ENTER CONFERENCE May 4th 2006

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ENTER CONFERENCE May 4th 2006

• Lin Marriott

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CESDI 27/28 How Do We Measure Up?

• Comparison of care in a Neonatal Intensive Care
  Unit with the
• Confidential Enquiry into Stillbirths and Deaths
  in Infancy - Project 27/28 Standards
• Staff perception of standards of care

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Background

• CESDI Project 27/28
• Prematurity is the major cause of neonatal deaths
• Focus of the national CESDI programme in 1997
• Prematurity accounts for 14 of all births
• accounts for 47 of all
  deaths
• Survival rates - 88 if born at 27/28 weeks

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Aim of Project 27/28 Enquiry

• To identify patterns of practice or service
  provision that might contribute to deaths of
  27/28 week infants, and make recommendations for
  future practice

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Project 27/28 Enquiry

• Conducted record review assessed
• Survival rates to 28 days of age of 27/28 week
  infants
• Conducted a Confidential Enquiry on all NND
• an equivalent group of survivors
• Enquiry provided 1st national data on survival
  rates

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CESDI Project 27/28 Standards

• 1. Resuscitation (5 standards)
• 2. Early thermal care (1 standard)
• 3. Surfactant therapy (2 standards)
• 4. Ventilatory support (3 standards)
• 5. Cardiovascular support (3 standards)

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Background NICU participating in the study

• Tertiary Level 3 Regional Neonatal Intensive Care
  Neonatal Surgery centre
• 13 intensive/high dependency care cots
• 10 special care cots
• 14 transitional care mother/baby beds
• Approximately 300 ICU admissions per year
• ( HDU SCBU transitional care)
• Provides 2150 ICU days per year
• Provides 1650 HDU days per year

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Aims of the study

• To assess whether the early clinical
  management of 27/28 week infants adhered to
  national guidanceTo determine if improvements
  in quality and safety of care were required

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Study Design

• Combined Quantitative / Qualitative approach
• Two phase design
• Phase One - Record Review
• Phase Two - Semi-Structured Staff Interviews

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Phase One Record Review

• Demographic data
• Infants 26-296 weeks gestation
• Mean birth weight 1170g (498-1570g)
• Records of infants born during a one year period
  audited
• Exclusion criteria outborn infants (n 12)
• 41 infants fulfilled criteria, all records were
  assessed (n41 - 100)
• All 41 infants survived to 28 days

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Phase Two Staff Interviews

• Participants
• Interviews were conducted with NICU staff
• Exclusion criteria staff who provided care only
  under direct supervision
• Interviewed in single professional peer groups
• Snr Sr, Sr, SN
• Consultant, SpR, SHO
• X 6 group interviews undertaken (n18 staff)

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Phase Two Staff Interviews

• Semistructured interviews asked for
• Understanding of principles and expected
  standards of practice
• Staff perceptions of what actually happened in
  practice

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RESULTS Record Review

• 5 out of the identified 14 CESDI standards
• fully met
• (36 documented compliance)
• 2 out of the remaining 9 specific standards
• partially met
• 7 standards unmet

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RESULTSStaff Interviews

• All 14 standards understood and articulated by
  staff
• (100 compliance on principles)
• 6 were perceived as actually met in practice
• (43 perceived compliance in practice)
• Perception of practice that did not meet the
  criteria closely matched results of record review

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Standards for Resuscitation

• A Consultant/SpR should be with an SHO for 27/28
  week infant deliveries
• 34 infants Consultant/SpR/both present (83)
• 1 infant - SHO alone present
• 1 infant - neonatologist not present
• 5 records had missing data on attendees, or
  signature/designation was illegible

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Standards for Resuscitation

• All infants received appropriate bag and mask
  ventilation when needed (n 28) 100
• 20 out of 25 infants who were seriously
  clinically compromised were intubated by 5
  minutes of age (80)
• But 5 out of 25 infants were not intubated by 5
  minutes of age (20)
• Of the 5 not intubated a median 4 attempts was
  required to achieve intubation (95 CI 2-5)

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• Staff perception delays in intubation were a
  source of anxiety to all staff
• I felt the baby wasnt responding to what we
  were doing and we needed to intubate - Sr
• We dont concentrate enough on the practical
  things. We talk too much on the theory of
  ventilation, but there are real practical things
  for us to learn, such as how you intubate SHO

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Standards for Resuscitation

• All infants received ongoing respiratory support
  in NICU
• 25 infants were ventilated on admission
• 16 infants received cpap

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Standards for early thermal care

• Infants temperature should be above 36c on
  admission to the NICU
• All 41 infants had a temperature gt 36c
• Mean temperature on admission 37.4c
• (95 CI 37.1- 37.7)
• (range 36.1- 39.5)

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Standards for Surfactant Therapy

• Surfactant should be administered to all
  intubated infants
• Surfactant should be administered within one
  hour of birth
• All 25 intubated infants received prompt
  surfactant therapy

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Standards for ventilatory support

