Quality Surveillance Team Neonatal Critical Care (NCC) Quality Indicators
Neonatal Critical Care Quality Indicators Introduction These neonatal critical care quality indicators have been developed using the following primary source documents: The specialist commissioners service specification for Neonatal Critical Care (Intensive Care, HDU and Special Care), E08/S/a. The British Association of Perinatal Medicine (BAPM), Service Standards for Hospitals Providing Neonatal Care (3rd edition), 2010. The BAPM Categories of Care 2011. The National Neonatal Audit Programme 2015 Annual Report on 2014 data. The NHSE special commissioners Neonatal Quality Dashboard. Toolkit for High Quality Neonatal Services. NHS & Department of Health, October 2009. NICE Neonatal Specialist Care Quality Standard QS4 2010. The definitions of the different categories of neonatal care and types of neonatal unit (NNU), are as in the source documents below, and can be summarised briefly as follows: Neonatal Care Categories. 1. Normal Care is that deliverable by a mother without professional help. This does not usually feature in documents specifying care categories but is stated here to define a baseline. 2. Transitional Care needs the mother to be resident within a healthcare setting, possibly providing some care herself but receiving support from a midwife or other healthcare professional (HCP). Transitional care may be delivered on a standard postnatal ward or a dedicated transitional care ward. 3. Special care is care which needs the input of specialist neonatal services, on some type of NNU but does not need High Dependency Care or Intensive Care. Special care is defined further by a list of specific procedures 4. High Dependency Care is care on a NNU which needs a greater degree of input than Special Care, but where the ratio of nurse to patient is less than for Intensive Care. It is further defined by a list of specific procedures 5. Intensive Care is care on a NNU which needs a greater degree of input than High dependency Care. It is further defined by a list of specific procedures Types of NNU. There are three types of NNU Special Care Units (SCUs), Local Neonatal Units (LNUs) and Neonatal Intensive Care Units (NICUs). Special care units (SCUs) provide special care for their own local population. Depending on arrangements within their neonatal network, they may also provide some high dependency services. In addition, SCUs provide a stabilisation facility for babies who need to be transferred to a neonatal intensive care unit. (NICU) or local neonatal unit (LNU) for intensive or high dependency care and they also receive transfers from other network units for continuing special care. June 17 2 neonatal critical care services
Local neonatal units (LNUs) provide neonatal care for their own catchment population, except for the sickest babies. They provide all categories of neonatal care, but they transfer babies who require complex or longer-term intensive care to a NICU, as they are not staffed to provide longer-term intensive care. The majority of babies over 27 weeks of gestation will usually receive their full care, including short periods of intensive care, within their LNU. Some networks have agreed variations on this policy, due to local requirements. Some LNUs provide high dependency care and short periods of intensive care for their network population. LNUs may receive transfers from other neonatal services in the network, if these fall within their agreed work pattern. Neonatal intensive care units (NICUs) are sited alongside specialist obstetric and foeto-maternal medicine services, and provide the whole range of medical neonatal care for their local population, along with additional care for babies and their families referred from the neonatal network. Many NICUs in England are co-located with neonatal surgery services and other specialised services in other networks. Networking NCC services are now required to be provided as part of NHS Operational Delivery Networks (ODNs). The term network is used to mean the sum total of all the NCC services in the area, linked together as a network, intended to fulfill the principles laid down by NHSE for an Operational Delivery Network and designated as such by the relevant commissioners. The term network governance body is used for the governance structure within an agreed, designated Operational Delivery Network which deals with the networking activities of the NCC services, whether that is a subspecialist part of a wider system which also deals with other services or one dedicated solely to NCC. All relevant provider services in the network should be represented (either directly or via agreed delegation arrangements) on, and come under the agreements of, the same network governance body, so that conversely the extent of the network is defined by those services which share the same single, named, network governance body. This implies that mothers and babies will normally be referred within the host network according to the agreed pathways, however some specialist neonatal surgery and cardiac may routinely go to other services. There is an overall principle to provide care as close to home as possible, but compatible with the category of care and type of unit needed by the neonate. However, since current neonatal ODN networks cover more than one (some, several) NICU/referring units complexes, this principle may not be optimally achieved merely by aiming to keep the neonate within its host network or network of first referral. The agreed pathways within a network may be able to go further than this towards achieving this principle. These indicators should be applied to the NNU. Responsibility for the first of these indicators (E08-17-001) lies with the chief executive, (or their authorised deputy), responsibility for the subsequent indicators lies with the lead clinician of the NNU. June 17 3 neonatal critical care services
