ENTER CONFERENCE May 4 th 2006 Lin Marriott

CESDI 27/28 – How Do We Measure Up? Comparison of care in a Neonatal Intensive Care Unit with the Confidential Enquiry into Stillbirths and Deaths in Infancy - Project 27/28 Standards + Staff perception of standards of care

Background: CESDI Project 27/28 Prematurity is the major cause of neonatal deaths Focus of the national CESDI programme in 1997 Prematurity accounts for 14% of all births & accounts for 47% of all deaths Survival rates - 88% if born at 27/28 weeks

Aim of Project 27/28 Enquiry: To identify patterns of practice or service provision that might contribute to deaths of 27/28 week infants, and make recommendations for future practice

Project 27/28 Enquiry Conducted record review & assessed: Survival rates to 28 days of age of 27/28 week infants Conducted a Confidential Enquiry on all NND + an equivalent group of survivors Enquiry provided 1 st national data on survival rates

CESDI Project 27/28 Standards 1. Resuscitation(5 standards) 2. Early thermal care(1 standard) 3. Surfactant therapy(2 standards) 4. Ventilatory support (3 standards) 5. Cardiovascular support(3 standards)

Background: NICU participating in the study Tertiary Level 3 Regional Neonatal Intensive Care + Neonatal Surgery centre 13 intensive/high dependency care cots +10 special care cots +14 transitional care mother/baby beds Approximately 300 ICU admissions per year (+ HDU + SCBU + transitional care) Provides 2150 ICU days per year Provides 1650 HDU days per year

Aims of the study To assess whether the early clinical management of 27/28 week infants adhered to national guidance To determine if improvements in quality and safety of care were required

Study Design Combined Quantitative / Qualitative approach Two phase design: Phase One - Record Review Phase Two -Semi-Structured Staff Interviews

Phase One: Record Review Demographic data: Infants: weeks gestation Mean birth weight 1170g ( g) Records of infants born during a one year period audited Exclusion criteria: outborn infants (n= 12) 41 infants fulfilled criteria, all records were assessed (n= %) All 41 infants survived to 28 days

Phase Two: Staff Interviews Participants: Interviews were conducted with NICU staff Exclusion criteria: staff who provided care only under direct supervision Interviewed in single professional peer groups: Snr Sr, Sr, SN Consultant, SpR, SHO X 6 group interviews undertaken (n=18 staff)

Phase Two: Staff Interviews Semi–structured interviews asked for: a)Understanding of principles and expected standards of practice b)Staff perceptions of what actually happened in practice

RESULTS Record Review: 5 out of the identified 14 CESDI standards = fully met (36% documented compliance) 2 out of the remaining 9 specific standards = partially met 7 standards = unmet

RESULTS Staff Interviews: All 14 standards = understood and articulated by staff (100% compliance on principles) 6 were perceived as actually met in practice (43% perceived compliance in practice) Perception of practice that did not meet the criteria closely matched results of record review

Standards for Resuscitation A Consultant/SpR should be with an SHO for 27/28 week infant deliveries 34 infants –Consultant/SpR/both present (83%) 1 infant - SHO alone present 1 infant - neonatologist not present 5 records had missing data on attendees, or signature/designation was illegible

Standards for Resuscitation All infants received appropriate bag and mask ventilation when needed (n 28) – 100% 20 out of 25 infants who were seriously clinically compromised were intubated by 5 minutes of age (80%) But 5 out of 25 infants were not intubated by 5 minutes of age (20%) Of the 5 not intubated: a median 4 attempts was required to achieve intubation (95% CI 2-5)

Staff perception: delays in intubation were a source of anxiety to all staff: “I felt the baby wasn’t responding to what we were doing and we needed to intubate” - Sr “We don’t concentrate enough on the practical things. We talk too much on the theory of ventilation, but there are real practical things for us to learn, such as how you intubate” – SHO

Standards for Resuscitation All infants received ongoing respiratory support in NICU 25 infants were ventilated on admission 16 infants received cpap

Standards for early thermal care Infants’ temperature should be above 36c on admission to the NICU All 41 infants had a temperature > 36c Mean temperature on admission = 37.4c (95% CI ) (range )

Standards for Surfactant Therapy Surfactant should be administered to all intubated infants Surfactant should be administered within one hour of birth All 25 intubated infants received prompt surfactant therapy

Standards for ventilatory support Regular blood gas analysis should be performed whilst the infant is receiving respiratory support All infants had regular blood gas monitoring But time of 1 st blood gas varied: 10 infants who were ventilated and had received surfactant did not have a blood gas performed for more than an hour post delivery Median: 51 minutes (95% CI ) (range: 10 – 170 minutes)

