Best Practices Challenges GWH Swindon perspective Dr K

Best Practices & Challenges GWH, Swindon perspective Dr K Girish Gowda Consultant Paediatrician GWH, Swindon Acknowledgement: Southwest Neonatal Network Dashboard

Overview • • GWH ATAIN trend Routine practices at GWH ATAIN Action Plan Share good things/ Challenges

2016 & 2017 ATAIN data ATAIN 2016 12 ATAIN 2017 11 10 9 8 7 6 5 4 3 2 1 0 Swindon Taunton Gloucester Cornwall RDE Bath

Swindon ATAIN Trend ATAIN rate trend 4 3. 86 % 3. 8 3. 6 % 3. 6 3. 4 3. 2 3. 12 % 3. 0 % 3 2. 8 2015 -16 2016 -17 2017 -18 April to September 2018

Swindon ATAIN Trend Total Live Briths Term admissions 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0 180 160 140 120 100 80 60 40 2015 -16 2016 -17 2017 -18 April to 2018 2015 -16 2016 -17 2017 -18 April to September 2018 Total Live births remain static but ATAIN rate is bit on the upper trend

2017 Data (Per 1000 Live Births) 140 120 Network 100 Swindon 80 Bath 60 Taunton 40 Gloucester 20 0 Respiratory Suspected Infection Hypoglycemia Jaundice Monitoring HIE

Practice in Swindon General Points • Antenatal Care: – Breast milk expression: two weeks prior to all elective Csection. – Robust antenatal care for diabetic patients – Antenatal Counselling with clear plan at delivery • Enthusiastic midwifery team and staff are good at following guidelines • Clear and easy to follow NEWS (Newborn Early Warning Score) chart

Practice in Swindon General Points • MSW (Midwife Support Worker) jointly look after babies on postnatal ward : one per shift. • Good working relationship between Maternity and Neonatal team • Monthly PAG (Perinatal Action Group) meeting – multidisciplinary team, discuss various issues including guideline approval

Practice in Swindon General Points • SCBU Nurses are good at challenging medical staff on unnecessary admissions. • Consultant availability and support: Daily postnatal ward rounds in presence of midwife incharge. Clear plan written notes.

Practice in Swindon Floor Plan- Good or Bad

Practice in Swindon Respiratory : A. All elective LSCS before 39 weeks consider antenatal steroids. B. Thermal Care : Delivery room optimal temperature, Baby Hat and skin to skin with proper covering baby with blankets. C. Grunting babies at birth otherwise well: stay with mother but reviewed in 30 – 60 min D. Registrars are encouraged to keep term babies on Delivery suite / post natal ward with frequent reviews and a clear plan.

Practice in Swindon Suspected Infection : 100 90 80 70 60 50 40 30 20 10 0 Term Admission per 1000 Live Births Early recognition and intervention as per NICE CG 149 All babies get “sepsis Identification Tool “ chart Network Swindon 2017/18 Respiratory Hypoglycemia Monitoring Network Swindon April - Sep 2018 Suspected Infection Jaundice Suspected HIE Antibiotic ward rounds – 02. 00 & 14. 00 hr Improved handover - Baby’s details on Handover sheet with a clear plan

Sepsis Identification Tool Chart

Practice in Swindon Hypoglycaemia: 100 90 80 70 60 50 40 30 20 10 0 Term Admission per 1000 Live Births Mat. Neo Wave 2 – Awaiting implementation of BAMP guideline Proposed changes are: Network Swindon 2017/18 Respiratory Hypoglycemia Monitoring Network Swindon April - Sep 2018 Suspected Infection Jaundice Suspected HIE • Reduced threshold of BS from 2. 6 to 2. 0 • Dextrose gel • Large babies are excluded • Strict on when to do blood sugar, e. g before second feed

Practice in Swindon Suspected HIE Trend : GWH 30 26 25 22 19 20 15 12 10 5 0 2015 2016 2017 April to Sept 2018

Practice in Swindon Suspected HIE 100 90 Term Admission per 1000 Live Births 80 70 60 Respiratory 50 Suspected Infection Hypoglycemia 40 Jaundice 30 20 12. 5 Monitoring 18. 4 Suspected HIE 10 0 Network 2017/18 Swindon 2017/18 Network Swindon April - Sep 2018