• Regular blood gas analysis should be performed
  whilst the infant is receiving respiratory
  support
• All infants had regular blood gas monitoring
• But time of 1st blood gas varied
• 10 infants who were ventilated and had received
  surfactant did not have a blood gas performed for
  more than an hour post delivery
• Median 51 minutes (95 CI 42- 59)
• (range 10 170 minutes)

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• Staff perception All staff thought that a blood
  gas should be taken within ½ an hour, many
  thought this was always achieved
• generally, we get a gas done within the 1st few
  minutes, or by ½ an hour SN
• But some did not
• weve had times when it can be an hour and a
  half, and its just not good enough Snr Sr
• we never achieve a blood gas within an hour
  Consultant

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Standards for ventilatory support

• Ventilation should be adjusted with the aim of
  maintaining a pH gt 7.25 and a Pa02 6-10kPa
• 12/25 infants (48) had a pHlt 7.25 in 1st 24
  hours of life
• Pa02 range 2.10 13.7kPa
• PC02 range 2.62 5.99kPa (PC02lt3.5 n10)

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• Staff perception
• We do not get enough gases in the early phase
  Consultant
• We need to be more aggressive, we sometimes get
  babies that are hypocarbic and we need to know
  and do more SpR

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Central Vascular Access

• All 41 infants fulfilled criteria for indwelling
  central venous access
• Achieved for 33/41 infants (80)

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• Staff perception
• Central vascular access was perceived as
  problematic by all, and revealed both internal
  and external pressures
• when you are doing a procedure you tend to
  lose track of time, and 10, 20 minutes pass very
  quickly, and if the baby is not well you feel a
  pressure to do it SHO
• junior Drs want to have a go at putting lines
  in, they need practice, but it takes longer and
  it depends how stable the baby is and what they
  can tolerate. I say they should have two
  attempts and thats enough. The SpR should do it
  Snr Sr

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Staff perception

• Differences in priorities between groups
• sometimes the nurses have everything done in
  ten minutes, some people it can take an hour, but
  we are not allowed to touch the baby to put in
  lines until its done SpR
• theres too many people and they just want to
  jump in and weve just brought the baby, and if
  they give us that initial ten minutes just to do
  your things, and then they can do theirs SN

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• Cardiovascular Support
• The mean BP should be maintained at or above
  the infants gestation
• 9/41 (22) infants were hypotensive
• All 9 hypotensive infants received volume
  expansion 3 received inotropic support
• A total of 19 infants received volume expansion
  within 24 hours of birth
• But 9 out of the 19 who received a fluid bolus
  normotensive with a normal blood pH value

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Staff perception key themes

• Prioritisation
• Teamwork
• Communication
• Time frames internal / external pressures
• key factors perceived to influence
  effectiveness of early care

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Implications

• Results closely matched the findings of the CESDI
  Enquiry
• Care provision at critical periods in the
  resuscitation and stabilisation of infants was
  not consistently optimised
• Early care was dependent on the effectiveness of
  the team responsible at the time - not
  organisational factors
• Support and supervision for the SHO was variable
  according to senior clinical staff on duty

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Implications

• Disparities with expected standards -wider
  implications for other vulnerable infants
• Potential impact on later morbidity/mortality
  beyond 28 days
• Leadership and prioritisation during early
  management of infants
• Clinical support, role clarification and teamwork
  issues

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Key strategies

• Competence of all grades of clinical staff more
  closely verified on induction
• Closer monitoring and formalisation of continuing
  clinical support
• Increased frequency of inter professional
  practical skills workshops

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Key strategies

• Increased awareness of, and improved
  clarification of responsibilities
• Nurse designated to provide 11 early care
• Brief debrief by team following each admission
• Amended documentation ongoing
• Algorithm to assist prioritisation of early care
• Re- audit maintain impetus

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Algorithm for the first hour care of sick
neonates
Designated doctors and nurse to attend delivery

• Infant
• lt30/40 plastic bag
• Airway stabilised
• Ventilation/CPAP if lt 30/40
• Curosurf

Time 1 Delivery to NICU
Designated nurse
NICU SHO
Delivery SpR
NICU SpR
Transfer to incubator Weigh OFC Connect
monitoring record Temp, RR, HR, Cuff BP
TC02/TCPC02 Support infant for PVL
Time 2 Arrival NICU to UAC/UVC insertion
Set up for central lines

• Check ETT ,
• Clinically assess vent/perfusion
• PVL, blood gas
• Blood sugar
• Px fluids and drugs
• Handover to NICU SpR
• Document delivery and treatment

Supervise SHO

• Central line insertion
• Maximum of 1artery
• Expected time
• not gt 30 mins

Time to PVL gas 5-10 minutes
Assist with central lines Support
infant Complete admission log Pass NGT
Time Expected UAC/UVC SHO SpR notgt30mins
Successful
Unsuccessful
SpR to insert lines

• Bloods
• gas
• X ray

Unsuccessful
Successful
Ensure complete, accurate documentation and
record times to intubation, Curosurf, lines and
ventilator changes, once infant stable.
Immediate short debrief if time allows
Inform consultant

• Amend ventilation
• Check ETT, line position

SpR or delegate to SHO- update parents asap
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Thank you any questions?