ATAIN - experience from South East Neonatal ODN

Vanessa Attrell

Neonatal Network Manager

17th October 2018

South East Neonatal

Operational Delivery Networks

Hosted by Medway Foundation Trust

Outline

• SE Neonatal ODN data and trends

• Term admission audit 2015: process & results

• NHSE CQUIN 2015/16: process & results

• NHS South: collaborative working 2017/18

• 2018/19: ATAIN Improving Value scheme

• What can we do to avoid term admissions?

• Joint & collaborative working to share best practice in reducing term admissions.

SENN data for 2010/11 • SE average rate of term admissions to live births 5% (variation

2-9%) includes NNU and TC:

• National Neonatal Audit Programme(NNAP) 2011

SE units rate of term admissions into NICU to live births 3-5% national average 4%.

• SEC % of admissions that were term babies:

Inborn, booked, 1st episode average 55%(43-66%)

• NDAU data national average admissions

2010/54% 2011/57%

SEC 2010: 43-66% 2011: 47-70%

Work in 2011/12

• NHS Outcome Framework 2011/12: indicator 5.5. Improving the safety of maternity services

• Shared the data widely with the Neonatal Networks, SHA Maternity lead, Heads of midwifery, PCT maternity commissioners.

• Introduced 2 year QIPP programme with measures to monitor term admissions.

• Neonatal data & analysis, presented at Neonatal Network Boards.

• Undertook Transitional Care scoping process, engaged with Trusts to produce SEC TC criteria.

SENN data 2013 – 2014

• July 2014 NHSE published national data.

• SE replicated NDAU data analysis

• Top reason for admission: Other 28% of babies

• Immediate request to Trusts to stop using ‘Other’ as a

reason for admission.

• SEC Respiratory 19% national data 30%

• SEC Infection 24% national data 9%

• SEC Hypoglycaemia10% national data 10%

• Suspected/confirmed infection appeared to be our

biggest problem.

SENN next stages: 2015 / 16

• September 2014, applied to the SEC Maternity SCN to

support a joint audit in 2015 on Term Admissions; based on

the information we knew on the top five reasons for

admission. The proposal was supported in January 2015,

audit across all Trusts June – August 2015.

• November 2014 several network members joined the national

work groups for reducing term admissions.

• Followed up with Trusts who were using ‘Other’ as a reason

for admission. ‘Other’ was removed from BadgerNet in

January 2015 as a result of the national data report.

• Introduced additional graphs to the SEC Monthly reports for

2015/16 to raise awareness in teams on term admission

numbers.

Network Monthly Quality Report 2015-16

Network Monthly Quality Report 2015-16

NHSE QIPP 2014-16 & CQUIN 2015/16 Collaborative working with NHSE area team & SE Neonatal Network

• Two year programme.

• Aim to reduce avoidable admissions and increase term babies receiving care beside their mother.

• 2014/15 TA into NNU 53% & beside mothers 47%

• 2015/16 TA into NNU 48% & beside mothers 52%

• Increase of 200 babies receiving care beside their mothers; with a decrease in LoS from 2.6 to 2.4 days.

• Rate of admissions to births remained the same at 8%

• National CQUIN developed by NHSE.

• Maternity & neonatal leads had to review

all TA into NNU each month & report.

• Trusts were asked to identify avoidable

admissions and put process in place to

manage these babies.

• 7 out of 11 Trusts participated

• One Trust introduced BAPM NEWTT

• One Trust implemented the Bobble Hat

Care bundle, based on a traffic light

triage system. This was a joint project

with maternity and neonatal staff with

excellent results

• Another Trust established a

Hypoglycaemia Pathway that has been

adopted across the SE NN.

What did we do about it?

• Created the Bobble Hat Care Bundle – Every baby receives a bobble hat straight away after

birth following a clinical assessment.

– A way of assessing mother and baby holistically to identify those families who require extra support following delivery

– RAG rated

– Bobble Hats knitted by the local community and local Guide Group produces bobbles.

– Presented at several national conferences and a Parliamentary meeting

Audit Results & learning: 1115 term admissions,

880 forms returned, 79% compliance rate.

Reasons National

2011-13

SEC

2013/14

SEC

2014/15

SEC

2015/16

SEC

Audit

2015

Infection 9% 24% 25% 40% 36%

Respiratory 30% 20% 20% 16% 20%

Hypoglycemia 10% 10% 10% 12% 11%

Jaundice 5% 6% 6% 6% 9%

HIE 3% 1.7% 1.3% 1.6% 4%

Poor Feeding 3% 3% 2% 2% 2%

Network Audit Results

Avoidable

• 72 babies (8%)

• Poor feeding

• Weight loss

• Social

• 257 days

• Potentially 1000

days a year

0bservation only

• 60 babies (7%)

• HIE/Asphyxia

• Maternal drug use

• Respiratory

• 231 days

• Potentially 900 days a year could be beside mother

Audit Recommendations: Jan 2016

• Review the clinical management of avoidable babies with Obstetric and Midwifery colleagues

• Review the Observation only babies; do they require observation on the NNU?

