the neonatal survey and yorkshire neonatal network report 2007 · the neonatal survey report 2007 3...

The Neonatal Survey Report 2007 1

The Neonatal Survey and Yorkshire Neonatal Network Report 2007

Contents

Introduction: ……………………………………………….. 7

Background: ……………………………………………….. 10

Population based data ………………………………………………. 11

Primary Care Trusts ………………………………………………. 12

Mortality/disease severity/CRIB data ………………………………. 35

Unit based data ………………………………………………………. 52

Network based data ………………………………………………………. 65

National Neonatal Audit Data ……………………………………… 67

References ……………………………………………………… 75

End Note ……………………………………………………… 76

Acknowledgements ……………………………………………………… 77

Appendix 1: Summary of current projects using TNS data

or involving the TNS team …………………………….......... 79

Appendix 2: Summary of current projects using YNN data

or involving the YNN team …………………………………. 87

Appendix 3: Admissions for neonatal intensive care by gestation,

year and survival at discharge, by PCT…………………….. 93

Appendix 4: Duration of ventilation and length of stay for

non-transferred ventilated babies, by hospital,

by year ………................................................................. 107

Appendix 5: Data Collection Forms 2007 …………………………. 125

2 The Neonatal Survey Report 2007

List of Tables and Figures

Table 1: Neonatal intensive care unit activity 2005 - 2007……….. 11

Table 2: Live births, perinatal mortality rates, and neonatal

mortality rates for the PCTs covered by TNS, 2006 (ONS) 12

Table 2a: Perinatal mortality rates and 95% CI for PCTs (ONS:VS1) 13

Table 2b: Neonatal mortality rates and 95% CI for PCTs (ONS:VS1) 14

Table 3: Ventilation days per 1000 births (95% C.I.) by PCT

as an average over 3 years ……………………………… 15

Table 4: Ventilation and CPAP days per 1000 births (95% C.I.)

by PCT as an average over 3 years ……………………… 16

Table 5: Percentage of babies ≤32 weeks gestation, receiving at

least one dose of steroid prior to delivery, by PCT……… 18

Table 6: Intensive care days used in babies ≤24 weeks gestation

by PCT as an average over 3 years

(number of babies) ………………………………………… 19

Table 6a: Rate of admission ≤24 weeks gestation (95% C.I.) per 1000

births by PCT (shown as 3-year averages) ……………….. 20

Table 7: Percentage of deliveries ≤32 weeks gestation not receiving

ventilation or CPAP by PCT (shown as 3-year averages) … 21

Table 8: Proportion of ventilated babies ≤32 weeks gestation

developing chronic lung disease, by PCT (shown as 3-year

averages)……………………………………………………… 23

Table 8a: Proportion of ventilated babies 25-32 weeks gestation

developing chronic lung disease, by PCT (shown as 3-year

averages)……………………………………………………… 24

Table 8b: Proportion of babies 25-32 weeks gestation developing

chronic lung disease, by PCT (shown as 3-year averages)... 25

Table 9: Rate of “neonatal encephalopathy” as an average over

3-years per 1000 live births, by PCT …………………. 26

Table 10: Percentage of neonatal unit admissions ≤32 weeks gestation

requiring surgery for necrotising enterocolitis, as an average

over 3 years by PCT………………………………………….. 27

Table 11a: Percentage of babies ≤32 weeks gestation undergoing an

ultrasound scan of the head: 2005-2007, by PCT……………. 29


Table 11b: Highest level of IVH recorded in babies undergoing

ultrasound scan of the head, 2005-2007 (neonatal unit

admissions ≤32 weeks gestation) by PCT ..…………………. 30

Table 11c: Number and percentage of babies ≤32 weeks undergoing

ultrasound scan of the head noted to have periventricular

leucomalacia (PVL) 2005-2007 ………..………………… 31

Table 12: Transfer activity during 2007 …………………. 33

Table 13: Rate per 1000 live births of babies treated for withdrawal

from maternal drug dependency, by PCT, as an average

over 3 years, (Yorkshire Neonatal Network only)…………. 34

Table 14: CRIB II –T data for 2007 – non-transfers ………………… 38

Table 15: CRIB II –T Transfers v non-transfers 2007.……………….. 38

Table 16: CRIB II –T data for 2005-2007, by PCT, including

transfers (20-32 weeks gestation) ………………………… 39

Table 17: CRIB II –T data for 2005-2007, by hospital, including

transfers (20-32 weeks gestation)………...………………… 41

Table 18: CRIB II –T data for the 2005-2007, by hospital:

Non-transfers only (20-32 weeks gestation) ……………… 43

Table 16a: CRIB II –T data for 2005-2007, by PCT, including transfers

(25-32 weeks gestation)………………………………………. 45

Table 17a: CRIB II –T data for 2005-2007, by hospital, including

transfers (25-32 weeks gestation) …….…………………… 47

Table 18a: CRIB II –T data for 2005-2007, by hospital: non-transfers

only (25-32 weeks gestation) ……..………………………….. 49

Table 19a: CRIB II –T data for 2005-2007 by network of intended place

of delivery at booking, including transfers (20-32 weeks

gestation) ……..……………………………………………… 51

Table 19b: CRIB II –T data for 2005-2007 by network of intended place

of delivery at booking, including transfers (25-32 weeks

gestation) ……..……………………………………………… 51

Table 20: Proportion of inborn ventilated babies who receive

surfactant, by hospital. ………………………………… 53

Table 21: Proportion of inborn ventilated babies of ≤32 weeks

gestation who receive surfactant, by hospital. ………… 54

Table 22: Percentage of babies ≤32 weeks gestation, receiving

at least 1 dose of steroid prior to delivery, by hospital…….. 55


Table 23: Proportion of babies ≤32 weeks gestation receiving TPN

and median length of treatment: 3-year rolling averages

by hospital, excluding transfers ………………… 57

Table 24: Rates of surgery for necrotising enterocolitis. Includes

babies ≤32 weeks gestation who spent the majorityof their

stay in that unit (3 year rolling averages) ………………… 58

Table 25: Ventilation days per baby as an average over 3 years,

by hospital (non transfers only)……………………………… 59

Table 26: Ventilation and CPAP days per baby as an average over

3 years, by hospital (non transfers only) ………………… 60

Table 27: Any oral or injected post natal corticosteroid use for babies

≤32 weeks gestation over 3 years, by hospital…………….. 61

Table 28: Rate of “neonatal encephalopathy” as an average over 3

years per 1000 births, by hospital of birth………………… 62

Table 29: Percentage of non-transferred babies ≤32 weeks gestation

undergoing an ultrasound scan of the head: 2005-2007 … 63

Table 30: The number of babies eligible for inclusion in TNS

with a missing NHS number in 2007 ………………… 64

Table 31: Proportion of ventilated babies who receive surfactant

by Network, 3 year rolling average ………………… 65

Table 32: Proportion of ventilated babies ≤32 weeks gestation who

receive surfactant, by Network, 3 year rolling average …… 65

Table 33: Proportion of babies ≤32 weeks gestation, receiving

at least 1 dose of steroid prior to delivery,

by Network, 3 year rolling average ………………… 66

Table 34: Proportion of babies ≤32 weeks gestation receiving TPN

and median length of treatment: 3 year rolling average,

by Network ………………………………………… 66

Table 35: Ventilation days per baby by Network, 3 year rolling

average ………………………………………………… 66

Table 36: Ventilation and CPAP days per baby by Network,

3 year rolling average ………………………………… 66

Table 37: No of babies ≤28 weeks gestation admitted with a

temperature <36C, together with the range of temperatures

in the first hour after delivery, by hospital, 2007 .……..… 68


Table 38: No of babies (26, 27 and 28 weeks gestation) receiving

surfactant within the first hour by hospital, 2007………….. 69

Table 39: No of inborn babies ≤28 weeks gestation with blood

pressure measured within the first hour, by

hospital, 2007 ………………………………………… 70

Table 40: No of families of inborn babies ≤32 weeks gestation who

had a consultation with a senior member of medical staff

(reg/cons) in the first 24 hours, by hospital, 2007 …..…… 71

Table 41: Screening for ROP of non-transferred babies <1250g,

by hospital, 2007 ………………………………………… 72

Table 42: No. of non-transferred babies ≤31 weeks gestation

discharged home on breast milk (wholly or partial),

by hospital, 2007 ………………………………… 73

Table 43: No. of non-transferred babies ≤31 weeks gestation

discharged home who received some breast milk as an

inpatient, by hospital, 2007 ………………………………… 74

Legend: PCT Funnel Plot Codes.……………………………………… 36

Legend: Hospital Funnel Plot Codes.…………………………………. 37

Figure 1 Stillbirth and perinatal mortality rates per 1000 births,

neonatal mortality rates per 1000 live births and total

births per year …………………………………………. 11

Figure 2 Unadjusted mortality ratios 2005-2007 by PCT,

inc. transfers (20-32 weeks gestation) …………………. 40

Figure 3 CRIB II –T adjusted mortality ratios 2005-2007 by PCT


Figure 4 Unadjusted mortality ratios 2005-2007 by hospital


Figure 5 CRIB II –T adjusted mortality ratios 2005-2007 by hospital


Figure 6 Unadjusted mortality ratios 2005-2007 by hospital,

non-transfers (20-32 weeks gestation)………………………. 44

Figure 7 CRIB II –T adjusted mortality ratios 2005-2007 by hospital,

non-transfers (20-32 weeks gestation) …………………. 44


Figure 8 Unadjusted mortality ratios 2005-2007 by PCT,

inc transfers, (25-32 weeks gestation)..………………………. 46

Figure 9 CRIB II –T adjusted mortality ratios 2005-2007 by PCT,

inc transfers (25-32 weeks gestation) ……………………….. 46


inc transfers (25-32 weeks gestation) …………………. 48

Figure 11 CRIB II –T adjusted mortality ratios 2005-2007 by

hospital, inc transfers, (25-32 weeks gestation)…………….. 48


non-transfers (25-32 weeks gestation) …………………. 50

Figure 13 CRIB II –T adjusted mortality ratios 2005-2007 by

hospital, non-transfers (25-32 weeks gestation) …………. 50


Introduction

Welcome to this years Neonatal Survey report. This report provides perinatal data

relating to an area made up of the former Trent Region plus Northamptonshire and also

the whole of Yorkshire. For those units in the original Trent Region this is the 14th such

report and 2007 was our 18th

year of data collection. For Northamptonshire units this

report contains information based on five years of data collection and for Yorkshire

three full years (although data collection did commence here in June 2004). The report

this year contains data from each of the areas covered and for the first time we have

now combined these into a single document. However the structure otherwise remains

largely unchanged with tables presenting population based data and others concentrating

on data by unit. Inevitably this means that the tables look different in a number of ways

with the three year rolling averages not being available for all hospitals / populations for

the whole period covered in this particular report. However we feel there are advantages

to having the combined tables as they allow additional cross comparison / bench

marking.

We have also included some data “by network” – based on mothers address. At the

moment these are not as precise as we would wish as we do not have a complete and

accurate set of postcodes relating to each of the networks, as when they were

established it was not entirely on the basis of existing organisational boundaries such as

PCTs or local authorities. This is an issue for some Networks more than others. We

will, during 2008/2009, discuss with the Networks whether they would like us to pursue

a precise geographical approach to analysis of their data (by deriving the appropriate

postcodes). An alternative approach, perhaps more relevant with increasing patient

choice, would be to analyse the data by network of booking. Nonetheless we hope the

current tables are helpful in demonstrating for the first time some aspects of how the

various networks compare (it is important to note that data for CNN does not include

Warwickshire).

We hope you will find the report both useful and informative. We would like to

acknowledge the great help and strong collaboration provided by each of the perinatal

services in the old Trent Region as well as those now in Yorkshire and

Northamptonshire. We would also like to acknowledge the support of the TIMMS

organisation (The Infant Mortality and Morbidity Studies).

In the past funding for the TNS came from a variety of departments within the Regional

office, but changes to the role of Regions meant that this mechanism could not continue.

More recently funding has been provided from various PCTs and/or the local neonatal

networks. We would like to acknowledge the importance of this stable funding

arrangement in allowing this unique survey to continue. We are starting the process of

renewing our contract which comes up for renewal at the end of this financial year.

However the relevant Commissioners for virtually the whole area covered by the TNS

have already funded a simple follow up programme for the next three years which

should add enormous value to the existing TNS data. Using a parental questionnaire we

plan to acquire follow up data at a corrected age of two years from all babies born at

less than 31 weeks (we are not including 31 and 32 week gestation babies as this

increases the numbers considerably). The prospective aspect of this work will start in

2009. By then we hoped to have agreed with each of the hospitals covered by TNS a

system for gaining consent. In addition we will attempt to gain consent for the 2007 and


2008 cohort of babies (by contacting the parents through their local paediatrician) in

order that follow up data is not delayed by two years. We will be writing to all

neonatologists about this again in due course.

The National Neonatal Audit Programme (NNAP www.ncap.org.uk/about.htm) was

established as one of the recommendations of the National Review of neonatal care

published in 2004. During the last 12 months they have received data from most UK

hospitals. The data for TNS hospitals was available but could not be supplied to NNAP

because of issues around confidentiality, the data protection act and the legal process by

which we are permitted to collect data without individual consent. A meeting in July

this year has identified a way forward and therefore data should soon be able to flow

from TNS units to NNAP. The national programme is looking, at least initially, at a

limited range of measures (not death rates for example) and hence is unlikely to

provide, in the short to medium term, sufficient clinical information to underpin clinical

governance in neonatal care locally. In 2007 we added new data items to TNS so that as

much of the national dataset as possible is collected and reported as part of the TNS

process. As a result you will notice some new tables appear in that section of the report

this year.

All that is missing from the NNAP dataset items are: 1) the information for those items

that potentially relate to mature babies as well as very preterm infants (such as exposure

to breast milk); and 2) follow up data at 2 years for the very preterm group. As indicated

above plans are in place to obtain the follow up data. The extra information relating to

mature infants could also be obtained but the cost (because of the greater numbers)

would be considerable and we will discuss with the Networks whether they wish to

widen the data collection in this way.

Our population based section of the report this year again relates to PCTs (we have used

this term rather than “health economies” by which we previously referred to Yorkshire

PCTs as the tables for the two “regions” are now combined.) However it is perhaps

sensible to repeat the comments in last year‟s report i.e. that the use of PCT boundaries

has brought some interesting differences to light. In particular those PCTs with a

predominantly urban base tend to have higher rates of neonatal activity (all types) than

those with a “rural mix”. The two Leicestershire PCTs are an excellent example of this

phenomenon.

Combined with the change to a single report covering the whole area we have decided

to show all totals in the first part of the report as a combined figure. This means that for

Yorkshire units some columns of data based on 3 year rolling averages are blank e.g.

2003-2005. In these situations rates for the whole population relate only to the old Trent

Region and Northamptonshire. Of course this effect will shortly disappear.

As in previous years we have tried to focus on a number of themes and potential

concerns regarding the present service. We have continued to include the introductory

comments before each section since we feel they are helpful in putting the data in

context, and are essential to those who are new to these reports. Those familiar with

previous reports will notice one or two changes to the format of the data presented as we

try and refine the information so that it is included in, what we hope is, its most useful

form. In particular I would like to draw your attention to the mortality tables adjusted

for disease severity. Please note we have continued to use a revised version of CRIB II

(first introduced in 2002) and to show results as a mortality ratio. Again this year the

http://www.ncap.org.uk/about.htm


information is supplemented with the use of funnel plots. The nature of these changes

is explained further in the introduction to the mortality section.

On a less positive note, again this year we have had to publish the report without the

benefit of up to date denominators from ONS or data about deaths outside the neonatal

unit from CEMACH. In the case of ONS including the 2007 data would have meant a

significant delay in publication of our report. We have however included the 2006

figures for births and deaths produced for our patch by ONS as these were absent from

the 2006 report. We have used these data on birth rates as our denominators for the

relevant TNS tables. The missing data from CEMACH is a major difficulty and hence

we plan to obtain this ourselves directly. As a result we hope the relevant tables will be

able to be restored next year.

We have in the last twelve months, been active in pursuing a number of projects, using

TNS data, for publication. As with previous TNS reports these are outlined in

Appendix 2.

We believe that the TNS and the report form an important part of clinical governance in

relation to perinatal care in Trent, Northamptonshire and Yorkshire and in this regard

we (the service as a whole) are far in advance of most other parts of the UK. In

comparison to most other specialties we are, similarly, in a much stronger position. If

we wish to maintain this lead it is important that the data presented here act as a

stimulus for discussion and further audit of any measures that seem out of line with the

picture as a whole presented here. Such investigations continue to provide some

fascinating insights into how services operate at a local level. We are always happy to

try and co-operate with this type of local audit by providing additional data where

necessary. We are working to streamline this process by providing an electronic version

of the report in which there will be access to the spreadsheets from which individual

tables are derived. This should be available in 2009.


Background The data for this report is derived from what was initially the Trent Neonatal Survey.

This was first established in 1987 and reviewed the whole neonatal service in Trent over

a one year period. The study recommenced data collection in February 1990 and has

continued since that time. The original exercise in 1987 collected data on every

admission to a neonatal unit in Trent. However, the analysis of that data revealed that

the majority of admissions were: a) mature babies, b) short duration, and c) did not

require intensive care. Therefore, when the survey was re-established in 1990, it was

decided to concentrate on those babies identified in the original study as being the most

labour intensive. As a result, the inclusion criteria for the study are as follows:

All babies:

a. less than or equal to 32 weeks gestation

b. less than or equal to 1500 grams birth weight

c. involved in transfers

d. who receive any intensive care

e. who died in a neonatal unit

f. at term who showed signs of severe hypoxic ischaemic encephalopathy

Clearly some babies fulfil more than one criterion.

(In 2004 we also started to collect data on all babies admitted because of symptoms

secondary to “drug withdrawal” following sustained in utero exposure. Changes to

policy since that time have meant that babies in the old Trent units are now rarely

admitted for this criterion alone and hence data from the “East Midlands” hospitals are

not available for inclusion in the relevant table. It is, however, included for the

Yorkshire units.)

Although units make data available, collection is carried out by research nurses who

visit the units regularly.

The definition of intensive care is clearly essential to such an exercise. At the time the

TNS was established neonatal care was divided into level 1 intensive care, level 2

intensive care and special care. Subsequently professional bodies have developed a

number of variations in the classification of these activities. A decision was taken early

in the study not to change the definitions used for the purposes of the survey. However,

when looking at trends in activity over time, it is often easier to consider days of

ventilator support and CPAP since this information is highly objective and is known to

be reproducible.

Some clinicians may feel that the report includes data that are too basic. This approach

has been adopted since it is recognised that many non-specialist/non-clinicians will wish

to read the material. It is hoped, however, that the report will be of interest to all

involved in perinatal care in the locality.

We have made every effort to include infants involved in cross-boundary flows in the

relevant sections of the report. Nevertheless the data are incomplete for some infants

and this has been noted in the text.


Population based data

Table 1 gives the regional totals for numbers of preterm babies and days of respiratory

support given to babies of all gestations. Of course this table now reflect the whole

region covered and hence the “trend” covers only 3 years. Conclusions must be limited

but it certainly does not suggest a continuing rise in the numbers of infants born 32

weeks gestation or indeed intensive care activity. However time will show whether this

was just a brief pause or whether indeed this was the start of a plateau in activity. We

will in due course look at our more longstanding data from the old Trent Region to gain

greater perspective.

Table 1: Neonatal intensive care unit activity, 2005-2007

2005 2006 2007

Days of ventilation 9252 11394 10151

Days of CPAP 15516 16917 15897

Days of CPAP + ventilation 24768 28311 26048

Days of ITC Level 1 29197 32246 30423

Babies born ≤ 32 weeks gestation

1785 1874 1877

As described in the introduction, in the following tables we are restoring our practice of

providing data from ONS on birth and death rates for the relevant local populations.

These figures are centrally collected and we feel provide useful background information

against which TNS data can be considered.


Figure 1: Stillbirth and perinatal mortality rates per 1000 births, neonatal mortality rates per 1000 live births and total births by year


Primary Care Trusts

NOTE: Latest data available from ONS: 2006

Table 2: Live births, perinatal mortality rates, and neonatal mortality rates for the PCTs covered by TNS, 2006 (ONS)

PCT Live Births

Perinatal Mortality

Rate

Neonatal Mortality

Rate

Barnsley 2747 7.6 2.5

Bassetlaw 1157 12.0 4.3

Bradford and Airedale 8153 10.6 5.2

Calderdale 2513 9.9 3.6

Derby City 3269 7.6 1.8

Derbyshire County 7587 6.3 3.2

Doncaster 3612 8.0 5.8

East Riding Of Yorkshire 3071 7.1 2.0

Hull Teaching 3500 9.9 5.1

Kirklees 5531 8.8 4.7

Leeds 9155 9.1 4.3

Leicester City 4747 13.2 5.9

Leics County and Rutland 7055 8.5 4.1

Lincolnshire 6849 7.3 3.9

North East Lincolnshire 1954 8.2 4.6

North Lincolnshire 1812 4.9 2.2

North Yorkshire and York 7755 6.9 3.1

Northamptonshire 8588 8.9 4.0

Nottingham City 3909 8.4 5.6

Nottinghamshire County 7154 7.9 3.6

Rotherham 2989 9.0 3.0

Sheffield 6341 7.7 4.3

Wakefield District 3803 7.6 3.4

Total 113251 8.5 4.0


Table 2 gives details of the total live births as well as perinatal and neonatal deaths for

2006. For the third consecutive year the total number of live births has risen: 107523 in

2004, 108830 in 2005. Figures for neonatal and perinatal mortality by PCT for the

years 2004 to 2006 are shown in Tables 2a and 2b.

