1. 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

2. 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

3. 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

4. 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

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

6. 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

7. Cycle of Change Management:
EOE Neonatal ODN
22 September 2018

8. 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

9. 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

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

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

12. Pre-implementation Audit (Baseline)
In March 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

13. Electronic Audit Proforma:
EOE Neonatal ODN
22 September 2018

14. 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

15. Study
Post implementation audit month number

16. 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

17. Fluids & Medications

18. 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

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

20. 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

21. 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

22. 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

23. 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 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

24. 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

25. 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

26. 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

27. 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

28. EOE Neonatal ODN
22 September 2018