• Review local guidelines on Infection and Jaundice in accordance with NICE guidelines

• Share good practice and learning from audits

• Introduce a risk management tool: BAPM NEWTT or Royal Surrey Bobble Hat Care bundle.

Regional ATAIN scheme 2017/18

• South Region Neonatal Networks Forum established, led by

NHSE South Clinical Director Specialised Commissioning.

• First meeting in June 2016, data analysts produced table to

show term admission rate into NNU against births and term

admissions into NNU as a % of NNU admissions.

• Variation: TA into NNU 2-12%; % of admissions that were term

babies on NNU 38-70%.

• Feb 2017 agreed a South Region ATAIN Improving Value

scheme for 2017/18 applicable to all Trusts.

• Agreed target: below 6% rate of term admissions into NNU.

• NHS South ATAIN Dashboard: produced by South West

• Monthly Highlight progress reports to NHS South.

What we did in 17/18 across the South to achieve the target

• All Trusts to have named ATAIN leads; maternity, obstetric, neonatal medical & nursing.

• Monthly graph to all ATAIN leads

• 2-3 monthly newsletter update

• Posters

• Engaged with LMS groups, Maternity Network, AHSN, Safety collaborative.

• Encouraged sharing of local initiatives to enable wide scale change.

SEC Monthly ATAIN graph 17/18

0

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ATAIN: Term Admissions % of live births target 4% for 2017/18

Term Admissions % of live births Term admissions into NNU % of live births

Term Admissions target Term Admissions into NNU target

SEC Births v Term Admissions

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Bir

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Births v Term Admissions Quarterly Tracker

All Term Admissions Term Admissions into NNU Births

2017/18: South % of admissions into NNU

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South West Thames Valley Wessex South East Coast East Midlands

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ATAIN South Dashboard 2017/18

Live Births All Live births delivered within the trust area (includes all gestational ages)

Term Admissions

≥37 weeks gestation, 1st episode of care only, NNU as location of care for any part of the neonatal episode (includes cardiac and surgical babies)

Principal Admit Reason

Total number of term admissions for each of the 6 most common principal admission reasons

HRG 3-5 Only

NNU 1 Day: Total number of term admissions receiving only HRG3-5 level care throughout neonatal episode with location of care NNU for 1 day only

NNU >1 Day: Total number of term admissions receiving only HRG3-5 level care throughout neonatal episode with location of care NNU for >1 day

Did we achieve our target?

Yes

NHS South ATAIN 2017/18

4.5%

5.3% 5.8%

4.2%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

TV W SW SEC

SENN Livebirths 2011-2018

50000

51000

52000

53000

54000

55000

56000

57000

58000

2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

SENN Term admissions all areas 2011 - 2018

0

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2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

East Midlands data

0%

1%

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5%

6%

7%

8%

9%

10%

2014/15 2015/16 2016/17 2017/18 (to Sept 2017)

Term admissions to NNU (as % live births)

NICU LNU SCU Network

What made a difference in 2017/18

• NHS South ATAIN programme

• South ATAIN Dashboard

• Participation from clinical teams • Maternity & obstetric involvement through

the Local Maternity System & Maternity Network.

• Acknowledgment this is not a ‘neonatal’ problem

• Maternal & Neonatal Health Safety Collaborative; sharing of initiatives

National ATAIN scheme 2018/19

• National target below 6% by March 2019

• NHS South target below 5% by March 2019

• All Trusts should review South ATAIN Dashboard each quarter; if your rates are increasing audit & review term admissions; national form for audit.

• E data collection form for Livebirths

• Exception reporting if above 5%

What have we learnt?

• Work together to make the changes needed to keep mums & babies together.

• Involve infant feeding team.

• Skin to skin

• Education; use the e-learning module

• Know your highest reason for admission

• Safety huddles

• Changes to Jaundice referral Pathway; use of bilirubin meters; seen and assessed by midwives

• Start AB’s in delivery suite; avoid NNU.

• Delivery packs with hats.

• Gestation awareness for planned sections

• Address delivery room temp if necessary.

SEC NN

2011/13

High numbers of

term

admissions:

Atlas of Variation

NHSOF

Network data

Established

reporting

Clinical

engagement

SEC NN

2014/16

Levers for

change:

QIPP

CQUIN

Audit

Measuring

progress

NHSE Safety lead

National focus on reducing term

admissions started in 2014

Safer Maternity Care Oct 2016

SEC NN

2016/17

Increased no of

babies beside

mothers

Regional

networking

ATAIN part of

national agenda

Sharing local

initiatives

2017/18

onwards

NHS South ATAIN

Programme of care

Improving value

SEC NN

Wider clinical

engagement

Trust ATAIN

leads

Commitment to

Right Care, Right

Place

ATAIN – network approach to change

Acknowledgements:

• Dr Aung Soe – SE NN Clinical lead

• Dr Peter Reynolds – SE NN Clinical lead

• Martin Webb – SEC NN Data administrator

• Pippa Griew – SW NN Data analyst

• All South Network Managers & clinical leads

• Royal Surrey County Hospital team & slide

• Contact details: vanessa.attrell@nhs.net