Table 2a: Perinatal mortality rates and 95% C.I. for PCTs (ONS: VS1)

PCT 2004 2005 2006

Barnsley 10.2 (6.9,15.0) 6.4 (3.9,10.4) 7.6 (5.0,11.7)

Bassetlaw 9.7 (5.4,17.5) 6.2 (3.0,13.0) 12.0 (7.1,20.3)

Bradford and Airedale 10.5 (7.9,14.0) 13.2 (10.9,16.0)† 10.6 (8.6,13.1)

Calderdale 11.3 (7.0,18.3) 7.6 (4.8,11.9) 9.9 (6.7,14.7)

Derby City 8.6 (5.9,12.6) 9.6 (6.7,13.8) 7.6 (5.1,11.2)

Derbyshire County 8.7 (6.8,11.1) 5.6 (4.1,7.6)* 6.3 (4.7,8.4)

Doncaster 8.4 (5.8,12.1) 9.2 (6.5,12.9) 8.0 (5.6,11.5)

E Riding of Yorkshire 6.9 (3.9,12.1) 6.6 (4.2,10.3) 7.1 (4.7,10.8)

Hull Teaching 9.3 (5.8,14.8) 8.7 (6.0,12.6) 9.9 (7.1,13.8)

Kirklees 10.0 (7.1,14.2) 10.1 (7.7,13.2) 8.8 (6.7,11.6)

Leeds 7.7 (5.6,10.6) 10.2 (8.3,12.6) 9.1 (7.3,11.3)

Leicester City 12.2 (9.4,15.9)† 10.2 (7.7,13.6) 13.2 (10.3,16.9)†

Leics County & Rutland 6.9 (5.2,9.2) 8.8 (6.9,11.3) 8.5 (6.6,10.9)

Lincolnshire 9.2 (7.1,11.8) 7.7 (5.9,10.1) 7.3 (5.5,9.6)

North East Lincolnshire 7.3 (4.3,12.3) 8.2 (5.0,13.4) 8.2 (5.0,13.4)

North Lincolnshire 10.1 (6.3,16.2) 8.0 (4.7,13.5) 4.9 (2.5,9.4)

North Yorkshire & York 6.7 (4.7,9.6) 7.2 (5.5,9.4) 6.9 (5.3,9.0)

Northamptonshire 8.3 (6.5,10.6) 6.6 (5.0,8.7) 8.9 (7.1,11.1)

Nottingham City 8.5 (5.9,12.2) 10.1 (7.3,13.9) 8.4 (6.0,11.8)

Notts County 5.3 (3.8,7.3)* 6.2 (4.6,8.4) 7.9 (6.1,10.2)

Rotherham 8.5 (5.7,12.6) 9.2 (6.3,13.4) 9.0 (6.2,13.1)

Sheffield 8.2 (6.2,10.8) 9.1 (7.0,11.8) 7.7 (5.8,10.2)

Wakefield District 9.4 (6.1,14.5) 11.0 (8.1,15.0) 7.6 (5.3,10.9)

Total 8.5 (7.9,9.1) 8.6 (8.1,9.2) 8.5 (8.0,9.1)

† Significantly higher than overall average

* Significantly lower than overall average


Table 2b: Neonatal mortality rates and 95% C.I. for PCTs (ONS: VS1)

PCT 2004 2005 2006

Barnsley 4.7 (2.7,8.3) 1.2 (0.4,3.7) 2.5 (1.2,5.2)

Bassetlaw 6.2 (3.0,13.0) 2.7 (0.9,8.4) 4.3 (1.8,10.3)

Bradford and Airedale 3.3 (2.0,5.5) 5.0 (3.7,6.8) 5.2 (3.8,7.0)

Calderdale 4.1 (1.8,9.2) 3.2 (1.6,6.4) 3.6 (1.9,6.9)

Derby City 3.7 (2.0,6.7) 3.0 (1.6,5.8) 1.8 (0.8,4.0)

Derbyshire County 4.1 (2.9,5.9) 2.8 (1.8,4.3) 3.2 (2.1,4.8)

Doncaster 3.5 (2.0,6.2) 5.1 (3.2,8.1) 5.8 (3.8,8.9)

E Riding Of Yorkshire 3.3 (1.5,7.4) 2.4 (1.1,5.0) 2.0 (0.9,4.5)

Hull Teaching 1.9 (0.7,5.4) 3.4 (1.9,6.1) 5.1 (3.2,8.1)

Kirklees 5.6 (3.5,8.9) 5.1 (3.5,7.4) 4.7 (3.2,6.9)

Leeds 3.4 (2.1,5.5) 4.8 (3.5,6.5) 4.3 (3.1,5.9)

Leicester City 4.4 (2.8,6.8) 4.1 (2.6,6.4) 5.9 (4.1,8.5)

Leics County & Rutland 1.7 (1.0,3.0)* 4.0 (2.8,5.8) 4.1 (2.8,5.9)

Lincolnshire 4.0 (2.7,5.9) 4.0 (2.7,5.8) 3.9 (2.7,5.7)



North Yorkshire & York 2.8 (1.6,4.9) 3.3 (2.2,4.9) 3.1 (2.1,4.6)


Nottingham City 4.5 (2.8,7.3) 5.1 (3.3,8.0) 5.6 (3.7,8.5)

Notts County 2.6 (1.6,4.1) 3.0 (1.9,4.7) 3.6 (2.5,5.3)

Rotherham 6.5 (4.1,10.2) 4.5 (2.6,7.7) 3.0 (1.6,5.8)

Sheffield 4.2 (2.9,6.2) 2.8 (1.7,4.5) 4.3 (2.9,6.3)

Wakefield District 3.8 (1.9,7.5) 5.2 (3.3,8.2) 3.4 (2.0,5.9)

Total 3.7 (3.3,4.1) 3.8 (3.4,4.2) 4.0 (3.6,4.4)


Basic activity data for each PCT are summarised in Appendix 3. All babies identified

by the current survey criteria are included. Babies are sub-divided by gestation, by

year, and whether they died before discharge. The themes are as observed previously

with each PCT behaving in a remarkably similar fashion:

1. at and below 27 weeks gestation, numbers are low and mortality relatively high;

2. in most PCTs greatest activity takes place in babies between 28 and 32 weeks

gestation (note this pattern is not entirely uniform e.g. Leicester and

Northampton) and here survival is very good;

3. considerable activity is generated by more mature babies where significant

numbers of deaths still occur (e.g. Bradford).

In the more mature babies many of the deaths are related to congenital malformations.

In 2007 95 deaths occurred on neonatal units amongst infants more mature than 32

weeks gestation; of these, 39 had a lethal anomaly.


Table 3 indicates the number of ventilator days generated by each PCT. In order to

standardise the information, the figures represent the number of days ventilation per

1000 births in each PCT. Babies are allocated by the mother‟s birth address. To

prevent the figures from being affected by short-term natural variation, the numbers

shown are three year averages. Ventilation has been used frequently in the past by the

TNS team, and others, as a proxy for intensive care, as discussed in the introduction.

This table has shown some striking changes in recent years. The most striking feature

of the figures now is variation introduced by the new PCT split. For example see the

two Leicestershire PCTs where the difference approaches 50% (in fact one is

significantly high and one is significantly low). Cross boundary flows in recent years

have been limited and their impact on any particular PCT‟s figures has been small again

this year.

Table 3: Ventilation days per 1000 births (95% C.I.) by PCT as an average over 3 years

PCT 2003-2005 2004-2006 2005-2007

Barnsley 92 (75,112) 89 (72,109) 99 (81,122)

Bassetlaw 66 (47,92) 104 (76,142) 82 (61,109)

Bradford and Airedale 133 (119,148)† 122 (110,135)†

Calderdale 72 (57,92) 75 (60,93)

Derby City 79 (66,95) 101 (84,121) 93 (76,113)

Derbyshire County 100 (89,112) 100 (89,112) 91 (81,103)

Doncaster 68 (56,82)* 77 (65,92) 113 (96,133)†

E Riding Of Yorkshire 77 (62,96) 71 (59,86)*

Hull Teaching 98 (82,117) 95 (80,112)

Kirklees 116 (102,133)† 118 (105,133)†

Leeds 105 (95,117) 83 (75,92)

Leicester City 118 (103,135)† 120 (106,136)† 138 (123,155)†

Leics Co and Rutland 79 (70,89) 81 (72,92) 76 (68,85)*

Lincolnshire 68 (59,78)* 76 (66,87)* 79 (69,90)

North East Lincolnshire 109 (86,138) 81 (64,103) 84 (67,105)

North Lincolnshire 76 (57,101) 95 (73,124) 96 (74,124)

North Yorkshire & York 58 (51,66)* 58 (51,66)*

Northamptonshire 94 (84,106) 77 (68,87)* 68 (60,77)*

Nottingham City 99 (86,115) 118 (103,135)† 124 (109,142)†

Nottinghamshire County 85 (76,96) 81 (72,91) 85 (76,95)

Rotherham 105 (87,126) 103 (85,125) 101 (84,121)

Sheffield 87 (75,101) 99 (85,115) 102 (88,118)

Wakefield District 77 (65,91) 87 (75,102)

Total 89 (86,93) 93 (90,96) 92 (89,95)




Table 4 combines ventilation and CPAP and was introduced some years ago to explore

the extent to which changes in the use of ventilation have resulted in increased CPAP

use. More recently the range of methods of providing respiratory support has increased

steadily and these have blurred the differences between what we call traditional

ventilation and traditional CPAP. As a result there is confusion about whether non

invasive ventilation should be included as ventilation, CPAP or a separate category. In

practice subdividing the various types of respiratory support is very difficult to do

accurately and therefore this table showing overall respiratory support is perhaps the

most useful is assessing trends in respiratory management. Interestingly there is

relatively little variation here with most variation apparently the result of population

differences (eg the two Leicestershire PCTs provide the highest and third lowest rates

despite one service providing the bulk of the care to both sets of patients).

Table 4: Ventilation and CPAP days per 1000 births (95% C.I.) by PCT as an average over 3 years

PCT 2003-2005 2004-2006 2005-2007

Barnsley 218 (186,255) 220 (189,257) 238 (205,277)

Bassetlaw 201 (154,262) 258 (200,332) 205 (160,262)

Bradford and Airedale 269 (244,296)† 270 (246,296)†

Calderdale 160 (130,198)* 172 (143,207)*

Derby City 159 (137,184)* 231 (199,268) 214 (182,251)


Doncaster 222 (193,255) 249 (219,283) 325 (288,366)†

E Riding Of Yorkshire 275 (236,320) 263 (230,300)

Hull Teaching 287 (252,327)† 285 (252,323)†

Kirklees 259 (230,292) 286 (257,319)†

Leeds 253 (232,276) 207 (191,224)*

Leicester City 299 (266,336)† 314 (281,351)† 327 (295,363)†

Leics County & Rutland 220 (198,244) 199 (179,221)* 177 (160,196)*

Lincolnshire 177 (159,197)* 183 (165,203)* 196 (177,217)*



North Yorkshire & York 119 (107,133)* 122 (110,135)*

Northamptonshire 306 (280,334)† 275 (252,300)† 236 (217,257)

Nottingham City 229 (201,262) 261 (230,296) 291 (257,329)†

Nottinghamshire County 221 (199,245) 224 (202,248) 234 (212,258)

Rotherham 230 (198,267) 255 (219,297) 281 (244,323)†

Sheffield 224 (201,250) 249 (223,278) 265 (237,297)

Wakefield District 235 (204,271) 252 (222,287)

Total 232 (225,240) 236 (230,242) 236 (230,242)

* Significantly lower than regional average

† Significantly higher than regional average


We have included, as previously, data relating to antenatal steroid use (Table 5).

Originally this was examined, along with other factors, as a possible explanation for the

observed variation in ventilation and CPAP demand between PCTs. Although this was

shown clearly not to be an important factor in explaining this variation we have

continued to include the information since clinicians feel it is an important issue in its

own right.

Steroid use continues at very high levels and rates of usage remain stable across the

whole range of PCTs. None of the figures recorded for an individual PCT differ

significantly from the Regional average.

Steroid use is one of the most difficult items to collect for the Neonatal Survey. It is not

always recorded in the infant‟s notes, and similarly finding the information from the

mother‟s records can be both difficult and time consuming (the nurses who collect this

data prefer to use the mother‟s drug chart to confirm that it really was given). Despite

the high rate of usage identified we nonetheless anticipate that there will be an element

of under-recording in the rates of use we report. However, this of course only becomes

important where the rate drops below the level that those involved in perinatal care, at a

local level, feel is the acceptable limit. We would be most grateful for any further

feedback about this issue from local information sources, which, in the past, have

provided a useful means of validating our data.


Table 5: Percentage of babies ≤32 weeks gestation, receiving at least one dose of steroid prior to delivery, by PCT

2005 2006 2007

PCT % (95% C.I.) % (95% C.I.) % (95% C.I.)

Barnsley 95 (85,99) 98 (87,100) 90 (75,98)

Bassetlaw 100 (85,100) 88 (61,99) 76 (52,92)

Bradford and Airedale 92 (86,97) 87 (80,93) 86 (79,92)

Calderdale 79 (60,93) 82 (64,94) 87 (73,95)

Derby City 84 (69,94) 91 (79,97) 80 (64,91)


Doncaster 91 (80,97) 91 (81,97) 94 (86,98)

E Riding Of Yorkshire 90 (76,98) 89 (78,96) 86 (73,94)

Hull Teaching 92 (80,98) 76 (61,87) 84 (72,93)

Kirklees 89 (80,95) 91 (83,97) 84 (74,92)

Leeds 87 (79,93) 88 (81,94) 92 (85,96)

Leicester City 89 (80,96) 89 (80,96) 88 (78,94)

Leics County & Rutland 85 (75,92) 82 (71,91) 85 (75,93)

Lincolnshire 84 (76,91) 87 (78,94) 85 (76,91)



North Yorkshire & York 94 (87,98) 86 (77,93) 90 (82,96)

Northamptonshire 90 (82,95) 91 (84,96) 90 (82,95)

Nottingham City 85 (74,93) 86 (75,93) 87 (78,94)

Notts County 90 (84,95) 88 (80,94) 82 (74,88)

Rotherham 87 (76,94) 86 (73,95) 88 (78,95)

Sheffield 85 (76,92) 89 (81,94) 88 (80,94)

Wakefield District 77 (65,88) 88 (77,95) 94 (83,99)

Total 88 (86,90) 88 (86,90) 88 (86,90)


The impact of babies born at or before 24 weeks gestation on the overall demand for

neonatal intensive care is shown in the next set of tables.

Table 6 has data on the numbers of babies at this gestation entering neonatal units and

the amount of intensive care being used to support them. The pattern this year, perhaps

because of the change in the way we are reporting the data, is a little different. Whilst

the number of babies being admitted continues to increase, the days on intensive care

fell back a little. However the number of days‟ intensive care per baby for the period

2005-2007 is around double the equivalent figure for 1998-2000.

Table 6: Intensive care days used in babies ≤24 weeks gestation by PCT as an average over 3 years (number of babies)

PCT 2003-2005 2004-2006 2005-2007

Barnsley 6 (5) 2 (4) 0 (1)

Bassetlaw 0 (1) 25 (1) 25 (1)

Bradford and Airedale 247 (19) 334 (28)

Calderdale 89 (5) 112 (5)

Derby City 27 (6) 52 (5) 60 (7)

Derbyshire County 156 (16) 153 (16) 104 (15)

Doncaster 102 (9) 90 (13) 87 (12)

E Riding Of Yorkshire 69 (6) 100 (6)

Hull Teaching 185 (9) 118 (7)

Kirklees 96 (10) 100 (11)

Leeds 168 (13) 123 (15)

Leicester City 225 (12) 152 (10) 96 (10)

Leics County & Rutland 204 (8) 270 (13) 166 (11)

Lincolnshire 183 (16) 227 (18) 220 (17)

North East Lincolnshire 28 (4) 31 (2) 30 (3)

North Lincolnshire 30 (2) 56 (5) 56 (5)

North Yorkshire & York 65 (9) 55 (13)

Northamptonshire 233 (26) 254 (22) 236 (17)

Nottingham City 111 (14) 135 (14) 258 (21)

Nottinghamshire County 201 (22) 270 (24) 312 (25)

Rotherham 119 (11) 111 (10) 146 (12)

Sheffield 305 (17) 361 (22) 254 (21)

Wakefield District 120 (10) 69 (9)

Total 1932 (170) 3228 (260) 3063 (272)


Table 6a supplements the data in the previous table (Table 6) and shows the rate at

which these babies were generated by each of the PCTs. The lack of CEMACH data

prevents us from providing the equivalent figure for those who died on labour ward but

even without this information one particular anomaly is very clear. The rate of

admission between PCTs, at the extremes, shows massive variation (19 fold). We know

from previous data that this does not simply reflect different attitudes but also different

rates of delivery at this gestation. The reason for this underlying difference is not

understood.

Table 6a: Rate of admission 24 weeks gestation (95% C.I.) per 1000 births by PCT (shown as 3-year averages)

PCT 2003-2005 2004-2006 2005-2007

Barnsley 0.7 (0.3,1.7) 0.5 (0.2,1.3) 0.1 (0.0,0.7)

Bassetlaw 0.3 (0.0,2.1) 0.3 (0.0,2.1) 0.3 (0.0,2.1)

Bradford and Airedale 0.9 (0.6,1.4) 1.2 (0.8,1.7)

Calderdale 0.8 (0.3,1.9) 0.7 (0.3,1.7)

Derby City 0.7 (0.3,1.6) 0.5 (0.2,1.2) 0.7 (0.3,1.5)


Doncaster 1.0 (0.5,1.9) 1.3 (0.8,2.2) 1.2 (0.7,2.1)

E Riding Of Yorkshire 0.8 (0.4,1.8) 0.7 (0.3,1.6)

Hull Teaching 1.0 (0.5,1.9) 0.7 (0.3,1.5)

Kirklees 0.8 (0.4,1.4) 0.7 (0.4,1.2)

Leeds 0.6 (0.4,1.0) 0.6 (0.4,1.0)

Leicester City 0.9 (0.5,1.6) 0.7 (0.4,1.3) 0.7 (0.4,1.3)


Lincolnshire 0.9 (0.6,1.4) 0.9 (0.6,1.4) 0.8 (0.5,1.3)



North Yorkshire & York 0.5 (0.3,1.0) 0.6 (0.3,1.0)


Nottingham City 1.3 (0.8,2.2) 1.3 (0.8,2.2) 1.9 (1.3,2.9)†

Nottinghamshire County 1.1 (0.7,1.7) 1.2 (0.8,1.8) 1.2 (0.8,1.8)

Rotherham 1.3 (0.7,2.3) 1.1 (0.6,2.0) 1.3 (0.7,2.3)

Sheffield 0.9 (0.6,1.4) 1.2 (0.8,1.8) 1.1 (0.7,1.7)

Wakefield District 1.3 (0.7,2.3) 1.0 (0.6,1.8)

Total 0.9 (0.8,1.0) 0.9 (0.8,1.0) 0.8 (0.7,0.9)



Table 7 describes the proportion of babies from each PCT 32 weeks gestation who

needed no active respiratory support (i.e. no ventilation or CPAP) after delivery. This

table shows much greater homogeneity than previously presumably because of greater

harmonisation of management strategies. However at the extremes there are quite major

differences for 2005-2007 unlike 2004-2006 where no PCT fell outside the 95% CIs for

the whole population.

Table 7: Percentage of deliveries ≤32 weeks gestation not receiving ventilation or CPAP, by PCT, (shown as 3 year averages)

2003-2005 2004-2006 2005-2007

PCT % (95% C.I.) % (95% C.I.) % (95% C.I.)

