1. 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

2. 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

3. 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

4. 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

5. Plan

6. 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

7. TIME LINE
Feb 15 – Apr 15
Pre-implementation audit

8. 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%)

10. Do

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

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

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

14. 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 available (556 babies)

15. 100 % compliance again!
14 April 2019
EOE Neonatal ODN

16. Study

17. Post implementation audit month number

18. Care bundle: Teamwork and peripheral actions

19. Antenatal counselling

20. Antenatal counselling

21. Antenatal steroids (full course) (%)

22. Antenatal steroids (full course) (%)

23. Antenatal steroids (full course) (%)

24. Antenatal magnesium sulphate (%)

25. Antenatal magnesium sulphate (%)

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

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

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

30. Care bundle: Thermoregulation

32. Hat applied (%)

33. Hat applied (%)

34. Hat applied (%)

35. Hat applied (%)

36. NLS guidance?

37. Care bundle: Saturation targeting

38. Resuscitation started in air (%)

39. Resuscitation started in air (%)

41. Care bundle: Initial respiratory support

42. PEEP from T0 (%)

43. PEEP from T0 (%)

44. Reason for intubation : InSurE

45. Reason for intubation : InSurE

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

47. Summarizing
14 April 2019
EOE Neonatal ODN

48. 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

49. 14 April 2019
EOE Neonatal ODN

50. 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

51. Act

52. 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!

54. 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 Guideline + care
bundle/pathway
Feb 15 – Apr 15
Pre-implementation audit

55. 14 April 2019
EOE Neonatal ODN

56. 14 April 2019
EOE Neonatal ODN