: that NNAP can and should report Denominator: All born 23 (or 24) - 31/40 inclusive Numerator: Inpatient deaths (including LW, NNU deaths, deaths on non NNAP units) and babies discharged with LOTA and expected death. Excluded deaths: Those due to lethal congenital malformation. (Eurocat classification) 3 year rolling averages Primary unit of analysis – networks Limited adjustment (gestation +/- ethnicity )

Work in progress - Mortality (3) Implications: Need for reporting of LW deaths via badger Development of system to for units to validate their deaths (incl LW deaths) Development of mechanisms to report late deaths prior to 44/40 GCA on non NNAP units Consultation: Lower gestational age limit Risk adjustment for ethnicity Case mix adjustment model – unit level reporting More communication from NNAP in 2015

Questions