Barnsley 33.8 (26.2,42.1) 32.2 (24.6,40.5) 30.3 (22.9,38.5)

Bassetlaw 35.0 (23.1,48.4) 33.9 (22.3,47.0) 31.1 (19.9,44.3)

Bradford and Airedale 33.2 (28.3,38.2) 34.8 (30.4,39.5)†

Calderdale 33.8 (23.6,45.2) 36.4 (27.4,46.3)

Derby City 31.2 (24.3,38.7) 32.5 (25.4,40.3) 39.9 (31.8,48.4)†


Doncaster 26.6 (20.4,33.5) 24.9 (19.1,31.4) 22.7 (17.4,28.7)


Hull Teaching 20.9 (14.3,29.0) 22.3 (16.0,29.6)

Kirklees 32.5 (26.7,38.7) 27.0 (21.9,32.6)

Leeds 25.4 (21.0,30.3) 26.9 (22.7,31.5)

Leicester City 30.0 (23.9,36.7) 25.1 (19.7,31.2) 23.3 (18.2,28.9)

Leics County & Rutland 37.2 (31.6,42.9)† 35.3 (29.6,41.4) 32.2 (26.5,38.2)

Lincolnshire 31.2 (26.0,36.8) 30.0 (24.9,35.4) 29.2 (24.2,34.5)




Northamptonshire 22.0 (17.8,26.7)* 27.5 (22.9,32.4) 28.6 (24.1,33.5)

Nottingham City 34.8 (28.3,41.6) 29.8 (23.8,36.4) 27.7 (22.0,34.0)

Notts County 31.5 (26.8,36.4) 32.5 (27.8,37.4) 33.4 (28.8,38.3)

Rotherham 20.3 (14.3,27.4)* 25.2 (18.6,32.6) 28.4 (22.1,35.4)

Sheffield 26.4 (21.7,31.5) 24.1 (19.6,28.9) 22.0 (17.6,27.0)*


Total 29.8 (28.3,31.4) 29.3 (28.1,30.6) 29.0 (27.8,30.2)

* Significantly lower than regional average, † Significantly higher than regional average


The next 3 tables relate to “chronic lung disease”. Last year we changed the definition

of chronic lung disease we used for the report to: babies who are still oxygen and/or

ventilator dependent at 36 weeks corrected gestational age. The changing approach to

management of babies with RDS (reduced reliance on ventilation and increased use of

CPAP) led us to reconsider our use of the “ventilated population” as a suitable group in

which to examine trends in the incidence of chronic lung disease. As a result we are

again including a table with the rate of chronic lung disease amongst the whole

population of babies entering a neonatal unit between 25 and 32 weeks gestation.

Therefore the tables describing babies with chronic lung disease are:

the entire group less than or equal to 32 weeks gestation who required

ventilation and who were alive at 36 weeks of corrected age (Table 8).

the entire group of babies 25 to 32 weeks gestation who were alive at 36 weeks

of corrected age (Table 8a).

the entire group of babies 25 to 32 weeks gestation who required ventilation and

who were alive at 36 weeks of corrected age (Table 8b).

The initial trend, when these data were first added to the annual report during the

1990s, was for the crude rate of chronic lung disease to increase year on year,

particularly in the group of babies 25 to 32 weeks gestation. However these rates have

been very stable in recent years and this trend continued in 2007 with some suggestion

of a decline. Certainly we know from more detailed analyses of these figures that the

risk of a surviving baby now being affected by chronic lung disease is not increasing

and may indeed be falling compared to the late 1980s and early 1990s.


Table 8: Proportion of ventilated babies ≤32 weeks gestation developing chronic lung disease, by PCT (shown as 3 year averages)

2003-2005 2004-2006 2005-2007

PCT

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

Barnsley 49 24 (13,39) 45 29 (16,44) 47 38 (25,54)

Bassetlaw 20 30 (12,54) 22 41 (21,64) 25 24 (9,45)

Bradford and Airedale 167 28 (21,36) 197 26 (20,33)

Calderdale 35 31 (17,49) 46 26 (14,41)

Derby City 65 15 (8,26)* 61 25 (14,37) 41 34 (20,51)

Derbyshire County 143 30 (23,38) 145 30 (22,38) 141 29 (22,37)

Doncaster 60 33 (22,47) 65 28 (17,40) 81 35 (24,46)

E Riding Of Yorkshire 46 33 (20,48) 61 23 (13,35)

Hull Teaching 51 35 (22,50) 66 35 (24,48)

Kirklees 117 38 (30,48) 143 31 (24,40)

Leeds 157 39 (32,48) 170 31 (24,39)

Leicester City 89 35 (25,46) 118 32 (24,41) 145 31 (24,39)

Leics County & Rutland 127 32 (24,41) 116 28 (20,37) 120 22 (15,30)

Lincolnshire 91 35 (25,46) 86 29 (20,40) 99 32 (23,42)

North East Lincolnshire 36 44 (28,62) 37 30 (16,47) 35 31 (17,49)

North Lincolnshire 27 19 (6,38) 29 24 (10,44) 27 26 (11,46)

North Yorkshire & York 109 14 (8,22)* 127 18 (12,26)

Northamptonshire 146 33 (25,41) 133 39 (31,48) 133 33 (25,42)

Nottingham City 88 24 (15,34) 97 21 (13,30) 113 20 (13,29)

Notts County 162 23 (17,31) 157 22 (15,29) 156 24 (18,32)

Rotherham 62 24 (14,37) 61 30 (19,43) 67 31 (21,44)

Sheffield 95 34 (24,44) 96 32 (23,43) 106 32 (23,42)

Wakefield District 78 21 (12,31) 91 23 (15,33)

Total 1260 29 (27,32) 2028 30 (28,32) 2237 28 (26,30)

* Significantly lower than regional average,


Table 8a: Proportion of ventilated babies 25-32 weeks gestation developing chronic lung disease, by PCT (shown as 3 year averages)

2003-2005 2004-2006 2005-2007

PCT

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

Barnsley 49 24 (13,39) 45 29 (16,44) 47 38 (25,54)

Bassetlaw 20 30 (12,54) 21 38 (18,62) 24 21 (7,42)


Calderdale 31 26 (12,45) 42 19 (9,34)

Derby City 64 16 (8,27) 59 24 (14,37) 39 33 (19,50)


Doncaster 58 33 (21,46) 64 28 (18,41) 78 35 (24,46)


Hull Teaching 50 34 (21,49) 64 33 (22,46)

Kirklees 114 37 (28,46) 140 31 (23,39)

Leeds 151 37 (29,45) 166 30 (23,38)

Leicester City 84 32 (22,43) 114 32 (23,41) 140 31 (23,39)


Lincolnshire 84 32 (22,43) 79 25 (16,36) 93 29 (20,39)





Nottingham City 85 21 (13,31) 95 19 (12,28) 107 19 (12,27)

Notts County 154 21 (15,28) 149 18 (12,25)* 147 20 (14,27)

Rotherham 57 19 (10,32) 56 25 (14,38) 61 28 (17,41)

Sheffield 89 29 (20,40) 90 28 (19,38) 103 30 (21,40)


Total 1151 28 (26,31) 1939 28 (26,30) 2142 26 (24,28)



Table 8b: Proportion of babies 25-32 weeks gestation developing chronic lung disease, by PCT (shown as 3-year averages)

2003-2005 2004-2006 2005-2007

PCT

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

No

. o

f

ve

nt.

ba

bie

s % (95%

C.I.)

Barnsley 134 9 (5,15) 129 10 (5,17) 133 14 (8,21)

Bassetlaw 56 11 (4,22) 57 14 (6,26) 57 9 (3,19)


Calderdale 67 12 (5,22) 94 9 (4,16)

Derby City 153 7 (3,12) 149 9 (5,15) 127 10 (6,17)


Doncaster 167 16 (10,22) 175 14 (9,20) 202 16 (11,22)


Hull Teaching 115 16 (10,24) 143 16 (10,23)

Kirklees 222 19 (14,25) 249 18 (13,23)

Leeds 312 18 (14,23) 364 14 (10,18)

Leicester City 181 15 (10,21) 208 17 (12,23) 233 19 (14,25)†


Lincolnshire 254 14 (10,19) 259 10 (7,14) 281 12 (8,16)





Nottingham City 181 10 (6,16) 184 10 (6,16) 190 11 (7,16)

Notts County 326 10 (7,14) 331 9 (6,12) 344 9 (6,13)

Rotherham 127 10 (6,17) 135 10 (6,17) 165 10 (6,16)

Sheffield 296 10 (7,14) 302 11 (8,15) 279 14 (10,18)


Total 2947 12 (11,14) 4542 13 (12,14) 4905 12 (11,13)


Table 9 concentrates on normal babies of 35 weeks gestation or more, i.e. babies in

whom a normal outcome would be anticipated. The data relates to the number of

babies in this category that show signs of presumed hypoxic ischaemic encephalopathy

at or soon after birth. Mildly affected babies are not collected by the Survey, as their

signs are too subjective. Infants as a minimum criteria have to suffer fits whilst others,

more severely affected, will also require ventilation. Despite restricting data collection

to infants who have these signs and a supportive history, not all infants identified will

have suffered from hypoxic ischaemic encephalopathy. Previous detailed audits of our


data collected in this way suggest a false positive rate of about 10%. The data are

shown by PCT as 3-year averages.

Table 9: Rate of “neonatal encephalopathy” as an average over 3 years per 1000 live births, by PCT

PCT 2003-2005 2004-2006 2005-2007

Barnsley 1.6 (0.9,2.8) 1.3 (0.7,2.4) 1.1 (0.6,2.1)

Bassetlaw 1.5 (0.6,3.6) 1.5 (0.6,3.6) 1.7 (0.8,3.8)


Calderdale 0.9 (0.4,2.0) 0.8 (0.4,1.8)

Derby City 1.0 (0.5,1.9) 0.9 (0.5,1.8) 1.0 (0.5,1.9)


Doncaster 1.8 (1.1,2.9) 2.0 (1.3,3.1) 2.0 (1.3,3.0)


Hull Teaching 2.3 (1.5,3.6)† 2.2 (1.4,3.3)†

Kirklees 0.9 (0.5,1.6) 1.3 (0.9,2.0)

Leeds 2.1 (1.6,2.8)† 2.0 (1.5,2.6)†

Leicester City 1.5 (1.0,2.3) 1.0 (0.6,1.7) 1.1 (0.7,1.8)


Lincolnshire 0.8 (0.5,1.3) 0.8 (0.5,1.3) 1.2 (0.8,1.8)





Nottingham City 2.1 (1.4,3.2)† 1.7 (1.1,2.7) 1.5 (0.9,2.4)

Notts County 1.3 (0.9,1.9) 1.1 (0.7,1.6) 1.1 (0.7,1.7)

Rotherham 1.1 (0.6,2.0) 1.4 (0.8,2.5) 1.5 (0.9,2.6)

Sheffield 0.7 (0.4,1.2) 0.4 (0.2,0.8)* 0.3 (0.1,0.7)*


Total 1.2 (1.1,1.4) 1.2 (1.1,1.3) 1.2 (1.1,1.3)

* Significantly lower than regional average, † Significantly higher than regional average

The “Regional Rate” appears stable however, as previously, there is still a great deal of

variation with almost adjacent PCTs showing now five fold differences. In addition

there are some quite major changes over time within particular PCTs.


Table 10 appeared for the first time in 2005 and shows rates of surgery for necrotising

enterocolitis (NEC). We have chosen this severe form of NEC in order to avoid

problems regarding diagnosis. Because of low numbers the use of 3 year averages is

important in removing some of the random swings seen when small numbers are

involved. Some interesting variation is seen and some significant differences. Before

drawing conclusions about high and low rates it would probably be sensible to correct

the rates for overall disease severity (as this may accentuate differences) and to consider

how policies regarding surgical management of NEC vary between centres. However

this would need more work. We would be grateful for feedback about whether such an

analysis would be helpful or indeed other comments on these data.

Table 10: Percentage of neonatal unit admissions ≤32 weeks gestation requiring surgery for necrotising enterocolitis, as an average over 3 years by PCT

PCT 2003-2005 2004-2006 2005-2007

Barnsley 1.4 (0.2,4.9) 0.7 (0.0,3.8) 0.7 (0.0,3.9)

Bassetlaw 1.7 (0.0,8.9) 1.6 (0.0,8.7) 1.6 (0.0,8.8)


Calderdale 5.0 (1.4,12.3) 4.7 (1.5,10.6)

Derby City 2.4 (0.6,5.9) 1.8 (0.4,5.3) 0.0 (0.0,2.5)


Doncaster 1.1 (0.1,3.8) 2.0 (0.5,4.9) 2.2 (0.7,5.0)

East Riding Of Yorkshire

3.1 (0.9,7.8) 3.2 (1.0,7.2)

Hull Teaching 7.8 (3.8,13.8)† 8.3 (4.5,13.7)†

Kirklees 1.2 (0.2,3.5) 2.5 (1.0,5.1)

Leeds 1.7 (0.6,3.6) 2.2 (1.0,4.1)

Leicester City 3.3 (1.4,6.7) 3.8 (1.8,7.1) 3.9 (1.9,7.0)


Lincolnshire 1.7 (0.5,3.9) 1.3 (0.4,3.3) 2.2 (0.9,4.5)





Nottingham City 1.0 (0.1,3.4) 3.2 (1.3,6.5) 5.6 (3.0,9.4)†

Nottinghamshire County 1.6 (0.6,3.5) 1.1 (0.3,2.7) 1.5 (0.6,3.3)

Rotherham 3.2 (1.0,7.2) 3.1 (1.0,7.2) 2.6 (0.9,6.0)

Sheffield 2.7 (1.3,5.1) 3.8 (2.0,6.4) 4.0 (2.2,6.8)


Total 1.9 (1.4,2.4) 2.2 (1.9,2.7) 2.4 (2.0,2.9)



For many years we did not collect data about the routine head scans performed on

premature babies. Although such scans have, for a long time, been part of normal

management in most, if not all, neonatal units, there was little standardisation of when

the scans were performed and how they were reported. As a result extracting such

information posed serious challenges if the data we obtained were to be both reliable

and useful. A number of developments led us to confront these issues and in 2002 we

started collecting data about head scan findings in babies 32 weeks gestation. We

have been influenced by a number of trials which have collected these data and as a

result simplified the information we seek to the following:

Did the baby have at least one head scan? (Table 11a)

What was the worst haemorrhage ever noted in this baby (sub divided left and right

with grades one and two combined and grades three and four combined (Table 11b)

What proportion of babies ≤32 weeks showed evidence of damage to the white

matter (periventricular leucomalacia PVL) (Table 11c)

Some interesting variation is noted but the underlying differences in both population

and the approach to classification makes the precise interpretation of these data difficult.

This variation represents an excellent opportunity for centres to audit each other‟s

practice in this regard by seeking additional (blinded) reports in a second (and even a

third) hospital.


Table 11a: Percentage of babies 32 weeks gestation undergoing an ultrasound scan of the head: 2005-2007 by PCT

PCT Total No. scanned %

Barnsley 142 121 85

Bassetlaw 61 38 62

Bradford and Airedale 443 327 74

Calderdale 107 78 73

Derby City 143 99 69

Derbyshire County 389 270 69

Doncaster 230 183 80

East Riding Of Yorkshire 158 95 60

Hull Teaching 157 120 76

Kirklees 278 162 58

Leeds 412 305 74

Leicester City 258 171 66

Leics County and Rutland 258 159 62

Lincolnshire 319 216 68

North East Lincolnshire 98 81 83

North Lincolnshire 82 63 77

North Yorkshire and York 304 206 68

Northamptonshire 377 321 85

Nottingham City 232 194 84

Nottinghamshire County 393 292 74

Rotherham 190 151 79

Sheffield 322 310 96

Wakefield District 183 138 75

Total 5536 4100 74


Table 11b: Highest level of IVH recorded in babies undergoing ultrasound scan of the head 2005-2007 (neonatal unit admissions ≤32 weeks gestation) by PCT

PCT Total None (%) Grade I or II

(%) Grade III or IV

(%)

Barnsley 121 92 76 19 16 10 8

Bassetlaw 38 32 84 3 8 3 8

Bradford and Airedale Teaching 327 264 81 46 14 17 5

Calderdale 78 68 87 6 8 4 5

Derby City 99 86 87 9 9 4 4

Derbyshire County 270 230 85 21 8 19 7

Doncaster 183 149 81 23 13 11 6

East Riding Of Yorkshire 95 82 86 9 9 4 4

Hull Teaching 120 107 89 8 7 5 4

Kirklees 162 128 79 20 12 14 9

Leeds 305 224 73 58 19 23 8

Leicester City 171 141 82 17 10 13 8

Leics County and Rutland 159 133 84 18 11 8 5

Lincolnshire 216 175 81 23 11 18 8

North East Lincolnshire 81 71 88 5 6 5 6

North Lincolnshire 63 47 75 10 16 6 10

North Yorkshire and York 206 152 74 45 22 9 4

Northamptonshire 321 277 86 27 8 17 5

Nottingham City 194 164 85 14 7 16 8

Nottinghamshire County 292 258 88 20 7 14 5

Rotherham 151 126 83 13 9 12 8

Sheffield 310 244 79 34 11 32 10

Wakefield District 138 100 72 30 22 8 6

Total 4100 3350 82 478 12 272 7


Table 11c: Number and percentage of babies ≤32 weeks gestation undergoing ultrasound scan of the head noted to have periventricular leucomalacia (PVL), 2005-2007

PCT Total PVL %

Barnsley 121 3 2

Bassetlaw 38 2 5

Bradford and Airedale Teaching 327 11 3

Calderdale 78 3 4

Derby City 99 3 3

Derbyshire County 270 14 5

Doncaster 183 4 2

East Riding Of Yorkshire 95 3 3

Hull Teaching 120 2 2

Kirklees 162 4 2

Leeds 305 11 4

Leicester City 171 22 13

Leics County and Rutland 159 20 13

Lincolnshire 216 11 5

North East Lincolnshire 81 1 1

North Lincolnshire 63 1 2

North Yorkshire and York 206 9 4

Northamptonshire 321 2 1


Nottinghamshire County 292 25 9

Rotherham 151 8 5

Sheffield 310 17 5

Wakefield District 138 6 4

Total 4100 208 5

The next set of figures relate to the subject of transfers. These data are difficult to

obtain especially when transfers occur to or from units outside the area we now cover.

Therefore we are always happy to receive feedback in relation to these data, especially

if there appear to be obvious anomalies.

Last year we made two important changes in the presentation of these data:

Our previous definition of inappropriate transfers had been based on the

definition in the first CSAG report [1] relating to neonatal intensive care. This

stated that transfers were inappropriate if:

1. infants travelled beyond their nearest referral centre (or centres if they were

more or less equidistant);

2. tertiary centres transferred out their own infants for non clinical reasons (ie

to get care that should have been available locally).


In 2006 the definition changed to a transfer outside the local network for non clinical

reasons (ie to get care that should have been available within the network). It is

important to remember that in choosing to analyse the data in this way we are assuming

that all in Network transfers are satisfactory and of course this may not always be true.

If the definition of inappropriate transfer were refined by Network teams (eg perhaps to

include movements of babies over excessive distances) it would be possible to provide

the additional information.

In keeping with the change to our other population based tables in 2006 we switched to

using the new PCTs as the descriptive denominator.

This year we have made the additional change of combining the two datasets previous

reported in the different sections of the report. If anyone is particularly keen to have the

relevant total activity for either the old “Trent” region or Yorkshire then we could

provide this.

The Neonatal Survey area – East Midlands and Yorkshire health regions

Total number of babies involved in transfer during 2007: 1182

Total number of transfer journeys during 2007: 1829

(mean journeys per baby: 1.5; maximum number of journeys by any baby: 6)

Total number of in utero transfers (IUTs): 363

Total number of flying squad transfers (FSTs): 472

The second CSAG review of neonatal intensive care [2], published at the end of 1996,

recommended that the rate of inappropriate transfers should be monitored as a measure

of quality. It was recommended that these inappropriate transfers did not exceed 10% of

the total transfers. The 10% figure was chosen arbitrarily as a reasonable target.

During discussion at the 1996 education day a figure of 1 inappropriate transfer per

1000 births was agreed as an acceptable standard for a population that was perhaps

more easily measured and monitored. We have continued to show the data in this format

however we appreciate that the neonatal review of 2003 recommended a “network

standard” of 95% on babies born in a network receiving their care in the network (Table

12). Because of our present difficulty in obtaining precise information about network

boundaries defined by post code we cannot supply these data with confidence. However

we have provided later in the report a number of tables based on the networks which

should be considered exploratory. One of these looks specifically at the number of

babies receiving care outside of the network and hence should be helpful in giving

further insight into the self sufficiency of individual networks. We hope by next year to

be able to provide separate information about transfers out of networks as opposed to

where care appears to take place outside the network boundary because of choice.

Clearly in the face of so much change we would be particularly interested in any

comments or queries regarding apparent anomalies.


