enter conference may 4 th 2006 lin marriott. cesdi 27/28 – how do we measure up? comparison of...
TRANSCRIPT
![Page 1: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/1.jpg)
ENTER CONFERENCE
May 4th 2006
Lin Marriott
![Page 2: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/2.jpg)
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
![Page 3: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/3.jpg)
![Page 4: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/4.jpg)
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
![Page 5: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/5.jpg)
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
![Page 6: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/6.jpg)
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 1st national data on survival rates
![Page 7: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/7.jpg)
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)
![Page 8: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/8.jpg)
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
![Page 9: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/9.jpg)
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
![Page 10: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/10.jpg)
Study Design
• Combined Quantitative / Qualitative approach
• Two phase design:
• Phase One - Record Review
• Phase Two - Semi-Structured Staff Interviews
![Page 11: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/11.jpg)
Phase One: Record Review Demographic data:• Infants: 26-29+6 weeks gestation
• Mean birth weight 1170g (498-1570g)
• 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=41 - 100%)
• All 41 infants survived to 28 days
![Page 12: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/12.jpg)
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)
![Page 13: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/13.jpg)
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
![Page 14: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/14.jpg)
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
![Page 15: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/15.jpg)
RESULTSStaff 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
![Page 16: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/16.jpg)
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
![Page 17: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/17.jpg)
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)
![Page 18: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/18.jpg)
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
![Page 19: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/19.jpg)
Standards for Resuscitation
• All infants received ongoing respiratory support in NICU
• 25 infants were ventilated on admission
• 16 infants received cpap
![Page 20: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/20.jpg)
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 37.1- 37.7)(range 36.1- 39.5)
![Page 21: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/21.jpg)
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
![Page 22: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/22.jpg)
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 1st 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 42- 59) (range: 10 – 170 minutes)
![Page 23: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/23.jpg)
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 1st 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
![Page 24: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/24.jpg)
Standards for ventilatory support
Ventilation should be adjusted with the aim of maintaining a pH > 7.25 and a Pa02 6-10kPa
• 12/25 infants (48%) had a pH< 7.25 in 1st 24 hours of life
• Pa02 range: 2.10 – 13.7kPa
• *PC02 range: 2.62 – 5.99kPa (PC02<3.5 n=10)
![Page 25: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/25.jpg)
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
![Page 26: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/26.jpg)
Central Vascular Access
• All 41 infants fulfilled criteria for indwelling central venous access
• Achieved for 33/41 infants (80%)
![Page 27: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/27.jpg)
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
![Page 28: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/28.jpg)
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
![Page 29: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/29.jpg)
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
![Page 30: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/30.jpg)
Staff perception – key themes
• Prioritisation
• Teamwork
• Communication
• Time frames – internal / external pressures = key factors perceived to influence
effectiveness of early care
![Page 31: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/31.jpg)
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
![Page 32: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/32.jpg)
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
![Page 33: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/33.jpg)
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
![Page 34: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/34.jpg)
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
![Page 35: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/35.jpg)
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 nurse NICU SHODelivery SpR
Transfer to incubatorWeigh & OFCConnect monitoring & record:Temp, RR, HR, Cuff BP TC02/TCPC02Support 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+gas5-10 minutes
NICU SpR
Supervise SHO
Time Expected :UAC/UVCSHO & SpR: not>30mins
Assist with central linesSupport infantComplete admission log Pass NGT
•Central line insertion•Maximum of 1artery•Expected time: not > 30 mins
SuccessfulUnsuccessful
•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
![Page 36: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/36.jpg)
![Page 37: 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](https://reader035.vdocuments.site/reader035/viewer/2022062221/56649f145503460f94c28e9a/html5/thumbnails/37.jpg)
Thank you any questions?