The National Neonatal Audit Programme Mike Watkinson for the NNAP Project Board

1. The National Neonatal Audit Programme Mike Watkinson for the NNAP Project Board NDAU

2. Definition of national audit • national coverage (achieved or intended) • main focus is the quality of clinical practice • measures practice against clinical criteria / guidelines and / or collects outcomes data • applies the audit cycle and / or monitors clinical / patient outcomes data in an ongoing way • is prospective i.e. does not include retrospective reviews of adverse outcomes such as confidential enquiries • includes patients in their governance and takes data from patients themselves.

3. National Neonatal Audit Programme: Background June 2003: a Clinical Advisory Group was set up by the DoH to consider how the needs of professionals, users and commissioners could be met in relation to the provision of neonatal care. The CAG strongly supported the need for a national audit programme, which would complement existing regional and local audit or data collection processes.

4. National Neonatal Audit Programme The RCPCH Science and Research Department won the tender to establish and run the NNAP for 2 years from January 2006 funded by the Healthcare Commission. First NNAP Annual Report in May 2008. In 2008 NNAP and again in 2010 received further funding from the Healthcare Quality Improvement Partnership (HQIP). Annual reports every May/June.

5. www.rcpch.ac.uk/nnap

6. Key aims of the audit • To assess whether babies requiring neonatal care received consistent care across England and Wales in relation to the audit questions. • To identify areas for improvement in neonatal units in relation to delivery and outcomes of care. • To provide a mechanism for ensuring consistent high quality care in neonatal services.

7. Methods: • Secure web-based NHS database • Patients anonymised • Only 23-30 fields per baby sent to NNAP

8. Audit questions for 2008 -2011/2 • Do all babies born between 26 and 28 weeks’ gestation receive surfactant? • Do all babies of <28 weeks gestation have their blood pressure taken within the 1st hour after birth? • Do all babies of </=28 weeks’ gestation have their temperature taken within the 1st hour after birth? • Do all babies <1501g or <32 weeks gestation undergo the first ROP screening examination as per the current guidelines? • Do all babies <33 weeks gestation receive their mother’s milk on any occasion whilst an inpatient?

9. Audit questions • How many babies <33 weeks gestation are receiving their mother’s milk when discharged home? • Are all mothers who deliver their babies between 24 and 34 weeks gestation given any dose of antenatal steroids? • Are all parents (or carers) of babies admitted to NNUs seen by a senior member of the neonatal team within 24 hours of admission? • How many babies born between 32–36 and 37+ weeks gestation receive care on NNUs? • Are rates of normal survival at 2 years comparable in similar babies from similar units?

10. Audit questions • What percentage of babies >35 weeks gestation have an encephalopathy within the first 3 calendar days of birth? • What percentage of babies admitted to a NNU have: • one or more episodes of a pure growth of a pathogen from blood or CSF • either a pure growth of a skin commensal or a mixed growth with >3 clinical signs at the time of blood sampling • How many positive blood cultures are there on a NNU per 1000 days of care for babies with a central venous line? (Includes umbilical venous and arterial catheters, percutaneous long lines, surgically inserted long lines) (TBC) • How many babies are admitted from a Midwifery Led Unit? (TBC)

11. Recruitment into NNAP

12. The practice of recording

13. The percentage of positive responses

14. Changes in practice • Improved care in the first hour(s) • Generally improved note-keeping • Targeting improved temperature control • Recording staff/parent conversations • Greater awareness of breast milk feeding • Triggering of local audits

15. Changes in practice • “Our rates of antenatal steroid administration were low. We informed the obstetricians, did an audit and amended local guidelines to raise the profile of this. • “It has helped us compare areas of practice with other centres and driven improvement, e.g. the standard expected for the various audited parameters is used to educate new trainees at induction and optimise practice.

16. Changes in practice “We updated the breast feeding policy. We introduced breast feeding support workers to help increase the breast feeding rates.” “We are trying to increase the percentage of infants <33 weeks receiving their mother’s breast milk. Our breast feeding nurse specialist not only supports mothers, but is actively involved in ongoing teaching and updating nursing staff with regard to breast feeding premature infants.”

17. Changes in practice “ This has had a big impact on the nursing staff. There was always a breast feeding policy, but now there has also been written a policy for babies on NNU. We used to charge parents for expressing kits, but we persuaded the head of nursing to give mothers 2 free kits. There has been improved liaison with the midwives so mothers get started on expressing ASAP and they are no longer given a day’s rest. Although the question is only about if the baby has ever received mother’s breast milk, it really has led to a huge change in the nursing staff practice.”

18. Changes in practice “ We are introducing a parent communication sheet into the medical notes to identify clearly when this is done and to help ensure it is recorded.” “ Doctors are encouraged to speak to parents within 24 hrs of admission and document the date and time of the discussion. Case notes have a stamp on page 1 to remind doctors to speak to parents.”

19. Outcomes and processes Temperature value as well as time ROP laser treatment as well as time of ROP screening Maternal milk at discharge rather than ‘any’ during stay Rates of encephalopathy Rates of infection

20. The most important question ? • Are rates of normal survival at two years comparable in similar babies from similar units?

21. 1st January - 31st December 2010 Number (%) Eligible babies (discharged in 2008) followed up in 2010 Bedfordshire and Hertfordshire 134 18 (13%) Cheshire and Merseyside 230 4 ( 2%) Eastern 236 39 (17%) Greater Manchester 254 15 ( 6%) Kent 145 19 (13%) London - North Central 124 82 (66%) London - North East 303 65 (21%) London - North West 255 52 (20%) London - South East 176 44 (25%) London - South West 127 90 (71%) Midlands – Central 1 0 Staffs, Shropshire, Black Country 40 13 (33%) Midlands South West 65 23 (35%) Northern 173 12 ( 7%) North Trent 45 0 Peninsula 117 32 (27%) Surrey and Sussex 132 21 (16%) Western 123 16 (13%) Trent 174 0 Yorkshire 5 0

22. Outliers

23. Funnel plot around the population 14 units below – 2 S.D. CMACE

24. Funnel plot around the standard 57 units below -2 S.D. CMACE

26. www.rcpch.ac.uk/nnap • A national / multi-centre audit • Recruits units slowly • Improves data completion slowly • Cannot presume 100% data accuracy • Is not dependent on a single database, but may benefit from one • Needs ‘champions’ at unit and regional levels • Needs to ask the right questions and reject the wrong ones • Will make mistakes, and must learn from them • Needs to think about outcomes v. processes • Needs a mechanism to deal with outliers – both good and bad • Will be told “You are wrong, we are right” • If you can keep your head, when those around you are losing theirs, • and blaming it on you ……….. NDAU

27. www.rcpch.ac.uk/nnap NNAP Project Board members 2011 Mike Watkinson Alan Fenton BAPM Neena Modi RCPCH / NDAU Andrew Wilkinson BAPM Roshan Adappa Wales Jane Abbott BLISS Mary Passant Networks representative Eugene Statnikov NDAU Sridevi Nagarajan NDAU Yvonne Silove HQIP Kim Davis RCPCH Rita Ranmar RCPCH NDAU