Table 12: Transfer activity during 2007

PCT No. of babies

involved in

transfer

No. of journeys

No. of urgent

post natal transfers

(flying squad)

No. of in utero

transfers

No. of babies inappropriately

transferred

Rate of babies inappropriately transferred per

1000 births (95% CI)

Barnsley 31 51 8 12 11 4.0 (2.2,7.2)

Bassetlaw 23 35 9 4 9 7.8 (4.1,15.0)

Bradford and Airedale

121 198 49 38 70 8.6 (6.8,10.9)†

Calderdale 42 66 10 16 10 4.0 (2.2,7.4)

Derby City 12 17 8 . 1 0.3 (0.0,2.1)*

Derbyshire County

41 56 16 16 13 1.7 (1.0,2.9)*

Doncaster 44 75 25 10 16 4.4 (2.7,7.2)

East Riding Of Yorkshire

38 56 7 16 20 6.5 (4.2,10.1)

Hull Teaching 29 43 1 18 30 8.6 (6.0,12.3)†

Kirklees 86 139 30 27 50 9.0 (6.8,11.9)†

Leeds 86 107 42 16 22 2.4 (1.6,3.6)

Leicester City 102 158 38 15 6 1.3 (0.6,2.9)*

Leics County and Rutland

99 135 33 17 16 2.3 (1.4,3.8)

Lincolnshire 75 141 43 41 24 3.5 (2.3,5.2)

North East Lincolnshire

12 22 10 3 9 4.6 (2.4,8.8)

North Lincolnshire

11 18 5 5 4 2.2 (0.8,5.9)

North Yorkshire and York

95 153 38 28 30 3.9 (2.7,5.6)

Northants 48 68 18 11 8 0.9 (0.5,1.8)*

Nottingham City 29 43 13 9 12 3.1 (1.8,5.5)

Nottinghamshire County

55 91 26 23 29 4.1 (2.8,5.9)

Rotherham 35 55 16 12 9 3.0 (1.6,5.8)

Sheffield 23 33 9 12 19 3.0 (1.9,4.7)

Wakefield District

45 69 18 14 17 4.5 (2.8,7.2)

Total 1182 1829 472 363 435 3.8 (3.5,4.2)



Table 13 shows the numbers of babies treated for neonatal abstinence syndrome by each

PCT in the Yorkshire Neonatal Network (YNN) only. Case ascertainment is considered

accurate as practice in units in the YNN is that treatment is always started either on


neonatal units alone and/or transitional care units. The YNN research nurses collected

data from both sites for this survey. We cannot rule out an element of underreporting. It

has proved difficult to identify the total number of babies exposed to substance misuse

in pregnancy. We present the rate for treated babies per 1000 births. Research data

suggests that approximately 40% of babies exposed to substance misuse in pregnancy

require treatment. A report from the Northern & Yorkshire Public Health Observatory

in 2002 identified a rate of substance misuse in pregnancy of approximately 9.3/1000

pregnancies. The YNN will examine this data in further detail over the coming years.

Table 13: Rate per 1000 live births of babies treated for withdrawal from maternal drug dependency, by PCT, as an average over 3 years (Yorkshire Neonatal Network only)

2004-2006 2005-2007

PCT Rate of admission per 1000

births

95% CI Rate of admission per 1000

births

95% CI


Calderdale 1.5 (0.8,2.8) 1.9 (1.1,3.2)

East Riding Of Yorkshire 0.7 (0.3,1.7)* 0.6 (0.2,1.4)*

Hull 5.4 (4.0,7.2)† 4.3 (3.2,5.8)†

Kirklees 1.5 (1.0,2.3) 1.3 (0.9,2.0)

Leeds 2.6 (2.0,3.3) 2.3 (1.8,3.0)

North Yorkshire and York 0.5 (0.3,0.9)* 0.6 (0.4,1.0)*


YNN 2.2 (1.9,2.5) 1.9 (1.7,2.2)

* Significantly lower than regional average † Significantly higher than regional average


Mortality/disease severity/CRIB data

Premature babies, even those of the same gestation, differ enormously in terms of their

potential to survive. Comparing mortality rates of individual neonatal units is therefore

fraught with difficulty. To help overcome this problem, a group originally based in

Dundee developed a disease severity scoring system for babies born at or before 32

weeks gestation [3]. It was based on birth weight, gestation, oxygen requirement in the

first 12 hours, whether the baby developed an acidosis, and whether the baby had a

congenital abnormality. The system (CRIB) has been extensively validated. To be

“abnormal”, the actual mortality rate for a particular hospital or Health District had to

lie outside the confidence intervals of the estimated mortality rate derived from CRIB.

In response to criticism that the system was out of date and inaccurate at the lowest

gestations the group produced a new version of the scoring system – CRIB II. [4]. This

new score comprises a weighting based on gestation and weight at birth, temperature on

admission and maximum base excess within one hour of admission. Data about

temperature on admission is needed in order to perform the full correction for disease

severity and this was added to the TNS data set from 2004. However, temperature at

admission is influenced by early neonatal care and therefore, it can be argued, it is

unsuitable for use in risk-adjusting. Our impression was that the CRIB II without

temperature (CRIB –T) adjusts as well as the full score and we have used this reduced

version of the score since 2004.

Data are shown as a mortality ratio (with confidence intervals) in which the outcome in

an individual unit / population is compared to the remainder of the population. This

year, in addition to the usual tables, the information on in-unit mortality is also

presented using funnel plots [5]. In the plots the estimated mortality ratio for each unit

is plotted against its expected number of deaths. As in the tables, a value for the

mortality ratio greater than 1 represents an observed number of deaths greater than the

expected number and a value less than 1 represents an observed number of deaths less

than the expected number.

For each set of babies two funnel plots are shown. The first of these shows the

mortality ratios unadjusted for disease severity. Here the ratio is calculated by dividing

the observed number of deaths by the number expected if the unit had the same overall

mortality rate as the rest of the area. The second plots shows the CRIB II –T adjusted

mortality ratios: the observed number of deaths divided by the number expected if the

unit had the same mortality rates as the rest of the area for babies with the same CRIB II

–T score. It can be seen from the plots that once disease severity is taken into account

the mortality ratios are usually less extreme.

On the plots 95% and 99.8% control limits are also drawn for reference. These lines fall

approximately two and three standard deviations respectively from the average and can

be used to assess statistical significance of any extreme observations.

Although the estimated adjusted mortality ratios are the same in the plots as in the

tables, the statistical assumptions and methods used to estimate the confidence intervals

are different and so the intervals are not the same.


It is felt that these plots may offer an easily interpretable picture of in-unit mortality.

For each cohort, plots for both the unadjusted and adjusted outcomes are given,

allowing the effect of risk-adjustment to be seen. We are interested in receiving

feedback on the usefulness of these plots.

On each plot particular PCTs or hospitals are shown by a number. The key to the

numbers used throughout are shown below:

Legend for PCT Funnel Plot Codes

Code PCT

1 Barnsley

2 Bassetlaw

3 Bradford and Airedale Teaching

4 Calderdale

5 Derby City

6 Derbyshire County

7 Doncaster

8 East Riding Of Yorkshire

9 Hull Teaching

10 Kirklees

11 Leeds

12 Leicester City

13 Leics County and Rutland

14 Lincolnshire

15 North East Lincolnshire

16 North Lincolnshire

17 North Yorkshire and York

18 Northamptonshire

19 Nottingham City

20 Nottinghamshire County

21 Rotherham

22 Sheffield

23 Wakefield District


Legend for Hospital Funnel Plot Codes

Code Hospital

1 Airedale DGH

2 Barnsley

3 Bassetlaw DGH

4 Boston Pilgrim

5 Bradford RI

6 Calderdale

7 Chesterfield & NDRH

8 Derby City General

9 Dewsbury DGH

10 Doncaster RI

11 Grimsby

12 Harrogate DGH

13 Huddersfield RI

14 Hull RI

15 Jessop

16 Kettering

17 Kings Mill

18 Leeds LGI

19 Leeds St James

20 Leicester GH

21 Leicester RI

22 Lincoln County

23 Northampton

24 Nottingham City

25 Pontefract DGH

26 QMC Nottingham

27 Rotherham DGH

28 Scarborough DGH

29 Scunthorpe

30 York

Historically we have always presented these data subdivided by large (referral units)

and small (non referral) units. Data have further been sub divided by whether infants

have been transferred. The pattern in for these data (see Table 14 and Table 15) has

shown some unusual trends in recent years. In 2007 the pattern shows that survival of

babies born <33 weeks and not transferred was better in small units. In babies <29

weeks of gestation no difference was seen. This pattern has been seen previously and its


re-emergence may reflect increasing centralisation of “sick” preterms although other

explanations are also possible. When comparing transfers and non transfers no

significant differences were seen.

Table 14: CRIB II-T data for 2007 - non-transfers

Total Actual deaths

Expected Deaths

Mortality ratio

(95% C.I.)

<33 weeks Large units 590 75 68.7 1.09 (1.00,1.19)†

<33 weeks Small units 597 25 31.3 0.80 (0.59,0.99)*

<29 weeks Large units 199 61 59.1 1.03 (0.94,1.14)

<29 weeks Small units 132 21 22.9 0.92 (0.65,1.16)

† Significantly higher than expected deaths

Table 15: CRIB II-T Transfers v non-transfers 2007

Total Actual deaths

Expected Deaths

Mortality ratio

(95% C.I.)

<33 weeks Transfers 651 82 83.0 0.99 (0.86,1.11)

<33 weeks Non-transfers 1187 100 99.0 1.01 (0.91,1.12)

<29 weeks Transfers 268 63 69.1 0.91 (0.79,1.03)

<29 weeks Non-transfers 331 82 75.9 1.08 (0.97,1.19)

In 1997 we started to include CRIB corrected mortality data for individual hospitals and

PCTs. The feedback we have received continues to indicate that individual units and

PCTs are keen to have these data and hence we are once again including the relevant

tables. At the end of this section we have included some exploratory tables based on

networks (Tables 19a and 19b). It is important to emphasise that at present these tables

are based on estimated rather than precise network populations. However at present all

show satisfactory survival. Feedback on any aspect of the presentation of the data would

be welcome.

The data are presented as 3-year averages as in the rest of the report but using mortality

ratios as described above. Using CRIB II –T the first tables relate to the whole

population of babies <33 weeks of gestation entering neonatal units. Table 16 shows the

data by PCT. Table 17 contains information from individual hospitals including

transfers when the bulk of intensive care took place in that unit. In Table 18 transfers

have been excluded.

Some significant variation is seen and in some cases the explanation seems clear (eg

low numbers, effect of transfers) however in other cases the explanation was not

apparent from the data available to The Survey. We are happy to collaborate with local

teams in carrying out additional reviews of these findings.


Table 16: CRIB II -T data for 2005-2007, by PCT, including transfers (20-32 weeks gestation)

PCT Actual deaths

Expected Deaths

Mortality ratio

(95% C.I.)

Barnsley 9 10.7 0.84 (0.38,1.33)

Bassetlaw 4 4.2 0.94 (0.17,1.88)

Bradford and Airedale 47 53.5 0.88 (0.68,1.07)

Calderdale 9 9.9 0.91 (0.42,1.54)

Derby City 14 14.5 0.97 (0.55,1.44)

Derbyshire County 33 35.6 0.93 (0.67,1.17)

Doncaster 21 26.3 0.80 (0.54,1.10)

East Riding Of Yorkshire 7 12.1 0.58 (0.23,0.94)*

Hull Teaching 15 15.9 0.95 (0.59,1.28)

Kirklees 28 23.4 1.20 (0.84,1.59)

Leeds 43 37.8 1.14 (0.91,1.40)

Leicester City 22 26.4 0.83 (0.51,1.18)

Leics County and Rutland 22 19.9 1.10 (0.74,1.46)

Lincolnshire 35 31.3 1.12 (0.83,1.44)

North East Lincolnshire 14 8.8 1.59 (0.94,2.48)

North Lincolnshire 12 11.3 1.07 (0.64,1.55)

North Yorkshire and York 32 25.8 1.24 (0.89,1.59)

Northamptonshire 32 35.8 0.89 (0.66,1.14)

Nottingham City 36 29.9 1.20 (0.92,1.51)

Nottinghamshire County 40 44.0 0.91 (0.69,1.14)

Rotherham 19 20.9 0.91 (0.58,1.27)

Sheffield 41 39.3 1.04 (0.82,1.27)

Wakefield District 21 18.8 1.11 (0.75,1.53)


Figure 2: Unadjusted mortality ratios 2005-2007 by PCT, including transfers (20-32 weeks gestation).

Figure 3: CRIB II -T adjusted mortality ratios 2005-2007 by PCT, including transfers (20-32 weeks gestation).


Table 17: CRIB II -T data for 2005-2007 by hospital, including transfers (20-32 weeks gestation)

Hospital Actual deaths

Expected Deaths

Mortality ratio

(95% C.I.)

Airedale DGH 4 6.3 0.64 (0.15,1.20)

Barnsley 1 4.8 0.21 (0.00,0.54)*

Bassetlaw DGH 0 0.3 0.00 (0.00,10.00)

Boston Pilgrim 1 1.5 0.68 (0.00,2.53)

Bradford RI 34 35.4 0.96 (0.69,1.23)

Calderdale 7 10.5 0.67 (0.24,1.12)

Chesterfield & NDRH 4 8.2 0.49 (0.11,1.00)*

Derby City General 27 25.1 1.07 (0.76,1.38)

Dewsbury DGH 11 11.4 0.96 (0.56,1.37)

Doncaster RI 4 8.8 0.45 (0.09,0.94)*

Grimsby 19 11.5 1.65 (1.13,2.20)†

Harrogate DGH 1 2.8 0.36 (0.00,0.78)*

Huddersfield RI 6 5.3 1.14 (0.41,1.92)

Hull RI 24 25.3 0.95 (0.65,1.25)

Jessop 102 84.4 1.21 (1.02,1.42)†

Kettering 9 9.4 0.96 (0.47,1.40)

Kings Mill 9 10.3 0.88 (0.42,1.42)

Leeds LGI 60 53.4 1.12 (0.88,1.40)

Leeds St James 45 34.2 1.32 (1.05,1.61)†

Leicester GH 2 8.4 0.24 (0.00,0.67)*

Leicester RI 54 43.9 1.23 (0.96,1.51)

Lincoln County 2 2.9 0.69 (0.00,1.92)

Northampton 11 18.6 0.59 (0.30,0.90)*

Nottingham City 57 51.4 1.11 (0.89,1.34)

Pontefract DGH 3 5.2 0.57 (0.00,1.21)

QMC Nottingham 39 48.4 0.81 (0.60,1.01)

Rotherham DGH 4 7.7 0.52 (0.12,0.87)*

Scarborough DGH 1 1.4 0.70 (0.00,1.78)

Scunthorpe 7 8.6 0.82 (0.36,1.27)

York 8 7.7 1.04 (0.46,1.68)

* Significantly lower than expected deaths † Significantly higher than expected deaths


Figure 4: Unadjusted mortality ratios 2005-2007 by hospital, including transfers (20-32 weeks gestation).

Figure 5: CRIB II -T adjusted mortality ratios 2005-2007 by hospital, including transfers (20-32 weeks gestation).


Table 18: CRIB II -T data for 2005-2007 by hospital: Non-transfers only (20-32 weeks gestation)


Expected Deaths

Mortality ratio

(95% C.I.)

Airedale DGH 4 4.3 0.93 (0.27,1.61)

Barnsley 1 3.9 0.26 (0.00,0.62)*

Bassetlaw DGH 0 0.2 0.00 (0.00,15.00)

Boston Pilgrim 1 0.6 1.58 (0.00,3.64)

Bradford RI 26 27.9 0.93 (0.67,1.22)

Calderdale 4 5.7 0.70 (0.17,1.25)

Chesterfield & NDRH 4 5.9 0.68 (0.15,1.36)


Dewsbury DGH 9 8.9 1.01 (0.59,1.53)

Doncaster RI 2 5.6 0.36 (0.00,0.95)*

Grimsby 18 11.0 1.64 (1.12,2.33)†

Harrogate DGH 1 1.1 0.94 (0.00,1.00)*

Huddersfield RI 5 4.3 1.16 (0.41,1.78)

Hull RI 16 20.8 0.77 (0.49,1.05)

Jessop 43 43.8 0.98 (0.78,1.21)

Kettering 7 7.2 0.97 (0.47,1.44)

Kings Mill 8 8.7 0.92 (0.42,1.52)

Leeds LGI 26 19.9 1.30 (0.95,1.73)

Leeds St James 20 14.3 1.39 (1.00,1.86)†

Leicester GH 2 1.3 1.58 (0.00,5.58)

Leicester RI 27 19.6 1.38 (0.97,1.83)

Lincoln County 2 2.4 0.82 (0.00,2.74)

Northampton 11 15.2 0.72 (0.41,1.03)

Nottingham City 34 29.8 1.14 (0.92,1.38)

Pontefract DGH 3 3.5 0.86 (0.00,1.77)

QMC Nottingham 26 30.3 0.86 (0.65,1.07)

Rotherham DGH 4 6.4 0.63 (0.19,1.00)

Scarborough DGH 1 0.5 1.86 (0.00,2.68)

Scunthorpe 6 8.7 0.69 (0.31,1.09)

York 8 5.8 1.38 (0.76,2.09)

* Significantly lower than expected deaths



Figure 6: Unadjusted mortality ratios 2005-2007 by hospital, non-transfers (20-32 weeks gestation).

Figure 7: CRIB II –T adjusted mortality ratios 2005 - 2007 by hospital, non-transfers (20-32 weeks gestation).


In 1999 we introduced three new tables 16a, 17a and 18a which are identical to tables

16, 17 and 18 except that infants 24 weeks gestation have been excluded. We took

this approach because we have been concerned about CRIB‟s ability to adjust

adequately for disease severity at very low gestations. Despite the introduction of CRIB

II –T we felt it sensible to include these tables in order that variations due to differences

in these very high risk infants are clear.

Although these tables are helpful in dealing with concerns that very immature infants

may distort the figures the smaller numbers of infants remaining widens the confidence

intervals and hence makes the figures more difficult to interpret. Nonetheless our

intention is to leave these Tables in the report in order that individual units and

Commissioners can use the data to identify the extent to which their death rates are

affected by the most immature babies.

Table 16a: CRIB II -T data for 2005-2007, by PCT, including transfers (25-32 weeks gestation).

PCT Actual deaths

Expected Deaths

Mortality ratio

(95% C.I.)

Barnsley 8 9.7 0.82 (0.37,1.39)

Bassetlaw 4 3.6 1.11 (0.28,2.08)

Bradford and Airedale 31 34.0 0.91 (0.64,1.19)

Calderdale 8 6.3 1.26 (0.53,2.09)

Derby City 9 10.1 0.89 (0.39,1.49)

Derbyshire County 23 27.2 0.84 (0.56,1.17)

Doncaster 14 18.7 0.75 (0.39,1.15)

East Riding Of Yorkshire 5 8.4 0.60 (0.16,1.06)

Hull Teaching 8 10.4 0.77 (0.29,1.27)

Kirklees 20 16.2 1.24 (0.74,1.78)

Leeds 32 27.3 1.17 (0.83,1.53)

Leicester City 17 20.1 0.85 (0.48,1.24)

Leics County and Rutland 14 12.8 1.10 (0.61,1.66)

Lincolnshire 23 20.1 1.15 (0.74,1.65)

North East Lincolnshire 12 6.9 1.75 (0.97,2.85)

North Lincolnshire 8 7.7 1.04 (0.46,1.70)

North Yorkshire and York 22 17.8 1.24 (0.79,1.78)

Northamptonshire 24 23.7 1.01 (0.68,1.35)

Nottingham City 20 17.1 1.17 (0.73,1.65)

Nottinghamshire County 23 25.7 0.89 (0.58,1.21)

Rotherham 13 13.4 0.97 (0.52,1.44)

Sheffield 23 25.5 0.90 (0.58,1.22)

Wakefield District 13 11.7 1.11 (0.58,1.65)


Figure 8: Unadjusted mortality ratios 2005-2007 by PCT, including transfers (25-32 weeks gestation).

Figure 9: CRIB II –T adjusted mortality ratios 2005-2007 by PCT, including transfers (25-32 weeks gestation).


Table 17a: CRIB II -T data for 2005-2007 by hospital, including transfers (25-32 weeks gestation).


Expected Deaths

Mortality ratio

(95% C.I.)