Staff perception: All staff thought that a blood gas should be taken within ½ an hour, many thought this was always achieved: “generally, we get a gas done within the 1 st few minutes, or by ½ an hour” – SN But some did not: “we’ve had times when it can be an hour and a half, and it’s just not good enough” –Snr Sr “we never achieve a blood gas within an hour” Consultant

Standards for ventilatory support Ventilation should be adjusted with the aim of maintaining a pH > 7.25 and a Pa kPa 12/25 infants (48%) had a pH< 7.25 in 1 st 24 hours of life Pa02 range: 2.10 – 13.7kPa *PC02 range: 2.62 – 5.99kPa (PC02<3.5 n=10)

Staff perception: “We do not get enough gases in the early phase” – Consultant “We need to be more aggressive, we sometimes get babies that are hypocarbic and we need to know and do more” – SpR

Central Vascular Access All 41 infants fulfilled criteria for indwelling central venous access Achieved for 33/41 infants (80%)

Staff perception: Central vascular access was perceived as problematic by all, and revealed both internal and external pressures: “when you are doing a procedure you tend to lose track of time, and 10, 20 minutes pass very quickly, and if the baby is not well you feel a pressure to do it ” – SHO “junior Drs want to have a go at putting lines in, they need practice, but it takes longer and it depends how stable the baby is and what they can tolerate. I say they should have two attempts and that’s enough. The SpR should do it” – Snr Sr

Staff perception: Differences in priorities between groups: “sometimes the nurses have everything done in ten minutes, some people it can take an hour, but we are not allowed to touch the baby to put in lines until it’s done” – SpR “there’s too many people and they just want to jump in and we’ve just brought the baby, and if they give us that initial ten minutes just to do your things, and then they can do their’s” – SN

Cardiovascular Support The mean BP should be maintained at or above the infants’ gestation 9/41 (22%) infants were hypotensive All 9 hypotensive infants received volume expansion – 3 received inotropic support A total of 19 infants received volume expansion within 24 hours of birth But 9 out of the 19 who received a fluid bolus = normotensive with a normal blood pH value

Staff perception – key themes Prioritisation Teamwork Communication Time frames – internal / external pressures = key factors perceived to influence effectiveness of early care

Implications Results closely matched the findings of the CESDI Enquiry Care provision at critical periods in the resuscitation and stabilisation of infants was not consistently optimised Early care was dependent on the effectiveness of the team responsible at the time - not organisational factors Support and supervision for the SHO was variable according to senior clinical staff on duty

Implications Disparities with expected standards -wider implications for other vulnerable infants Potential impact on later morbidity/mortality beyond 28 days Leadership and prioritisation during early management of infants Clinical support, role clarification and teamwork issues

Key strategies Competence of all grades of clinical staff more closely verified on induction Closer monitoring and formalisation of continuing clinical support Increased frequency of inter professional practical skills workshops

Key strategies Increased awareness of, and improved clarification of responsibilities Nurse designated to provide 1:1 early care Brief debrief by team following each admission Amended documentation – ongoing Algorithm to assist prioritisation of early care Re- audit + maintain impetus

Algorithm for the first hour care of sick neonates Designated doctors and nurse to attend delivery Time 1: Delivery to NICU Infant: <30/40 plastic bag Airway stabilised Ventilation/CPAP if < 30/40 Curosurf Time 2: Arrival NICU to UAC/UVC insertion Designated nurseNICU SHODelivery SpR Transfer to incubator Weigh & OFC Connect monitoring & record: Temp, RR, HR, Cuff BP TC02/TCPC02 Support infant for PVL Check ETT, Clinically assess vent/perfusion PVL, blood gas Blood sugar Px fluids and drugs Handover to NICU SpR Document delivery and treatment Set up for central lines Time to PVL +gas 5-10 minutes NICU SpR Supervise SHO Time Expected : UAC/UVC SHO & SpR: not>30mins Assist with central lines Support infant Complete admission log Pass NGT Central line insertion Maximum of 1artery Expected time: not > 30 mins Successful Unsuccessful Bloods gas X ray SpR to insert lines Unsuccessful Successful Inform consultant Amend ventilation Check ETT, line position Ensure complete, accurate documentation and record times to intubation, Curosurf, lines and ventilator changes, once infant stable. Immediate short debrief if time allows SpR or delegate to SHO- update parents asap

Thank you any questions?