Continued resuscitation at 10 mins

Swindon Audit 2017: Cooling Criteria

Suspected HIE between Networks 8 7 6 5 5. 2 4. 6 4. 4 4 ATAIN Rate 6. 9 3 Suspected HIE 2 1 0 1. 8 TV&W April to Sep 2018 2. 3 South West South. East Coast

on M g 20 rin ito 6 R 12 BS 40 SB 4 O bs m iu on ec 10 M 0 1 ra py he 16 ot 14 ot 20 Ph 27 bs Apr-18 NA S O bs S O GB 15 PR OM tic io ib nt IV A 0 2. ea t 13 BW < r S 50 45 40 35 30 25 20 15 10 5 0 Ca 6 6+ 3 to +0 34 Post-natal ward / TC May-18 44 37 23 17 12 22 25 11

“More than normal care” on PNW 400 358 356 300 250 200 150 Total Live Birth 137 (40 %) 133 100 50 0 Apr-18 May-18 Additional Care

ATAIN – Action Plan 2018/19 Sl No. Aim/Objectives Action Outcome/Success Criteria 1 To improve the accuracy This highlighted the need for Employing data of data input on Badger a Admin staff: Data Analyser analyser. by ensuring we (GWH) No “missed data” or comply with and record “inaccurate data” on in line with the NNMDS badger. (National Neonatal Minimum Data Set) 2 Minimise admission of babies Retrospective Audit – to study the Reduction in babies with HIE. most common reasons and needing CFM or cooling Completed Audit : implement measures as needed. a. “HIE Care Bundle“ Continue the current project of “Each Baby Counts” & “Saving b. Network to revisit / revise Babies’ Lives”. Current HIE guideline Learn from individual cases.

Proposed “HIE / Neonatal Neuro-Protection (NNP) Care bundle”

ATAIN – Action Plan 2018/19 Sl No. 3 Aim/Objectives Action Outcome/Success Criteria Mandatory e-learning on “Avoidable Term Admission” (RCPCH accredited). Available via Training Tracker Staff to be made Aware of this by email, newsletter, poster. To cover this on Induction for new staff Audit to show many have completed the training module this year. Aim for 80% completion. ? 4 2017 data shows, 27% of all Retrospective audit on these Implementing the learning term admissions staying less babies and implement points from the audit results. than 24 hrs measure to minimise this Aim to reduce this to <20% by next year.

Something to Celebrate / Share 1. Good ATAIN rate 2. Good NNAP 2016 / 2017 3. Good MBBRACE on still births 2016/17 4. Nursing recruitment 5. Badger. Net Admin Staff 6. Extended & robust Outreach SCBU Nursing Services 7. Monthly Coffee morning run by Parents / SCBU nurse 8. Improved quality of Badger. Net daily summary (entered by Nursing staff) Challenges: 1. Split Tier 1 (SHO) Rota 2. Quality of Badger Discharge letters (Doctors complete it) 3. To keep our ATAIN target at the current rate. 4. TC implementation

ATAIN TEAM • • • Swindon ATAIN core Team: § Neonatal Consultant ATAIN lead: Dr Gowda (GG) § Obstetric Consultant ATAIN lead : Dr Sinha (AS) § Senior Midwifery Team ATAIN lead: Mrs Kathryn Owen(KO) § Senor Midwife: Karin Jones (KJ) § Senior Neonatal Nurse : Mrs Nikki Taylor (NT) SB – Dr. Sarah Bates, Consultant Paediatrician/Neonatologist STZ- Dr. Stanley Zengeya, Consultant Paediatrician/Neonatologist CG – Cathy Gale, Breast feeding co-ordinator midwife JE- Julie Edwards, Sister in charge on DAU AM – Alison Morton, Sister In charge on Day Assessment Unit EC – Emma Churchill, Service Manager Women and Children Division RM- Rob Mc. Kinlay, Data Quality Administrator and Risk Management GT- Gemma Texeira, Data Quality Administrator DJ- Donna Johnson, Midwife JH- Julie Herring, MSW

• Thank you