Airedale DGH 3 4.8 0.62 (0.00,1.28)

Barnsley 0 4.0 0.00 (0.00,0.75)*

Bassetlaw DGH 0 0.3 0.00 (0.00,10.00)

Boston Pilgrim 1 0.9 1.08 (0.00,2.94)

Bradford RI 22 19.9 1.10 (0.69,1.53)

Calderdale 6 9.0 0.67 (0.21,1.19)



Dewsbury DGH 5 6.3 0.80 (0.17,1.48)

Doncaster RI 4 8.8 0.46 (0.11,0.98)*

Grimsby 17 9.8 1.73 (1.17,2.44)†

Harrogate DGH 0 1.8 0.00 (0.00,1.67)

Huddersfield RI 4 4.2 0.96 (0.21,1.90)

Hull RI 16 16.9 0.95 (0.56,1.34)

Jessop 66 54.1 1.22 (0.97,1.51)

Kettering 7 7.8 0.89 (0.39,1.45)

Kings Mill 7 8.9 0.79 (0.28,1.38)

Leeds LGI 49 37.8 1.29 (0.99,1.68)

Leeds St James 31 22.6 1.37 (1.01,1.75)†

Leicester GH 2 8.3 0.24 (0.00,0.66)*

Leicester RI 39 26.9 1.45 (1.04,1.89)†

Lincoln County 2 2.9 0.69 (0.00,1.96)

Northampton 7 12.2 0.57 (0.19,0.96)*

Nottingham City 30 28.5 1.05 (0.75,1.39)

Pontefract DGH 1 3.3 0.30 (0.00,1.09)

QMC Nottingham 21 27.6 0.76 (0.48,1.08)

Rotherham DGH 2 5.2 0.39 (0.00,0.89)*

Scarborough DGH 1 1.4 0.70 (0.00,1.82)

Scunthorpe 4 6.2 0.64 (0.15,1.25)

York 4 4.4 0.91 (0.18,1.77)




Figure 10: Unadjusted mortality ratios 2005-2007 by hospital including transfers (25-32 weeks gestation).

Figure 11: CRIB II –T adjusted mortality ratios 2005-2007 by hospital, including transfers (25-32 weeks gestation).


Table 18a: CRIB II -T data for 2005-2007, by hospital: Non-transfers only (25-32 weeks gestation).


Expected Deaths

Mortality ratio

(95% C.I.)

Airedale DGH 3 3.5 0.85 (0.00,1.70)

Barnsley 0 2.9 0.00 (0.00,1.03)

Bassetlaw DGH 0 0.2 0.00 (0.00,15.00)

Boston Pilgrim 1 0.7 1.49 (0.00,3.64)

Bradford RI 16 14.8 1.08 (0.65,1.54)

Calderdale 3 4.0 0.75 (0.00,1.43)



Dewsbury DGH 4 3.8 1.06 (0.24,2.27)

Doncaster RI 2 5.5 0.37 (0.00,0.95)*

Grimsby 16 8.8 1.81 (1.14,2.60)†

Harrogate DGH 0 0.1 0.00 (0.00,30.00)

Huddersfield RI 3 2.9 1.03 (0.00,1.91)

Hull RI 9 13.8 0.65 (0.29,1.07)

Jessop 24 26.0 0.92 (0.62,1.29)

Kettering 5 5.4 0.93 (0.25,1.55)

Kings Mill 6 7.0 0.86 (0.28,1.61)

Leeds LGI 20 13.4 1.50 (1.00,2.14)†

Leeds St James 16 10.4 1.54 (1.02,2.16)†

Leicester GH 2 1.3 1.56 (0.00,4.57)

Leicester RI 18 9.3 1.93 (1.21,2.88)†

Lincoln County 2 2.4 0.83 (0.00,2.44)

Northampton 7 9.9 0.71 (0.27,1.18)

Nottingham City 18 16.3 1.11 (0.70,1.53)

Pontefract DGH 1 1.7 0.58 (0.00,1.80)

QMC Nottingham 11 15.8 0.69 (0.37,1.01)

Rotherham DGH 2 3.9 0.52 (0.00,1.04)

Scarborough DGH 1 0.5 1.91 (0.00,2.86)

Scunthorpe 3 6.0 0.50 (0.00,1.00)

York 4 3.4 1.18 (0.28,2.36)




Figure 12: Unadjusted mortality ratios 2005-2007 by hospital, non-transfers (25-32 weeks gestation).

Figure 13: CRIB II –T adjusted mortality ratios 2005-2007 by hospital, non-transfers (25-32 weeks gestation).

.


Table 19a: CRIB II -T data for 2005-2007 by network of intended place of delivery at booking, including transfers (20-32 weeks gestation)


Expected Deaths

Mortality ratio

(95% C.I.)

Central Newborn 24 22.6 1.06 (0.73,1.46)

North Trent 52 49.1 1.06 (0.82,1.33)

Trent Perinatal 42 45.2 0.93 (0.68,1.21)

Yorkshire 63 64.0 0.98 (0.76,1.25)

Table 19b: CRIB II -T data for 2005-2007 by network of intended place of delivery at booking, including transfers (25-32 weeks gestation)


Expected Deaths

Mortality ratio

(95% C.I.)

Central Newborn 18 16.5 1.09 (0.65,1.59)

North Trent 37 35.8 1.03 (0.73,1.47)

Trent Perinatal 24 28.9 0.83 (0.54,1.20)

Yorkshire 44 41.6 1.06 (0.72,1.45)


Unit based data

There are 30 hospitals with neonatal facilities in the area of the East Midlands and

Yorkshire covered by the survey. The services they each provide are organised as part

of a clinical network. Each network has agreed the type of service each neonatal unit

will provide. Neonatal surgery is available within each network but in Sheffield

neonatal surgery is provided by Sheffield Children‟s Hospital. In-patient activity at that

hospital is not included in the Neonatal Survey and this is also true for the small group

of term babies receiving neonatal surgery in the paediatric intensive care units around

the region.

In 2007 all of the neonatal units included in the Survey offered some level of neonatal

care to their inborn babies who met the inclusion criteria for the Survey. However the

nature of the care varied significantly. Therefore the units that make up the neonatal

service operate in very different ways and are difficult to compare. In addition, babies

involved in transfer (a high proportion of the intensive care population) will normally be

exposed to the influence of at least two hospitals. Therefore, the data that follows

should be considered with these differences in mind.

The figures in Appendix 4 demonstrate the pattern of activity within the various

hospitals. For each unit, total days intensive care level one (ITC), total days ventilation,

total days CPAP, and total days TPN are given for all babies cared for in the individual

units during 2007 (note: part days are rounded up to the nearest whole day). Two

graphs show, for the past six years, the mean duration of ventilation, and mean length of

stay for ventilated babies who were not involved in any transfer between units (and

hence spent their entire course in that particular hospital).

In order to gain a clearer picture of the “normal” length of stay, it is necessary to

exclude the small number of infants with a particularly prolonged stay on the unit,

perhaps because of severe chronic lung disease. On this occasion we have not included

details of such an analysis, but information obtained previously indicates that such

infants are responsible for most of the apparent variation between units.

The use of surfactant in ventilated infants is amongst the good practice statement issued

by the British Association for Perinatal Medicine in respect of the management of

respiratory distress syndrome in preterm infants. Table 20 shows the pattern of use by

the units covered by the Neonatal Survey (all ventilated infants are included even if they

were only ventilated briefly as a prelude to transfer). Given that some infants are

ventilated for reasons other than respiratory distress syndrome, it would be

unreasonable to expect 100% of babies to receive surfactant. This is especially true of

units where a significant numbers of babies are ventilated as a result of surgery. In

order to provide a clearer picture Table 21 includes only ventilated infants 32 weeks

gestation. Rates of use in this group are generally very high.


Table 20: Proportion of inborn ventilated babies who receive surfactant, by hospital

2005 2006 2007

Hospital % (95% C.I.) % (95% C.I.) % (95% C.I.)

Airedale DGH 80 (56,95) 72 (46,91) 88 (61,99)

Barnsley 71 (41,92) 67 (29,93) 74 (48,91)

Bassetlaw DGH 50 (1,99) 100 (2,100) 60 (14,95)

Boston Pilgrim 50 (6,94) 50 (11,89) 100 (2,100)

Bradford RI 82 (70,92) 83 (69,92) 83 (70,93)

Calderdale 91 (58,100) 82 (56,97) 73 (49,90)

Chesterfield & NDRH 87 (66,98) 75 (50,92) 83 (61,96)

Derby City General 82 (65,94) 64 (46,80) 94 (78,100)

Dewsbury DGH 68 (48,84) 81 (60,94) 82 (65,94)

Doncaster RI 76 (52,92) 89 (66,99) 81 (58,95)

Grimsby 76 (54,91) 81 (58,95) 70 (47,87)

Harrogate DGH 50 (11,89) 100 (2,100) 50 (1,99)

Huddersfield RI 77 (56,92) 77 (46,95) 79 (49,96)

Hull RI 73 (58,85) 69 (55,81) 65 (52,77)

Jessop 67 (53,79) 79 (67,88) 85 (74,93)

Kettering 83 (61,96) 76 (54,91) 76 (56,90)

Kings Mill 64 (40,83) 81 (58,95) 90 (72,98)

Leeds LGI 52 (40,64)* 61 (49,72) 55 (42,67)*

Leeds St James 70 (55,83) 74 (60,85) 79 (65,90)

Leicester GH 55 (35,74) 60 (14,95) 64 (30,90)

Leicester RI 59 (47,71) 52 (39,65)* 51 (40,63)*

Lincoln County 80 (44,98) 75 (34,97) 56 (21,87)

Northampton 87 (69,97) 88 (73,96) 63 (43,79)

Nottingham City 75 (64,85) 70 (59,80) 85 (74,93)

Pontefract DGH 78 (52,94) 88 (61,99) 74 (51,90)

QMC Nottingham 59 (47,70) 61 (49,72) 54 (41,66)*

Rotherham DGH 94 (71,100) 63 (24,92) 71 (47,89)

Scarborough DGH 67 (9,100) 50 (1,99) 100 (39,100)

Scunthorpe 54 (25,81) 65 (38,86) 88 (47,100)

York 85 (66,96) 81 (63,93) 67 (48,83)

Overall 70 (67,74) 70 (67,74) 71 (68,74)



Table 21: Proportion of inborn ventilated babies of ≤32 weeks gestation who receive surfactant, by hospital

2005 2006 2007

Hospital % (95% C.I.) % (95% C.I.) % (95% C.I.)

Airedale DGH 100 (66,100) 90 (55,99) 100 (69,100)

Barnsley 100 (66,100) 100 (29,100) 91 (58,99)

Bassetlaw DGH . . . . 100 (29,100)

Boston Pilgrim 100 (2,100) 100 (2,100) 100 (2,100)

Bradford RI 95 (82,99) 95 (82,99) 100 (90,100)

Calderdale 100 (69,100) 100 (75,100) 100 (76,100)



Dewsbury DGH 85 (62,97) 93 (68,99) 100 (81,100)

Doncaster RI 93 (66,99) 100 (69,100) 91 (58,99)

Grimsby 100 (78,100) 100 (79,100) 100 (78,100)

Harrogate DGH 100 (2,100) 100 (2,100) . .

Huddersfield RI 94 (71,99) 100 (66,100) 90 (55,99)

Hull RI 93 (77,99) 91 (75,99) 91 (76,99)

Jessop 88 (74,97) 93 (83,99) 93 (83,99)

Kettering 100 (79,100) 93 (66,99) 100 (80,100)

Kings Mill 91 (58,99) 94 (69,99) 100 (83,100)

Leeds LGI 91 (75,99) 95 (82,99) 96 (80,99)

Leeds St James 97 (83,99) 100 (89,100) 97 (82,99)

Leicester GH 85 (54,99) 100 (15,100) 100 (39,100)

Leicester RI 89 (74,97) 82 (64,94) 96 (81,99)

Lincoln County 100 (54,100) 67 (9,99) 100 (15,100)

Northampton 100 (85,100) 100 (86,100) 100 (80,100)

Nottingham City 96 (86,99) 98 (89,99) 98 (88,99)

Pontefract DGH 100 (69,100) 100 (69,100) 100 (73,100)

QMC Nottingham 92 (78,99) 91 (78,98) 76 (58,89)*

Rotherham DGH 100 (73,100) 100 (39,100) 91 (58,99)

Scarborough DGH 100 (2,100) 100 (2,100) 100 (15,100)

Scunthorpe 100 (54,100) 85 (54,99) 100 (47,100)

York 100 (81,100) 100 (85,100) 94 (71,99)

Overall 94 (92,97) 94 (91,96) 95 (93,97)


Table 22 relates to use of antenatal steroids and supplements the data analysed by PCT (Table

5). Only inborn babies are included (i.e. includes in utero transfers but excludes all babies

involved in flying squad transfers). The data demonstrates clearly that obstetricians are


achieving very high levels of antenatal steroid use. There is variation but we wish to

acknowledge that it is difficult to extract these data with certainty. However where we have

investigated these variations previously the differences have appeared genuine. Clearly some

infants deliver without time for antenatal steroids to be given and different units will be affected

by this phenomenon in a random manner.

Table 22: Percentage of babies 32 weeks gestation, receiving at least 1 dose of steroid prior to delivery, by hospital

2005 2006 2007

Hospital % (95% C.I.) % (95% C.I.) % (95% C.I.)

Airedale DGH 94 (78,100) 91 (71,99) 68 (45,87)

Barnsley 88 (69,98) 95 (77,100) 86 (63,97)

Bassetlaw DGH 100 (75,100) 100 (47,100) 73 (39,94)

Boston Pilgrim 86 (57,99) 78 (52,94) 87 (66,98)

Bradford RI 95 (86,99) 81 (70,89) 90 (80,96)

Calderdale 91 (71,99) 84 (66,95) 87 (70,97)



Dewsbury DGH 79 (61,92) 93 (75,100) 83 (65,95)

Doncaster RI 95 (82,100) 94 (82,99) 95 (84,99)

Grimsby 88 (73,96) 90 (72,98) 90 (75,98)

Harrogate DGH 67 (9,100) 100 (73,100) 100 (29,100)

Huddersfield RI 93 (77,100) 95 (73,100) 83 (61,96)

Hull RI 86 (74,94) 81 (70,90) 81 (69,90)

Jessop 85 (77,92) 90 (83,96) 90 (82,96)

Kettering 77 (58,91) 88 (74,97) 91 (78,98)

Kings Mill 83 (67,94) 84 (69,94) 78 (62,89)

Leeds LGI 90 (80,97) 80 (68,90) 96 (87,100)

Leeds St James 81 (68,91) 94 (82,99) 93 (83,98)

Leicester GH 91 (76,99) 90 (69,99) 100 (75,100)

Leicester RI 86 (74,94) 88 (73,96) 81 (62,93)

Lincoln County 85 (68,95) 82 (63,94) 93 (76,100)

Northampton 96 (86,100) 96 (87,100) 96 (86,100)

Nottingham City 91 (82,96) 86 (76,93) 94 (86,98)

Pontefract DGH 79 (59,92) 89 (70,98) 92 (73,99)

QMC Nottingham 94 (84,99) 87 (76,94) 79 (66,89)

Rotherham DGH 96 (80,100) 77 (58,91) 85 (71,94)

Scarborough DGH 100 (59,100) 75 (19,100) 100 (47,100)

Scunthorpe 80 (56,95) 91 (75,99) 100 (82,100)

York 97 (83,100) 86 (72,95) 97 (84,100)

Overall 89 (86,91) 88 (86,90) 89 (86,91)


We have retained the analysis of TPN (intravenous nutrition) use introduced a few years

ago. To ensure comparability of groups (i.e. „like with like‟) we have used the

population of babies 32 weeks gestation who were not involved in any kind of

transfer. Table 23 shows consecutive three-year averages. Individual units seem

broadly consistent in their use of TPN, but between units there is a great deal of

variation, not only in the percentage of preterm infants receiving TPN, but also in the

number of days for which it is given. Since this is an area for which “evidence” is not

available this variation is, perhaps, not surprising. However amongst the larger units

the heterogeneity seems to have diminished over time.


Table 23: Proportion of babies ≤32 weeks gestation receiving TPN and median length of treatment: 3 year rolling averages by hospital, excluding transfers

2003-2005 2004-2006 2005-2007

Hospital % (95% C.I.)

Me

dia

n

da

ys

TP

N % (95%

C.I.)

Me

dia

n

da

ys

TP

N % (95%

C.I.)

Me

dia

n

da

ys

TP

N

Airedale DGH 22 (12,33)* 5 28 (19,40) 6

Barnsley 44 (32,57) 7 46 (34,58) 7 52 (39,64) 7

Bassetlaw DGH 0 (0,13)* . 0 (0,14)* . 0 (0,12)* .

Boston Pilgrim 0 (0,10)* . 0 (0,8)* . 0 (0,7)* .

Bradford RI 52 (45,59)† 9 47 (41,54) 9

Calderdale 37 (25,50) 6 37 (26,49) 6

Chesterfield 35 (25,46) 10 39 (29,49) 10 45 (35,54) 11

Derby City General 26 (20,33)* 7 25 (19,32)* 7 30 (23,37)* 7

Dewsbury DGH 42 (31,54) 12 45 (35,56) 14

Doncaster RI 40 (32,49) 6 35 (27,45) 5 32 (24,41) 5

Grimsby 47 (37,57) 9 48 (38,58) 10 45 (36,55) 9

Harrogate DGH 0 (0,15)* . 0 (0,19)* .

Huddersfield RI 54 (41,67) 8 43 (31,55) 8

Hull RI 53 (45,61)† 10 60 (53,67)† 10

Jessop 48 (42,53)† 9 44 (38,50) 11 43 (38,49) 12

Kettering 38 (29,48) 8 40 (31,50) 8 41 (32,51) 8

Kings Mill 19 (12,28)* 8 18 (12,27)* 11 21 (15,30)* 9

Leeds LGI 57 (48,65)† 10 55 (47,62)† 11

Leeds St James 55 (46,64)† 13 56 (48,64)† 11

Leicester GH 33 (24,44) 8 35 (25,46) 8 28 (17,41) 9

Leicester RI 45 (37,53) 10 47 (39,56) 10 51 (41,61) 11

Lincoln County 6 (2,12)* 7 3 (1,8)* 6 7 (3,14)* 5

Northampton 38 (31,46) 10 39 (31,46) 9 41 (33,48) 9

Nottingham City 42 (36,48) 10 47 (41,54) 11 49 (42,55) 10

Pontefract DGH 11 (5,20)* 8 13 (6,22)* 11

QMC Nottingham 38 (30,45) 11 46 (38,53) 10 60 (52,67)† 10

Rotherham DGH 18 (10,28)* 5 12 (6,22)* 7 15 (8,23)* 8

Scarborough DGH 0 (0,21)* . 0 (0,22)* .

Scunthorpe 62 (49,74)† 14 58 (45,69)† 10 55 (43,67) 10

York 54 (43,64)† 7 48 (38,58) 6

Overall 36 (34,38) 9 40 (38,41) 9 41 (40,43) 9




Again this year we are able to supplement the data we have regarding feeding practice by

including data about rates of surgery for necrotising enterocolitis (Table 24) (see also Table 10).

As we have included babies based on where they received the majority of their care those units

accepting babies for surgery inevitably have higher rates. Although we have been experimenting

with including babies who have milder forms of NEC collecting such data consistently is

difficult. We would be grateful for feedback on the usefulness of these current tables. Table 24: Rates of surgery for necrotising enterocolitis. Includes babies ≤32 weeks gestation who spent the majority of their stay in that unit. (3 year rolling averages)

2003-2005 2004-2006 2005-2007

Hospital % (95% C.I.) % (95% C.I.) % (95% C.I.)

Airedale DGH 0.0 (0.0,4.1) 0.0 (0.0,3.7)

Barnsley 1.1 (0.0,6.2) 1.0 (0.0,5.7) 0.0 (0.0,4.2)

Bassetlaw DGH 0.0 (0.0,10.9) 0.0 (0.0,12.3) 0.0 (0.0,10.6)

Boston Pilgrim 2.2 (0.1,11.8) 2.0 (0.1,10.6) 1.7 (0.0,9.1)

Bradford RI 0.4 (0.0,2.1) 0.0 (0.0,1.2)*

Calderdale 0.7 (0.0,3.8) 0.7 (0.0,3.6)

Chesterfield & NDRH 0.8 (0.0,4.3) 0.7 (0.0,3.9) 0.7 (0.0,3.7)

Derby City General 0.9 (0.1,3.2) 0.8 (0.1,3.0) 0.4 (0.0,2.2)

Dewsbury DGH 1.0 (0.0,5.4) 0.8 (0.0,4.4)

Doncaster RI 0.0 (0.0,2.1) 0.0 (0.0,2.1) 0.0 (0.0,1.9)*

Grimsby 0.0 (0.0,2.7) 0.8 (0.0,4.3) 2.2 (0.5,6.4)

Harrogate DGH 0.0 (0.0,12.3) 0.0 (0.0,11.6)

Huddersfield RI 0.0 (0.0,4.7) 3.3 (0.7,9.2)

Hull RI 6.6 (3.6,11.1)† 7.6 (4.6,11.8)†

Jessop 4.1 (2.5,6.2) 4.6 (3.0,6.7)† 5.1 (3.4,7.2)†

Kettering 0.7 (0.0,3.9) 0.7 (0.0,3.8) 0.0 (0.0,2.3)

Kings Mill 0.0 (0.0,3.0) 0.0 (0.0,2.5) 0.0 (0.0,2.2)

Leeds LGI 6.4 (4.0,9.6)† 6.2 (4.0,9.0)†

Leeds St James 2.2 (0.7,5.1) 1.1 (0.2,3.2)

Leicester GH 0.0 (0.0,2.2) 0.6 (0.0,3.1) 0.7 (0.0,3.8)

Leicester RI 4.4 (2.4,7.4) 6.7 (4.1,10.1)† 5.4 (3.3,8.4)†

Lincoln County 0.0 (0.0,2.8) 0.0 (0.0,3.1) 0.0 (0.0,3.8)

Northampton 0.5 (0.0,2.7) 0.0 (0.0,1.8)* 0.0 (0.0,1.8)*

Nottingham City 1.0 (0.3,2.6) 1.8 (0.7,3.6) 2.6 (1.3,4.8)

Pontefract DGH 0.9 (0.0,5.0) 1.0 (0.0,5.3)

QMC Nottingham 5.6 (3.3,8.8)† 4.0 (2.1,6.9) 5.8 (3.4,9.2)†

Rotherham DGH 1.0 (0.0,5.2) 1.0 (0.0,5.4) 0.8 (0.0,4.3)

Scarborough DGH 0.0 (0.0,9.3) 0.0 (0.0,9.5)

Scunthorpe 1.1 (0.0,5.8) 0.0 (0.0,3.7) 0.0 (0.0,4.0)

York 0.0 (0.0,3.1) 0.0 (0.0,2.6)

Overall 1.9 (1.4,2.4) 2.3 (1.9,2.7) 2.5 (2.1,2.9)

† Significantly higher than regional average. * Significantly lower than regional average


The next two tables relate to the use of ventilation and CPAP in individual units (Tables

25 and 26). Included in the analysis are non transfers of all gestations who required

ventilation and or CPAP. As usual the tables are presented as three year averages. The

same marked variation is seen as with TPN use. Although much of the variation

reflects the different types of unit that make up the service there are also significant

differences between otherwise similar units.

Table 25: Ventilation days per baby as an average over 3 years, by hospital (non transfers only)

Hospital 2003-2005 2004-2006 2005-2007

Airedale DGH 0.8 (0.7,1.0)* 1.0 (0.9,1.2)*

Barnsley 0.6 (0.5,0.8)* 0.7 (0.6,0.9)* 1.1 (0.9,1.3)*

Bassetlaw DGH 0.2 (0.1,0.4)* 0.1 (0.0,0.2)* 0.3 (0.2,0.5)*

Boston Pilgrim 0.2 (0.1,0.3)* 0.3 (0.2,0.5)* 0.2 (0.1,0.3)*

Bradford RI 2.0 (1.9,2.2) 1.9 (1.8,2.0)

Calderdale 1.1 (0.9,1.3)* 0.9 (0.7,1.1)*

Chesterfield & NDRH 1.4 (1.2,1.6)* 1.3 (1.1,1.5)* 1.2 (1.0,1.4)*


Dewsbury DGH 3.2 (2.9,3.5)† 3.1 (2.8,3.4)†

Doncaster RI 0.8 (0.7,0.9)* 0.8 (0.7,0.9)* 0.8 (0.7,0.9)*

Grimsby 2.3 (2.1,2.5) 2.1 (1.9,2.3) 1.9 (1.7,2.1)

Harrogate DGH 0.3 (0.2,0.5)* 0.2 (0.1,0.3)*

Huddersfield RI 3.2 (2.9,3.6)† 3.1 (2.8,3.5)†

Hull RI 1.9 (1.8,2.0)* 2.0 (1.9,2.1)

Jessop 4.0 (3.8,4.2)† 4.0 (3.8,4.2)† 3.6 (3.4,3.8)†

Kettering 1.9 (1.7,2.1)* 1.5 (1.3,1.7)* 1.1 (1.0,1.2)*

Kings Mill 1.7 (1.5,1.9)* 1.6 (1.4,1.8)* 1.2 (1.1,1.4)*

Leeds LGI 3.0 (2.8,3.2)† 2.8 (2.6,3.0)†

Leeds St James 2.8 (2.6,3.0)† 2.3 (2.1,2.5)†

Leicester GH 1.1 (1.0,1.3)* 0.8 (0.7,0.9)* 0.5 (0.4,0.6)*

Leicester RI 4.4 (4.2,4.6)† 4.7 (4.5,4.9)† 4.4 (4.2,4.6)†

Lincoln County 0.5 (0.4,0.6)* 0.4 (0.3,0.5)* 0.4 (0.3,0.5)*

Northampton 2.9 (2.7,3.1)† 2.0 (1.9,2.2) 1.3 (1.2,1.4)*

Nottingham City 2.7 (2.5,2.9)† 3.0 (2.8,3.2)† 2.7 (2.5,2.9)†

Pontefract DGH 0.8 (0.7,1.0)* 1.0 (0.9,1.2)*

QMC Nottingham 3.5 (3.3,3.7)† 4.0 (3.8,4.2)† 4.0 (3.8,4.2)†

Rotherham DGH 1.0 (0.9,1.2)* 0.8 (0.7,1.0)* 0.7 (0.6,0.8)*

Scarborough DGH 0.3 (0.2,0.6)* 0.4 (0.2,0.7)*

Scunthorpe 1.8 (1.6,2.1)* 1.3 (1.1,1.5)* 1.3 (1.1,1.5)*

York 1.5 (1.3,1.7)* 1.4 (1.2,1.6)*

Overall 2.3 (2.3,2.3) 2.1 (2.1,2.1) 2.0 (2.0,2.0)

* Significantly lower than regional average † Significantly higher than regional average


Table 26: Ventilation and CPAP days per baby as an average over 3 years, by hospital (non transfers only)

Hospital 2003-2005 2004-2006 2005-2007

Airedale DGH 1.9 (1.7,2.1)* 2.5 (2.3,2.8)*

Barnsley 2.7 (2.4,3.0)* 2.9 (2.6,3.2)* 4.4 (4.1,4.8)*

Bassetlaw DGH 0.7 (0.5,1.0)* 0.6 (0.4,0.9)* 0.7 (0.5,1.0)*

Boston Pilgrim 1.6 (1.3,1.9)* 1.7 (1.4,2.0)* 1.5 (1.3,1.8)*

Bradford RI 5.7 (5.5,6.0) 5.9 (5.7,6.2)

Calderdale 3.5 (3.2,3.9)* 3.6 (3.3,4.0)*

Chesterfield & NDRH 5.2 (4.8,5.6)* 5.3 (5.0,5.7)* 5.1 (4.8,5.4)*

Derby City General 5.1 (4.8,5.4)* 5.6 (5.3,5.9) 5.7 (5.4,6.0)

Dewsbury DGH 6.5 (6.1,6.9) 7.6 (7.2,8.0)†

Doncaster RI 4.1 (3.8,4.4)* 3.9 (3.6,4.2)* 4.0 (3.8,4.3)*

Grimsby 5.6 (5.3,6.0)* 6.5 (6.1,6.9) 6.5 (6.1,6.9)†

Harrogate DGH 1.3 (1.0,1.6)* 1.2 (1.0,1.5)*

Huddersfield RI 7.4 (6.9,8.0)† 7.6 (7.1,8.2)†

Hull RI 7.4 (7.1,7.7)† 7.4 (7.2,7.6)†

Jessop 9.5 (9.2,9.8)† 9.6 (9.3,9.9)† 9.5 (9.2,9.8)†

Kettering 6.5 (6.2,6.9) 5.6 (5.3,5.9) 4.3 (4.0,4.6)*

Kings Mill 3.5 (3.2,3.8)* 4.0 (3.7,4.3)* 3.7 (3.4,4.0)*

Leeds LGI 6.7 (6.4,7.0)† 5.8 (5.6,6.0)

Leeds St James 7.2 (6.9,7.5)† 6.4 (6.1,6.7)†

Leicester GH 4.0 (3.7,4.3)* 3.3 (3.0,3.6)* 1.6 (1.4,1.8)*

Leicester RI 10.3 (10.0,10.6)† 9.7 (9.4,10.1)† 8.4 (8.1,8.7)†

Lincoln County 3.5 (3.2,3.8)* 2.9 (2.7,3.2)* 3.0 (2.7,3.3)*

Northampton 11.0 (10.6,11.4)† 9.0 (8.7,9.3)† 7.1 (6.8,7.4)†

Nottingham City 7.3 (7.0,7.6)† 7.9 (7.6,8.2)† 7.4 (7.1,7.7)†

Pontefract DGH 2.6 (2.4,2.9)* 3.4 (3.1,3.7)*

QMC Nottingham 7.1 (6.8,7.4)† 8.2 (7.9,8.5)† 8.6 (8.3,8.9)†

Rotherham DGH 2.9 (2.6,3.2)* 2.6 (2.4,2.9)* 2.6 (2.4,2.8)*

Scarborough DGH 0.4 (0.2,0.7)* 0.4 (0.2,0.7)*

Scunthorpe 7.4 (6.9,7.9)† 6.5 (6.1,7.0) 7.0 (6.5,7.5)†

York 3.3 (3.0,3.6)* 3.4 (3.1,3.7)*

Overall 6.4 (6.3,6.5) 6.0 (5.9,6.1) 5.6 (5.5,5.7)

* Significantly lower than regional average. † Significantly higher than regional average

Table 27 is a new table relating to postnatal steroid use. We added this item in 2003 to assess

the extent of postnatal steroid use as this is a somewhat controversial treatment. We felt that the

data might be informative when used in conjunction with the above Tables regarding the

amount of respiratory support used in individual units. The data shown relate to steroid use

during each hospital stay and hence transferred babies are included more than once in the

denominator. However steroid use has been allocated only to the hospital that administered the

drug (sometimes this will also have been in more than one hospital). It has not been possible to


identify a group where steroids have been given specifically for chronic lung disease rather than

some other indication. It seems reasonable to assume chronic lung disease was the commonest

indication but some use will have been for blood pressure support. The variation shown is very

marked. We are keen to have feedback on whether this is the most helpful way to display these

data.

Table 27: Any oral or injected post natal corticosteroid use for babies ≤32 weeks gestation, over 3 years, by hospital

2003-2005 2004-2006 2005-2007

Hospital No % (95% C.I.) No % (95% C.I.) No % (95% C.I.)

Airedale DGH 3 2.8 (0.6,8.0) 2 1.8 (0.2,6.4)

Barnsley 4 2.8 (0.8,7.0) 3 2.3 (0.5,6.5) 2 1.7 (0.2,6.0)

Bassetlaw DGH 1 1.1 (0.0,6.0) 1 1.3 (0.0,7.2) 0 0 (0.0,5.9)

Boston Pilgrim 0 0 (0.0,4.1) 0 0 (0.0,4.1) 0 0 (0.0,4.2)

Bradford RI 11 3.7 (1.9,6.6) 10 2.9 (1.4,5.3)

Calderdale 3 1.8 (0.4,5.2) 3 1.8 (0.4,5.2)

Chesterfield & NDRH 0 0 (0.0,2.1)* 0 0 (0.0,2.1)* 1 0.6 (0.0,3.3)

Derby City General 15 5.7 (3.2,9.2) 11 4.2 (2.1,7.3) 9 3.5 (1.6,6.5)

Dewsbury DGH 9 6.8 (3.1,12.5) 7 4.4 (1.8,8.9)

Doncaster RI 2 0.9 (0.1,3.2) 1 0.4 (0.0,2.5)* 0 0 (0.0,1.5)*

Grimsby 7 4.6 (1.9,9.2) 6 4.3 (1.6,9.2) 4 2.7 (0.7,6.7)

Harrogate DGH 1 2.0 (0.0,10.4) 1 1.7 (0.0,9.1)

Huddersfield RI 4 3.7 (1.0,9.1) 5 4.3 (1.4,9.8)

Hull RI 16 7.4 (4.3,11.7)† 19 7.7 (4.7,11.7)†

Jessop 22 4.0 (2.5,6.0) 28 5.1 (3.4,7.4) 48 9.4 (7.0,12.2)†

Kettering 3 2.0 (0.4,5.7) 4 2.6 (0.7,6.5) 2 1.2 (0.1,4.3)

Kings Mill 1 0.7 (0.0,3.6) 0 0 (0.0,2.2)* 0 0 (0.0,2.0)*

Leeds LGI 23 6.7 (4.3,9.9)† 18 5.3 (3.2,8.3)

Leeds St James 18 7.0 (4.2,10.8)† 14 5.2 (2.9,8.5)

Leicester GH 6 2.4 (0.9,5.1) 3 1.4 (0.3,4.1) 3 1.7 (0.4,5.0)

Leicester RI 23 6.3 (4.0,9.3) 26 7.2 (4.7,10.3)† 25 6.7 (4.4,9.7)†

Lincoln County 1 0.5 (0.0,2.8)* 0 0 (0.0,2.1)* 0 0 (0.0,2.7)*

Northampton 11 5.3 (2.7,9.2) 8 3.6 (1.6,7.0) 2 0.9 (0.1,3.3)

Nottingham City 17 4.0 (2.3,6.3) 15 3.6 (2.1,5.9) 6 1.6 (0.6,3.5)

Pontefract DGH 0 0 (0.0,2.6)* 0 0 (0.0,2.8)

QMC Nottingham 14 4.2 (2.3,7.0) 8 2.5 (1.1,4.9) 5 1.7 (0.5,3.9)

Rotherham DGH 1 0.6 (0.0,3.5) 0 0 (0.0,2.5)* 0 0 (0.0,2.2)*

Scarborough DGH 2 2.8 (0.3,9.8) 1 1.6 (0.0,8.4)

Scunthorpe 1 0.9 (0.0,4.8) 1 0.8 (0.0,4.6) 1 1.0 (0.0,5.2)

York 2 1.3 (0.2,4.5) 2 1.1 (0.1,4.1)

Overall 129 3.6 (3.1,4.1) 207 3.5 (3.0,4.0) 190 3.2 (2.8,3.7)

* Significantly lower than regional average. † Significantly higher than regional average


Table 28 relates to cases of moderate and severe hypoxic ischaemic encephalopathy in each unit

and includes only inborns (i.e. post natal transfers are excluded). The information supplements

the data provided by PCT in table 9 and it is important to understand that the same caveats

apply to the data in both these tables – we recognise there is likely to be a number of

misdiagnoses and hence cases should be considered +/- 10%. However, we hope that units find

the information helpful in “benchmarking” their performance and will provide an opportunity,

with future reports, to monitor this over time. As always the rate in some units is falling whilst

in others it is rising however the overall rate across the East Midlands and Yorkshire is stable.

Table 28: Rate of “neonatal encephalopathy” as an average over 3 years per 1000 births, by hospital of birth

Hospital 2003-2005 2004-2006 2005-2007

Airedale DGH 0.7 (0.3,1.9) 0.7 (0.3,1.7)

Barnsley 1.2 (0.6,2.4) 1.0 (0.5,2.1) 1.1 (0.6,2.2)

Bassetlaw DGH 1.6 (0.7,3.6) 1.5 (0.7,3.3) 1.5 (0.7,3.3)

Boston Pilgrim 1.5 (0.8,2.9) 1.9 (1.1,3.4) 2.3 (1.3,4.0)

Bradford RI 1.2 (0.8,1.9) 1.2 (0.8,1.9)

Calderdale 1.0 (0.5,2.1) 0.7 (0.3,1.6)

Chesterfield & NDRH 1.3 (0.7,2.3) 1.2 (0.6,2.2) 1.0 (0.5,2.0)


Dewsbury DGH 0.9 (0.4,1.9) 1.4 (0.8,2.4)

Doncaster RI 2.0 (1.3,3.1) 2.2 (1.5,3.3)† 2.4 (1.6,3.5)†

Grimsby 0.8 (0.3,1.9) 0.6 (0.2,1.6) 0.9 (0.4,2.0)

Harrogate DGH 1.7 (0.8,3.6) 1.2 (0.5,2.7)

Huddersfield RI 0.8 (0.3,1.9) 0.9 (0.4,1.9)

Hull RI 1.6 (1.0,2.5) 1.7 (1.2,2.5)

Jessop 0.8 (0.5,1.3) 0.5 (0.3,0.9)* 0.4 (0.2,0.8)*

Kettering 1.1 (0.6,2.0) 1.0 (0.6,1.8) 1.1 (0.6,1.9)

Kings Mill 2.0 (1.2,3.3) 1.6 (0.9,2.8) 1.3 (0.7,2.4)

Leeds LGI 2.3 (1.6,3.4)† 2.1 (1.4,3.0)

Leeds St James 2.2 (1.4,3.3) 2.1 (1.4,3.1)

Leicester GH 1.5 (0.9,2.4) 1.1 (0.6,1.9) 0.8 (0.4,1.5)

Leicester RI 1.6 (1.1,2.4) 1.1 (0.7,1.7) 1.7 (1.2,2.5)

Lincoln County 0.7 (0.3,1.6) 0.5 (0.2,1.2) 1.1 (0.6,2.0)

Northampton 1.0 (0.6,1.8) 0.6 (0.3,1.3) 0.9 (0.5,1.7)

Nottingham City 2.1 (1.5,2.9)† 1.7 (1.2,2.4) 1.4 (0.9,2.1)

Pontefract DGH 1.4 (0.8,2.5) 1.7 (1.0,2.8)

QMC Nottingham 0.7 (0.4,1.4) 0.8 (0.4,1.5) 1.1 (0.6,1.9)

Rotherham DGH 1.2 (0.6,2.3) 1.4 (0.8,2.5) 1.6 (0.9,2.8)

Scarborough DGH 1.1 (0.5,2.6) 0.6 (0.2,1.9)

Scunthorpe 1.3 (0.6,2.7) 1.1 (0.5,2.4) 1.0 (0.4,2.2)

York 1.5 (0.9,2.6) 2.1 (1.3,3.3)

Overall 1.4 (1.2,1.6) 1.3 (1.2,1.4) 1.3 (1.2,1.4)


Table 29 supplements information included earlier in the report about head scanning. This table

identifies the rate of scanning of babies ≤32 weeks in different units. There is marked variation

clearly reflecting different unit policies and the lack of an established gold standard in terms of

practice.

Table 29: Percentage of non-transferred babies 32 weeks gestation undergoing an ultrasound scan of the head: 2005-2007

Hospital Total No. scanned % (95% C.I.)

Airedale DGH 74 63 85 (75,92)

Barnsley 66 58 88 (78,95)

Bassetlaw DGH 29 12 41 (24,61)*

Boston Pilgrim 53 27 51 (37,65)*

Bradford RI 219 163 74 (68,80)

Calderdale 73 56 77 (65,86)

Chesterfield & NDRH 110 108 98 (94,100)†

Derby City General 183 125 68 (61,75)*

Dewsbury DGH 88 43 49 (38,60)*

Doncaster RI 137 116 85 (78,90)

Grimsby 108 94 87 (79,93)

Harrogate DGH 18 1 6 (0,27)*

Huddersfield RI 68 43 63 (51,75)*

Hull RI 202 140 69 (62,76)*

Jessop 306 294 96 (93,98)†

Kettering 114 108 95 (89,98)†

Kings Mill 126 78 62 (53,70)*

Leeds LGI 172 127 74 (67,80)

Leeds St James 156 125 80 (73,86)

Leicester GH 60 35 58 (45,71)*

Leicester RI 106 76 72 (62,80)

Lincoln County 89 44 49 (39,60)*

Northampton 170 141 83 (76,88)

Nottingham City 246 215 87 (83,91)†

Pontefract DGH 78 57 73 (62,82)

QMC Nottingham 180 160 89 (83,93)†

Rotherham DGH 102 84 82 (74,89)

Scarborough DGH 15 9 60 (32,84)

Scunthorpe 76 54 71 (60,81)

York 108 98 91 (84,95)†

Overall 3532 2754 78 (77,79)

* Significantly lower than overall average. † Significantly higher than overall average


Table 30 provides information about the timely allocation of NHS number. As you will be

aware for some time now this should occur with the birth notification. However in the early

months it was clearly more successful in some units than others. For the second consecutive

year the data show very low rates of missing numbers and we will soon be in a position to use

this as the identifier for the survey and thereby improve confidentiality. NHS number is being

used in relation to data passed to the National Neonatal Audit Programme. Because of the

consistency of performance across the region we will not include this table again after this year.

Table 30: The number of babies eligible for inclusion in TNS with a missing NHS number in 2007

Hospital of birth Total Missing NHS no. %

Airedale DGH 51 0 0

Barnsley 54 0 0

Bassetlaw DGH 31 0 0

Boston Pilgrim 47 0 0

Bradford RI 158 1 1

Calderdale 82 0 0

Chesterfield & NDRH 82 0 0

Derby City General 127 0 0

Dewsbury DGH 95 1 1

Doncaster RI 141 0 0

Grimsby 99 0 0

Harrogate DGH 38 0 0

Huddersfield RI 53 1 2

Hull RI 172 1 1

Jessop 217 0 0

Kettering 111 2 2

Kings Mill 92 0 0

Leeds LGI 197 1 1

Leeds St James 186 0 0

Leicester GH 78 0 0

Leicester RI 236 0 0

Lincoln County 72 0 0

Northampton 141 0 0


Pontefract DGH 87 1 1

QMC Nottingham 169 0 0

Rotherham DGH 104 0 0

Scarborough DGH 22 0 0

Scunthorpe 40 0 0

Wakefield 3 0 0

York 90 0 0

Other place of birth 273 74 27


Network based data

As indicated in the introduction to this year‟s report we are including some of our tables

reworked to show the data by Network. We must emphasise that these tables should be

considered exploratory for a number of reasons:

1) We do not have a full set of postcodes for the individual network populations as

these are not clearly defined;

2) We have not agreed with Commissioner the most useful population to use as a

denominator (i.e. the address of the mother or the address of the hospital of

booking);

3) We have not established a full enough set of checks on cross boundary losses for

some parts of the area that we cover.

These are in addition to the fact that we only collect data for part of CNN. However we

hope to agree a way forward for 1) to 3) above over the next 12 months. In the interim

in the following tables babies have been allocated based on the mother‟s hospital of

booking.

Table 31: Proportion of ventilated babies who receive surfactant, by Network, 3 year rolling average.

2005-2007

Network % (95% C.I.)

Central Newborn 64 (58,71)

North Trent 80 (74,84)

Trent Perinatal 72 (66,78)

Yorkshire 74 (69,78)

Overall 73 (70,76)

Table 32: Proportion of ventilated babies ≤32 weeks gestation who receive surfactant, by Network, 3 year rolling average.

2005-2007






Overall 94 (92,96)


Table 33: Proportion of babies ≤32 weeks gestation, receiving at least 1 dose of steroid prior to delivery, by Network, 3 year rolling average

2005-2007






Overall 88 (86,90)

Table 34: Proportion of babies ≤32 weeks gestation receiving TPN and median length of treatment: 3 year rolling average, by Network

2005-2007

Network % (95% C.I.) Median days TPN

Central Newborn 43 (37,49) 9

North Trent 45 (41,50) 11

Trent Perinatal 47 (43,52) 10

Yorkshire 50 (46,54) 10

Overall 47 (45,49) 10

Table 35: Ventilation days per baby, by Network, 3 year rolling average

2005-2007


Central Newborn 2.8 (2.7,2.9)*

North Trent 3.6 (3.5,3.7)†

Trent Perinatal 3.0 (2.9,3.1)

Yorkshire 2.7 (2.6,2.8)*

Overall 3.0 (3.0,3.0)

Table 36: Ventilation and CPAP days per baby, by Network, 3 year rolling average

2005-2007


Central Newborn 6.3 (6.1,6.5)*

North Trent 9.3 (9.1,9.5)†

Trent Perinatal 8.0 (7.8,8.2) †

Yorkshire 7.1 (7.0,7.2)*

Overall 7.6 (7.5,7.7)

* Significantly lower than overall average. † Significantly higher than overall average


National Neonatal Audit Data

As mentioned in the introduction we have been collecting as many of the National

Neonatal Audit Project data items as possible (i.e. those that fit our existing pattern of

data collection). Each data item is intended as a straightforward benchmarking measure

against a parameter known to be associated with an important outcome or an important

aspect of care. These follow in tables 37 to 43.

Some of these items have been collected have been collected for 3 years but many are

new this year. Some items (eg table 40: No of inborn babies ≤32 weeks gestation with a

consultation within the first 24 hours, by hospital, 2007) have been difficult to collect as

the relevant information has, to date, been poorly recorded. With increasing attention

we anticipate improved levels of recording and ascertainment in subsequent years.

The other point to make is that the definitions have lead to a number of “quirks” in the

data. For example most very preterm babies now move from Leicester Royal Infirmary

to Leicester General Hospital when they reach an equivalent age of 32 weeks of

gestation. As a consequence the vast majority are excluded from table 41 (Screening for

ROP of non-transferred babies <1250g, by hospital, 2007) because they are “transfers”.


Table 37: No of babies ≤28 weeks gestation admitted with a temperature <36C, together with the range of temperatures in the first hour after delivery, by hospital 2007

Hospital Total No. temp recorded

No. within 1st hour

No. below 36C

(%) Range

Airedale DGH 11 11 11 3 (27) 34.3 to 37.5

Barnsley 12 12 12 3 (25) 35.8 to 39.4

Bassetlaw DGH 1 1 1 0 (0) 36.4 to 36.4

Boston Pilgrim 2 2 2 1 (50) 34.5 to 36.8

Bradford RI 42 42 38 2 (5) 35.2 to 39.0

Calderdale 13 13 11 2 (18) 34.6 to 39.0

Chesterfield & NDRH 16 16 16 0 (0) 36.0 to 37.5

Derby City General 38 37 38 12 (32) 33.9 to 37.7

Dewsbury DGH 14 12 13 7 (54) 35.0 to 36.6

Doncaster RI 27 26 28 1 (4) 35.6 to 37.7

Grimsby 18 18 18 4 (22) 34.6 to 38.6

Harrogate DGH 2 2 2 0 (0) 36.1 to 36.4

Huddersfield RI 10 10 7 4 (57) 35.0 to 37.3

Hull RI 22 22 20 8 (40) 34.5 to 37.6

Jessop 50 49 45 12 (27) 33.8 to 38.6

Kettering 16 16 11 5 (45) 32.7 to 38.9

Kings Mill 23 23 22 3 (14) 35.4 to 38.8

Leeds LGI 26 26 25 1 (4) 35.8 to 38.2

Leeds St James 20 20 17 3 (18) 35.3 to 38.5

Leicester GH 6 6 5 0 (0) 36.0 to 37.3

Leicester RI 37 37 34 6 (18) 35.1 to 38.7

Lincoln County 7 7 7 5 (71) 35.5 to 36.1

Northampton 17 17 16 0 (0) 36.0 to 37.4

Nottingham City 38 38 36 10 (28) 34.6 to 38.8

Pontefract DGH 12 12 12 1 (8) 35.7 to 37.8

QMC Nottingham 38 35 33 8 (24) 34.0 to 38.2

Rotherham DGH 18 18 18 3 (17) 34.5 to 37.2

Scarborough DGH 3 3 3 1 (33) 34.9 to 37.2

Scunthorpe 7 7 7 1 (14) 35.0 to 37.6

York 11 10 10 2 (20) 35.0 to 37.6


Table 38: No of inborn babies (26, 27 and 28 weeks gestation) receiving surfactant within the first hour, by hospital, 2007

Hospital Total No. received surfactant

No. within 1st hour

(%)

Airedale DGH 9 8 7 (88)

Barnsley 12 12 12 (100)

Bassetlaw DGH 1 1 0 (0)

Boston Pilgrim 1 1 1 (100)

Bradford RI 24 23 19 (83)

Calderdale 11 11 10 (91)

Chesterfield & NDRH 14 10 9 (90)

Derby City General 25 19 15 (79)

Dewsbury DGH 12 12 11 (92)

Doncaster RI 22 22 20 (91)

Grimsby 9 9 8 (89)

Harrogate DGH 2 2 2 (100)

Huddersfield RI 7 6 5 (83)

Hull RI 20 18 13 (72)

Jessop 24 21 17 (81)

Kettering 11 8 5 (63)

Kings Mill 16 15 13 (87)

Leeds LGI 17 17 13 (76)

Leeds St James 13 13 11 (85)

Leicester GH 5 4 4 (100)

Leicester RI 25 24 24 (100)

Lincoln County 5 5 5 (100)

Northampton 15 15 12 (80)

Nottingham City 28 27 24 (89)

Pontefract DGH 11 11 9 (82)

QMC Nottingham 26 23 19 (83)

Rotherham DGH 11 11 11 (100)

Scarborough DGH 3 3 2 (67)

Scunthorpe 6 6 5 (83)

York 7 7 7 (100)

Overall 392 364 313 (86)


Table 39: No of inborn babies ≤28 weeks gestation with blood pressure measured within the first hour, by hospital, 2007

Hospital Total No. within 1st

hour

(%) (95% CI)

Airedale DGH 11 3 27 (6,61)

Barnsley 12 12 100 (74,100)†

Bassetlaw DGH 1 0 0 (0,98)

Boston Pilgrim 2 2 100 (16,100)

Bradford RI 42 11 26 (14,42)*

Calderdale 13 4 31 (9,61)

Chesterfield & NDRH 16 16 100 (79,100)†

Derby City General 39 32 82 (66,92)

Dewsbury DGH 16 7 44 (20,70)

Doncaster RI 28 28 100 (88,100)†

Grimsby 18 0 0 (0,19)*

Harrogate DGH 2 1 50 (1,99)

Huddersfield RI 10 4 40 (12,74)

Hull RI 22 18 82 (60,95)

Jessop 51 26 51 (37,65)

Kettering 16 12 75 (48,93)

Kings Mill 23 18 78 (56,93)

Leeds LGI 26 15 58 (37,77)

Leeds St James 20 20 100 (83,100)†

Leicester GH 6 4 67 (22,96)

Leicester RI 37 17 46 (29,63)

Lincoln County 7 6 86 (42,100)

Northampton 17 15 88 (64,99)

Nottingham City 38 27 71 (54,85)

Pontefract DGH 12 12 100 (74,100)†

QMC Nottingham 41 18 44 (28,60)

Rotherham DGH 18 17 94 (73,100)†


Scunthorpe 7 0 0 (0,41)*

York 12 6 50 (21,79)

Overall 566 353 62 (58,66)

* Significantly lower than overall average.



Table 40: No of families of inborn babies ≤32 weeks gestation who had a consultation with a senior member of medical staff (reg/cons) in first 24 hours, by hospital, 2007

Hospital Total No. within 1

st

24 hours

(%) (95% CI) No. not recorded

No. after 24 hours

Airedale DGH 22 16 73 (50,89) 6 0

Barnsley 27 4 15 (4,34)* 22 1

Bassetlaw DGH 16 3 19 (4,46)* 12 1

Boston Pilgrim 25 5 20 (7,41)* 20 0

Bradford RI 82 63 77 (66,85)† 16 3

Calderdale 43 16 37 (23,53) 27 0

Chesterfield & NDRH

50 7 14 (6,27)* 43 0

Derby City General 84 45 54 (42,65) 31 8

Dewsbury DGH 34 7 21 (9,38)* 26 1

Doncaster RI 74 42 57 (45,68) 32 0

Grimsby 53 51 96 (87,100)† 2 0

Harrogate DGH 8 8 100 (63,100)† 0 0

Huddersfield RI 34 11 32 (17,51)* 23 0

Hull RI 73 60 82 (71,90)† 12 1

Jessop 127 45 35 (27,44)* 73 9

Kettering 47 42 89 (77,96)† 3 2

Kings Mill 53 36 68 (54,80) 13 4

Leeds LGI 72 24 33 (23,45)* 44 4

Leeds St James 81 23 28 (19,40)* 49 9

Leicester GH 14 12 86 (57,98)† 2 0

Leicester RI 101 93 92 (85,97)† 6 2

Lincoln County 31 11 35 (19,55) 19 1

Northampton 54 42 78 (64,88)† 9 3

Nottingham City 104 49 47 (37,57) 43 12

Pontefract DGH 33 13 39 (23,58) 18 2

QMC Nottingham 76 42 55 (43,67) 30 4

Rotherham DGH 51 24 47 (33,62) 18 9

Scarborough DGH 5 3 60 (15,95) 2 0

Scunthorpe 23 20 87 (66,97)† 2 1

York 38 10 26 (13,43)* 27 1

Overall 1535 827 54 (51,56) 630 78




Table 41: Screening for ROP of non-transferred babies <1250g, by hospital, 2007

Hospital Total

On

un

it

at

49

days

Scre

en

betw

een

42 a

nd

49 d

ay

s

(%)

Scre

en

befo

re 4

2

days

(%)

Scre

en

aft

er

49

days

(%)

Airedale DGH 10 7 3 (43) 4 (57) 0 (0)

Barnsley 8 8 4 (50) 3 (38) 1 (13)

Bradford RI 34 18 2 (11) 16 (89) 0 (0)

Calderdale 11 11 8 (73) 2 (18) 1 (9)

Chesterfield & NDRH 14 13 7 (54) 3 (23) 3 (23)

Derby City General 33 16 1 (6) 12 (75) 3 (19)

Dewsbury DGH 13 8 3 (38) 5 (63) 0 (0)

Doncaster RI 11 10 0 (0) 8 (80) 2 (20)

Grimsby 13 7 2 (29) 2 (29) 3 (43)

Huddersfield RI 5 4 1 (25) 3 (75) 0 (0)

Hull RI 26 18 13 (72) 4 (22) 1 (6)

Jessop 47 29 20 (69) 8 (28) 1 (3)

Kettering 15 9 4 (44) 4 (44) 1 (11)

Kings Mill 10 10 4 (40) 2 (20) 4 (40)

Leeds LGI 20 11 3 (27) 7 (64) 1 (9)

Leeds St James 24 17 6 (35) 7 (41) 4 (24)

Leicester GH 2 0 . (.) . (.) . (.)

Leicester RI 16 6 1 (17) 4 (67) 1 (17)

Lincoln County 4 1 1 (100) 0 (0) 0 (0)

Northampton 20 18 10 (56) 8 (44) 0 (0)

Nottingham City 39 16 5 (31) 2 (13) 9 (56)

Pontefract DGH 7 4 1 (25) 2 (50) 1 (25)

QMC Nottingham 21 13 8 (62) 3 (23) 2 (15)

Rotherham DGH 15 10 5 (50) 2 (20) 3 (30)

Scarborough DGH 1 0 . (.) . (.) . (.)

Scunthorpe 10 6 4 (67) 0 (0) 2 (33)

York 8 6 4 (67) 0 (0) 2 (33)

Overall 437 276 120 (43) 111 (40) 45 (16)


Table 42: No. of non-transferred babies ≤31 weeks gestation discharged home on breast milk (wholly or partial), by hospital, 2007

Hospital Total Home on breast milk

(%) (95% CI)

Airedale DGH 17 12 71 (44,90)

Barnsley 17 4 24 (7,50)



Bradford RI 41 22 54 (37,69)

Calderdale 23 11 48 (27,69)

Chesterfield & NDRH 21 8 38 (18,62)


Dewsbury DGH 19 13 68 (43,87)

Doncaster RI 30 14 47 (28,66)

Grimsby 19 9 47 (24,71)

Harrogate DGH 0 . . .


Hull RI 42 18 43 (28,59)

Jessop 51 23 45 (31,60)

Kettering 26 9 35 (17,56)

Kings Mill 30 15 50 (31,69)

Leeds LGI 33 7 21 (9,39)*

Leeds St James 45 6 13 (5,27)*

Leicester GH 4 3 75 (19,99)

Leicester RI 12 4 33 (10,65)


Northampton 32 18 56 (38,74)

Nottingham City 56 36 64 (50,77)†

Pontefract DGH 19 3 16 (3,40)*


Rotherham DGH 26 10 38 (20,59)


Scunthorpe 13 4 31 (9,61)

York 26 7 27 (12,48)

Overall 715 314 44 (40,48)




Table 43: No. of non-transferred babies ≤31 weeks gestation discharged home who received some breast milk as an inpatient, by hospital, 2007

Hospital Total Any breast milk

(%) (95% CI)

Airedale DGH 17 16 94 (71,100)

Barnsley 17 17 100 (80,100)



Bradford RI 41 32 78 (62,89)

Calderdale 23 18 78 (56,93)

Chesterfield & NDRH 21 18 86 (64,97)


Dewsbury DGH 19 16 84 (60,97)

Doncaster RI 30 26 87 (69,96)

Grimsby 19 18 95 (74,100

Harrogate DGH 0 . . .


Hull RI 42 40 95 (84,99)

Jessop 51 43 84 (71,93)

Kettering 26 23 88 (70,98)

Kings Mill 30 20 67 (47,83)

Leeds LGI 33 25 76 (58,89)

Leeds St James 45 34 76 (60,87)

Leicester GH 4 4 100 (40,100)

Leicester RI 12 11 92 (62,100)


Northampton 32 26 81 (64,93)

Nottingham City 56 51 91 (80,97)

Pontefract DGH 19 16 84 (60,97)


Rotherham DGH 26 20 77 (56,91)


Scunthorpe 13 13 100 (75,100)

York 26 17 65 (44,83)

Overall 15 597 83 (81,86)


References

1. Clinical Standards Advisory Group. Neonatal Intensive Care: Access to and

availability of specialist services. March 1993 HMSO.

2. Clinical Standards Advisory Group 1995. Neonatal Intensive Care: Access to

and availability of specialist services. December 1996 RCPCH London.

3. The International Neonatal Network. The CRIB (Clinical Risk Index for

Babies) score: a tool for assessing initial neonatal risk and comparing

performance of neonatal intensive care units. Lancet 1993; 342:193-198.

4. Gareth Parry, Janet Tucker, William Tarnow-Mordi and UK Neonatal Staffing

Study Collaborative Group. CRIB II: an update of the clinical risk index for

babies score. The Lancet, Volume 361, Issue 9371, 24 May 2003, Pages 1789-

1791.

5. Spiegelhalter DJ. Funnel plots for comparing institutional performance.

Statistics in Medicine 2005;24:1185-1202.


End note

In order that this information could be made available at the earliest opportunity this

report has been produced at great speed. The information included is based on previous

discussions with clinicians and managers, however inevitably we will not have met

everyone‟s requirements. We remain happy to respond to individual requests. For

supplementary information please contact:

Professor David Field

TIMMS

Department of Health Sciences

University of Leicester

22-28 Princess Road West

Leicester

LE1 6TP

[email protected]

Dr Bryan Gill

Lead Clinician

Yorkshire Neonatal Network

Leeds PCT

Sycamore Lodge

7a Woodhouse Cliff

Leeds LS6 2HF

[email protected]


Acknowledgements

These data are available thanks to the collaboration of every neonatal and obstetric

service in the East Midlands and Yorkshire regions.

We also wish to thank the following units from adjacent regions who gave us access to

data relating to TNS and YNN babies requiring intensive care in their hospitals during

2007:

Burton on Trent

Macclesfield

St Mary‟s, Manchester

Milton Keynes

Nuneaton

Stockport

The information presented in this report has been collected thanks to the tireless and

meticulous work of the following:

Dilys Ainsworth

Andrea Firth

Bernadette Hargreaves

Claire Inglis

Karen Lynch

Gill Mellors

Maria Sharpe

Pauline Shaw

Patricia Watson

Joy Yates

The data were transformed into a report thanks to the heroic efforts of:

Julie Faulkes

Helen Holden

Di Lockley

Bradley Manktelow

Martin Perkins

masterfully orchestrated by Liz Draper.

ALL OF THIS WORK HAS BEEN FUNDED BY TRENT RHA, THE TRENT

DISTRICT HEALTH AUTHORITIES, PCTs AND NEONATAL NETWORKS

OF THE EAST MIDLANDS AND YORKSHIRE.


Appendix 1: Summary of current projects using TNS data or

involving the TNS team

Current Projects Predicting neonatal mortality among very preterm infants: a comparison of three versions of the CRIB score

Manktelow BN, Draper ES, Field DJ

Objective:

To validate CRIB and CRIB II mortality prediction scores in a UK population of infants

born at ≤32 weeks gestational age and investigate CRIB II calculated without admission

temperature.

Methods:

Infants born 22-32 weeks gestational age to mothers resident in a geographically

defined UK region in 2005-2006 and admitted for neonatal care were identified.

Predictive probabilities for mortality were calculated using CRIB, CRIB II and CRIB II

without temperature at admission (CRIB II(-T)) using published algorithms and then after

recalibration.

Predictive abilities of the scores were investigated overall and for groups defined by

gestational age and admission temperature and summarised by c-statistics, Cox‟s

regression, Brier scores and Spiegelhalter‟s z-scores.

Results: 3268 infants were included: 317 (9.7%) died before discharge. Using published

algorithms all scores showed excellent discrimination (c=0.92). CRIB predicted well the

total number of deaths (324.4) but both versions of CRIB II under-predicted the total

number of deaths (255.2 & 216.6). All scores performed poorly for subgroups based on

gestation and admission temperature.

After recalibration CRIB II displayed excellent predictive characteristics overall

(Spiegelhalter‟s z-score: p=0.53) and in the gestation groups (p=0.64 & 0.42) but not for

the temperature groups (p=0.0.026 & 0.97). CRIB II(-T) displayed excellent predictive

characteristics for all groups: overall p=0.53; gestation groups p=0.64 & 0.42;

temperature groups p=0.42 & 0.66.

Conclusions: The CRIB II score without the component for temperature at admission shows good

predictive characteristics once recalibrated to new data. This version of the score

should be used when benchmarking neonatal intensive care units.


Assessing socio-economic inequalities in very pre-term birth rates: does choice of measure or geographic area matter?

Smith LK, Draper ES, Manktelow BN, Field DJ

Objectives To explore the use of a range of area based measures of deprivation at different

geographic levels to monitor socioeconomic inequalities in very premature birth and

identify women at higher risk of preterm delivery.

Design A cohort study of very pre-term birth data linked to population birth data and six

deprivation measures at two area levels (ward and super output area (SOA)).

Setting Former Trent NHS region in the UK, approximately 55,000 births per year.

Participants

Incident cases were all singleton births of 22+0

to 32+6

weeks gestation between

01/01/1994 and 31/12/2003 (7179 births) identified from population surveys of neonatal

services, stillbirths and late fetal losses. Population denominators were 549,618 total

births in the same period by ward, approximated at SOA level using 2001 census data.

Main Results

Analyses of the incidence of very preterm birth confirmed wide socioeconomic

inequalities. The measures based on smaller areas showed stronger gradients in very

preterm birth. Choice of deprivation measure was less important as all measures showed

broadly similar gradients in socioeconomic inequalities in very preterm birth. For SOA

level measures, there was a median increase in risk of very preterm birth of 160% for

women from the most deprived areas compared to those from the least deprived areas,

while using ward level measures the median increased risk was 101%.

Conclusions

Deprivation measures at super output area level can be a useful tool in monitoring

inequalities in very preterm birth and may aid targeting of high risk women for future

research.


Characteristics of neonatal units that care for very preterm infants in Europe: results from the MOSAIC Study

Van Reempts P, Gortner L, Milligan D, Cuttini M, Petrou S, Agnostino R, Field D, Den

Ouden L, Børch, Mazela J, Carrapato M, Zeitlin J, for the MOSAIC Research Group

Objectives

The goal was to compare existing guidelines for level III units in 10 European regions

and to analyze the characteristics of neonatal units that care for very preterm infants.

Methods

The Models of Organising Access to Intensive Care for Very Preterm Births project

combined a prospective cohort study on all births between 22 weeks, 0 days and 31

weeks, 6 days of gestation in 10 European regions and a survey of neonatal unit

characteristics. Units that admitted ≥5 infants at <32 weeks of gestation were included

in the analysis (N = 111). Place of hospitalization of infants who were admitted to

neonatal care was analyzed by using the cohort data (N = 4947). National or regional

guidelines for level III units were reviewed.

Results

Six of 9 guidelines for level III units included minimum size criteria, based on number

of intensive care beds (6 guidelines), neonatal admissions (2), ventilated patients (1),

obstetric intensive care beds (1), and deliveries (2). The characteristics of level III units

varied, and many were small or unspecialized by recommended criteria: 36% had fewer

than 50 very preterm annual admissions, 22% ventilated fewer than 50 infants annually,

and 28% had fewer than 6 intensive care beds. Level II units were less specialized, but

some provided mechanical ventilation (57%) or high-frequency ventilation (20%) or

had neonatal surgery facilities (17%). Sixty-nine percent of level III and 36% of levels I

to II units had continuous medical coverage by a qualified paediatrician. Twenty-two

percent of infants who were <28 weeks of gestation were treated in units that admitted

fewer than 50 very preterm infants annually (range: 2%-54% across the Models of

Organising Access to Intensive Care for Very Preterm Births regions).

Conclusions

No consensus exists in Europe about size or other criteria for NICUs. A better

understanding of the characteristics associated with high-quality neonatal care is

needed, given the high proportion of very preterm infants who are cared for in units that

are considered small or less specialized by many recommendations.


Modelling neonatal mortality by gestational age, birth weight and sex among very preterm babies using fractional polynomials

Manktelow BN, Draper ES, Field DJ

Background:

Amongst babies born at term the relationship between birth weight and neonatal

mortality follows a reverse J-shape curve. However, it is unclear whether such a

relationship exists among very-preterm babies (≤ 32 weeks gestational age). Since

gestational age is the strongest predictor of mortality in this group, it is the relationship

between birth weight for gestational age and mortality that is important for these babies.

This paper investigates the nature of this relationship, in particular through the use of

fractional polynomials.

In previous studies birth weight for gestational age has been modelled using

conventional polynomial terms or by grouping. However, these methods may be

inappropriate as conventional polynomials have a limited range of shapes and grouping

by birth weight is unrealistic. Fractional polynomials allow a more flexible approach to

modelling.

Methods:

All babies born alive from 2000 to 2004 at 32 weeks gestational age or less within the

area of the former Trent Regional Health Authority, UK, were identified from two

population based registers (TNS & CEMACH). Infants with acutely lethal congenital

abnormalities (including hydrops fetalis) were excluded.

The relationship between 28-day mortality and gestational age, birth weight and sex was

investigated in a logistic regression model. The data were first modelled using

conventional polynomial terms, allowing up to cubic functions for gestational age, birth

weight, their interaction and their interactions with sex. The final model chosen was

that with the lowest AIC. A second model was then derived using backward selection

and fractional polynomials (up to degree 2) for the continuous variables and their

interactions.

Results:

4895 babies were initially identified but 54 were excluded due to acutely life-

threatening congenital abnormalities, 12 because of missing data and 4 had birth

weights for gestational age considered implausible. Therefore, 4825 babies remained

for analysis.

Using the conventional polynomial approach to model the data, a model comprising 9

terms was selected (AIC=1905.806) of the form:

sexβgestbwtβbwtβgestbwtβbwtβ

gestbwtβbwtβgestβgestββPdied

.*..*..

*....logit

9

3

8

3

7

2

6

2

5

43

2

210

This model displayed a reverse-J shaped relationship between 28-day mortality and

birth weight for gestational age within the observed range of birth weights. However,

this model was not clinically plausible as increasing mortality with increasing

gestational age was predicted at high birth weights for infants at high gestational ages.

Alternative models (with higher values for AIC) also showed features that were

clinically implausible.

A parsimonious, and clinically plausible, model was derived using fractional

polynomials showing a decreasing monotonic relationship between 28-day mortality

and birth weight for gestational age (AIC=1904.406):


sexβbwtβgestββPdied ...logit 3

2

210

Conclusions: The unrealistic characteristics of the models derived using conventional

polynomials are likely to have arisen because of the limited range of shapes for the

functions available using that approach. Fractional polynomials offer a straightforward

methodology to produce a simple and clinically plausible model. This approach may be

useful when investigating the relationship between birth weight for gestational age and

other outcomes.

A comparison of methods of estimating confidence intervals for an indirectly standardized outcome ratio based on logistic regression models

Manktelow BN, Draper ES, Field DJ, Abrams KR

In comparing the performance of health care providers the ratio of the number of

observed events to the expected number is often used. The expected number of events

in the dataset of interest is estimated by using the coefficient estimates from a logistic

regression model using a large, reference dataset. However, a variety of methods have

been suggested for estimating a confidence interval for such ratios and it is unclear

which method is the most appropriate, particularly for small datasets where the

assumptions made may not hold.

We investigate, via a simulation study, the performance of three previously proposed

methods (Hosmer & Lemeshow, 1995; Zhou & Romano, 1997), and contrast these

with approach using the bootstrap. For each simulation, two datasets were created: a

small dataset to represent the health care provider of interest and a large set to represent

the reference data. Using the same empirical distribution for each dataset, morbidity

scores were input and observations were sampled using a logistic model with a known

linear predictor. These observations were then used to estimate the outcome ratio and

confidence intervals. Twenty-seven different scenarios were simulated with 1,000

repetitions in each case, varying: (i) the size of the dataset of interest; (ii) the size of the

reference dataset; (iii) the underlying probability of death within the dataset of interest.

For each scenario the Type I error rates and coverage were calculated and compared.

Of the analytical methods, the method proposed by Hosmer and Lemeshow (1995)

produced type I error rates more consistently closer to the true rate, although the error

tended to be one sided. All three methods tended to have inflated error rates when the

true ratio was greater than unity and reduced rates when the true rate was less than

unity. These methods are contrasted with the bootstrap approaches which consistently

more appropriate type I error rates. The bootstrap approach also has a number of other

potential advantages including the ability to be easily extended to more complex

scenarios.

Hosmer D.W. and Lemeshow S. (1995). Confidence interval estimates of an index of

quality performance based on logistic regression models. Statistics in Medicine 14,

2161-2172.

Zhou H. and Romano P.S. (1997). Confidence interval estimates of an index of quality

performance based on logistic regression models (Letter). Statistics in Medicine 16,

1301-1303.


Recent Publications Cusack JM, Manktelow BN, Field DJ. Impact of service changes on neonatal transfer

patterns over 10 years. Archives of Disease in Childhood Fetal & Neonatal Edition

2007;92(3):F181-184.

Draper, ES; Field, DJ. Epidemiology of prematurity - How valid are comparisons of

neonatal outcomes? Seminars in Fetal & Neonatal Medicine Oct 2007, 12(5): 337-343.

Field D, Bajuk B, Manktelow BN, Vincent T, Dorling J, Tarnow-Mordi W, Draper

ES,

Henderson Smart D. Geographically based comparisons of preterm birth and perinatal

mortality within the United Kingdom and Australia. Archives of Disease in Childhood

Fetal & Neonatal Edition 2008; 93(3):F212-F216.

Field DJ, Dorling JS, Manktelow BN, Draper ES. Survival of Extremely Premature

Babies in a Geographically Defined Population: 2000 - 2005 Compared With 1994 -

1999. British Medical Journal 2008; 336:1221-1223.

Kamoji VM, Dorling JS, Manktelow B, Draper ES, Field DJ. Antenatal umbilical

Doppler abnormalities: an independent risk factor for early onset neonatal necrotizing

enterocolitis in premature infants. Acta Paediatrica 2008;97(3):327-331.

Milligan DWA, Carruthers P, Mackley B, Ward Platt MP, Collingwood Y, Wooler L,

Gibbons J, Draper E, Manktelow BN. Nursing workload in UK tertiary neonatal units.

Archives of Disease in Childhood Fetal & Neonatal Edition, June 2008;

doi:10.1136/adc.2008.142232

Sabri K, Manktelow B, Anwar S, Field DJ, Woodruff G. Ethnic variations in the

incidence and outcome of severe ROP: a prospective study. Canadian Journal of

Ophthalmology. [In press]

Smith LK, Draper ES, Manktelow BN, Dorling JS, Field DJ. Socio-economic

inequalities in very pre-term birth rates. Archives of Disease in Childhood Fetal &

Neonatal Edition 2007; 92(1):F11-F14.

Smith LK, Draper ES, Manktelow BN, Field DJ. Deprivation and infection among

spontaneous very preterm births: a twelve year retrospective study. Obstetrics and

Gynecology 2007;110:325-329.

Telford K, Waters L, Vyas H, Manktelow BN, Draper ES, Marlow N. Respiratory

outcome in late childhood following neonatal continuous negative pressure ventilation.

Archives of Disease in Childhood Fetal & Neonatal Edition 2007;92(1):F19-F24.

Tiruvoipati R, Bangash M, Manktelow B, Peek GJ. Efficacy of prone ventilation in

adult patients with acute respiratory failure: A meta-analysis. Journal of Critical Care

2008; 23(1):101-110.

Tiruvoipati R, Pandya H, Manktelow B, Smith J, Dodkins I, Elbourne D, Field D.

Referral pattern of neonates with severe respiratory failure for extracorporeal membrane

oxygenation. Archives of Disease in Childhood Fetal & Neonatal Edition, Jun 2007;

doi:10.1136/adc.2006.113167

Van Reempts, P; Gortner, L; Milligan, D; Cuttini, M; Petrou, S; Agostino, R; Field, D;

den Ouden, L; Borch, K; Mazela, J; Carrapato, M; Zeitlin, J. Characteristics of neonatal

units that care for very preterm infants in Europe: Results from the MOSAIC study.

Pediatrics, Oct 2007, 20(4):e815-e825.


Zeitlin, J; Draper, ES; Kollee, L; Milligan, D; Boerch, K; Agostino, R; Gortner, L; Van

Reempts, P; Chabernaud, JL; Gadzinowski, J; Breart, G; Papiernik, E; MOSAIC Res

Grp. Differences in rates and short-term outcome of live births before 32 weeks of

gestation in Europe in 2003: Results from the MOSAIC cohort. Pediatrics, 2008, 121

(4): E936-E944.


.


Appendix 2: Summary of current projects using YNN data or

involving the YNN team

Current projects: Full reports are available from the Dr Bryan Gill.

1. A Survey of Parental Perceptions and Experiences of Neonatal Care across the Yorkshire Neonatal Network

Executive Summary

Neonatal services throughout the Yorkshire Neonatal Network (YNN) have continued

to develop, embracing issues of matching supply with demand, maximising limited

resource availability, to working in partnership with agreed referral patterns and

collective protocols. However it was recognised that one of the most important

fundaments to successful neonatal network management was to stay attuned to the

needs and wishes of the service user. Thereby commissioning a study of parental

experiences of care within the network has enabled the YNN to engage with service

users, which has both provided the first indicators of parental perceptions of care and

marked the progress made by the YNN to date.

Following ethical approval the study of parental perceptions was undertaken in all 12

neonatal units within the YNN. The study was performed by the YNN over a three

month period of the summer of 2006. Questionnaires were distributed to parents and

encompassed 9 domains inclusive of Transport, Communication and Visiting, Care,

Decision-Making/Participation, Support, Education and Information, Preparation for

Discharge Home, Facilities, and Yorkshire Neonatal Network Experience. An overall

response rate of 72% was achieved with 286 parents returning the questionnaires out of

a possible denominator of 395. Descriptive analyses were undertaken. The following

key findings are summarised below:-

Findings

Parents perceived that the YNN provided good care to their baby/babies

Health professionals always understood the needs of the baby

Health professionals did not always offer appropriate levels of understanding of

the families‟ needs

Communication with parents and parental engagement in decision making or

informed choice was perceived, at times, as being lower than that which the

parents and families desired

The inflexibility of visiting for grandparents, children, and relatives who

travelled long distances caused some concern amongst family members

The majority of parents considered that an early transfer back to their home unit

was preferable for them


Parents perceived that during the lead up to discharge more education and

information opportunities should be delivered to parents by experienced health

professionals

On occasion discharge planning opportunities appear to have been missed at

crucial times during the parents‟ stay within the NNU

Parents expressed value in talking to other parents with premature infants

Parents expressed a view that where units were going through “service-changes”

they were keen to be involved in future modifications

There was a relative lack of understanding of the existence or role of the

Neonatal Network

Recommendations

The YNN recommends that the neonatal units within the network and the Network

undertake to:-

Provide greater understanding of the families‟ needs

Improve channels of communication and greater engagement with parents in

decision making and offering of informed choice

Increased flexibility of visiting particularly with grandparents, children and

relatives who travel long distances

Earlier transfers back to home units where possible

More flexible education and information opportunities delivered at critical times

by experienced health professionals

Increased use of parent-to-parent support networks

Service user involvement through focus groups and questionnaires to map long-

term perceptions and involvement in service modifications


2. Care and management of substance-exposed newborn

infants across the Yorkshire Neonatal Network

Executive Summary

Background: The Advisory Council on the Misuse of Drugs (ACMD)(2003) and UK

prevalence statistics demonstrate an increase in the numbers of newborn infants born

each year that are exposed to illicit substances in utero (Department of Health 2005).

Affected newborn infants present a problem to neonatal services as they may require

treatment for many weeks, leading to a prolonged stay on the neonatal unit, resulting

both in significant bed occupancy and financial implications.

There is little evidence to inform best practice in the care and management of substance

exposed infants in the UK. Recent national surveys both in the UK (Johnson et al 2003)

and abroad (Sarkar et al 2006) demonstrate a wide variation in the management of

substance misusing mothers and their offspring. The aim of the study was to survey the

current care and management of substance-exposed newborn infants across the

Yorkshire Neonatal Network (YNN).

Methodology: A research project comprising three strands was undertaken:

A questionnaire survey regarding treatment protocols/guidelines for management

substance using mothers and their infants sent to the Lead Nurse for each of the 12

YNN Units.

An audit to establish prevalence rates of substance-exposed newborn infants

admitted to neonatal units across the YNN.

A retrospective review of medical records of newborn infants treated for neonatal

abstinence syndrome in 2004.

Key Findings

Guidelines

11 of the 12 units across the YNN have a protocol/guideline for the management of

neonatal drug withdrawal. At the time of the study the 12th unit had a guideline in

preparation.

Assessment of drug withdrawal (Scoring systems)

There is little standardisation of scoring systems across the network.

All units expressed an interest in the development of a network scoring system.

Pharmacological Treatment of NAS

The commonest first line treatment for NAS across the YNN is oral morphine.

Many treatment guidelines advise a starting dose of oral morphine of 40

mcg/kg/dose (4 hourly).

Doses up to 100mcg/kg/dose 4 hourly are given in the network.

A second line agent was administered to over 25% of affected infants.

Weaning Strategies and Duration of Stay

Weaning strategies varied according to the scoring systems used.

The length of stay is determined by individual guidelines and according to treatment

duration.


The median duration of treatment was 13.5 days and ranged from 12-18 days in

total.

The median total length of stay was 22 days and ranged from 19.5 – 25 days

Communication Pathways and Planning Process

All 12 units reported they are able to identify substance misuse problems and the

level of support available for the mother.

Not all units are able to identify the agencies involved with the family.

In some areas across the network specialised drug liaison services are set-up for

pregnant substance misusing women and in other areas there is contact with a Drug

Liaison Midwife.

44 infants (86%) went home with their parents and 5 (10%) home with foster

parents.

Over half of the sample had social work involvement or supervision.

Follow-up appointments were offered in 80% of cases.

No babies were discharged home on treatment.

In some areas, outreach or community support was offered as routine practice in

addition to hospital based follow-up.

Attendance at appointments was generally poor for this group with high DNA rate.

The provision of outreach support appeared to show improved follow-up

compliance

Feeding

The majority of units report encouraging mothers to breastfeed.

Only one newborn infant was breastfed and only one other was combined breast and

bottle fed at time of discharge.

Conclusions:

The network is performing well with 11 of the 12 units having a protocol or

guidelines for the management of neonatal drug withdrawal at the time of the study.

This project has demonstrated significant variation across the Yorkshire Neonatal

Network in the care and management of substance-exposed newborn infants. The

differences may in part, reflect a lack of evidence to inform best practice.

There is little evidence in the literature to support the use of a specific scoring chart,

as a result a wide variety of scoring charts are currently in use.

The available evidence suggests that the most effective first line agent is oral

morphine. Most, but not all units across the network use oral morphine as their

treatment of choice.

Polydrug use is increasingly common during pregnancy; infants born to such

mothers may be particularly difficult to treat. Within the network phenobarbitone,

chloral hydrate and oral morphine have been used as second line agents.

In combination with pharmacological treatment other practices in the care and

management of substance-exposed newborn infants need to be encouraged, such as

breastfeeding and non pharmacological supportive care.


The median duration of stay (22 days) was lower across the network than has been

shown in previous work in the UK (Johnson et al. 2003).

There was some variation in duration of stay across units within the YNN, whilst it

may be that this relates to the degree and speed of weaning treatments, the numbers

were insufficient to draw any definite conclusions.

This survey showed significant variation in the standards for agency involvement,

communication and long term follow-up for the families and affected children.

Recommendations:

The extensive literature search and main findings from this work lead us to the

following recommendations:

Care of the pregnant substance misuser

Pregnant substance misusing women should be engaged in drug treatment / have

contact with specialised ante-natal drug liaison services.

Scoring Systems

The development of a standardised scoring system for use across the network should

be a priority.

Treatment of NAS

Oral morphine should be the first-line treatment of choice.

A starting dose of 40mcg/kg/dose 4 hourly is likely to effective.

Within the network an evidence based protocol for second line treatment should be

developed. The current evidence available may support the use of phenobarbitone in

such situations.

Weaning Strategy

Once an appropriate scoring system has been developed, a weaning strategy based

on such scores can be developed.

Once treatment has been discontinued the newborn infant should be observed for a

period of 48 hours before discharge.

Communication Pathways and Planning Process

Breast feeding should be actively encouraged where appropriate.

Information sharing between services should be optimised throughout the infant‟s

stay.

Educational events should continue to take place across the network to regularly

update on clinical practice and educate within individual units.

Once a network guideline is in place regular audit will be essential to monitor

outcome.


Appendix 3: Admissions for neonatal intensive care by

gestation, year and survival at discharge by PCT.


Appendix 4:

Duration of ventilation and length of stay for non-transferred ventilated

babies, by hospital, by year.


Appendix 5:

Data Collection Forms 2007


THE NEONATAL SURVEY - DATA COLLECTION FORM

(East Midlands & South Yorkshire)


THE NEONATAL SURVEY – TRANSFER DATA COLLECTION FORM (East Midlands & South Yorkshire)


YORKSHIRE NEONATAL NETWORK – DATA COLLECTION FORM


YORKSHIRE NEONATAL NETWORK – TRANSFER DATA COLLECTION FORM

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