Indicators Structure and Process Number Indicator Data Source E08-17-001 The NNU is part of the ODN network governance group Self-declaration The NNU should be party to an agreement with the relevant commissioners that it is a component of a named neonatal ODN network. The agreement should specify: the neonatal services within the network the NNU representation on the network governance body. The terms of reference relating to the NNU and the network governance body. E08-17-002 The NNU is represented at network governance group meetings Self-declaration The NNU should send clinical representation to all the governance group meetings. Annual report including meeting attendance E08-17-003 There are named personnel for lead roles Self-declaration The NNU should have single named personnel for the following unit leadership roles(2) lead nurse lead consultant neonatologist/paediatrician One person may occupy more than one role as appropriate within the boundaries of their professional discipline. June 17 4 neonatal critical care services
lead for non-medical staff training lead for discharge planning lead for breast feeding lead for family centred care lead for bereavement support Each of these should have an agreed list of responsibilities and time specified in their timetable for the role. E08-17-004 There is a multidisciplinary team of specialist AHPs Self-declaration The NNU should have the following specialist allied health professionals with time specified for neonatal care neonatal / paediatric dietitians neonatal occupational therapists neonatal physiotherapists neonatal pharmacist speech and language therapist person providing psycho-social support Each of the above should meet the staffing requirements specified in the Toolkit for high quality neonatal services (DH 2009) The time specified may form part of the individual s wider role. The service may be network-wide E08-17-005 The NNU meets the requirements for medical staffing Self-declaration The NNU medical establishment meets the requirements as specified in the Toolkit for high quality neonatal services (DH 2009) Medical rotas should be available for a review visit June 17 5 neonatal critical care services
E08-17-006 There is 24/7 consultant neonatologist advice Self-declaration The NICU provides 24/7 consultant neonatologist advice and support service for health care professionals including: paediatricians delivering neonatal care at LNU and SCU within the network For networks with more than one neonatal intensive care unit, this may be shared between the units medical rotas should be available for a peer review visit E08-17-007 The NNU meets the requirement for nurse staffing Self-declaration Nurse staffing levels meet the requirements specified in the Toolkit for Neonatal Services (DH2009),and in particular meet the following staff to baby ratios: 1:1 for babies requiring intensive care 1:2 for babies requiring high dependency care 1:4 for babies requiring special care E08-17-008 There is training for registered and non-registered nursing staff Self-declaration At least 70% (special care) and 80% (high dependency and intensive care) of the nursing workforce establishment should hold a current nursing and Midwifery Council (NMC) registration. At least 70% of the registered nursing and midwifery workforce establishment hold an accredited post-registration qualification in specialised neonatal care (qualified in specialty (QIS)) Annual report including details of training. Details of competencies should be available for a review visit Non-registered staff providing direct nursing care should undertake competency based training appropriate to their role and responsibilities. There should be a record of training for each member of staff. June 17 6 neonatal critical care services
E08-17-009 There are integrated community support/ outreach services Self-declaration There should be a neonatal community support / outreach team to provide advice and support for families caring for their babies at home. The team may either be an integrated hospital/community team or a team of community professionals. The NNU should: ensure the members of the team have the specialist training required provide information on the babies care plan ahead of discharge arrange for parents to meet the community team prior to discharge E08-17-010 There are network agreed pathways in place Self-declaration There are network agreed neonatal pathways in place which are integrated with other maternal and new-born pathways. The pathways should include: in-utero and postnatal transfers for neonatal special care, high dependency care and intensive care neonatal surgical care neonatal specialist cardiac care ophthalmology discharge and follow up as specified in the services specification palliative care Patient pathways specify how the different hospitals and groups of professionals should interact at defined stages of the patient journey, for diagnosis, assessment, management or follow up. Where relevant, pathways should take into account nationally or internationally agreed guidance and standards including pathways E08-17-011 There are clinical guidelines for the care of babies on the unit Self-declaration There should be clinical guidelines in place for the care of babies on the unit. Guidelines should be consistent with current network and national guidelines Clinical guidelines cover guidelines, protocols, SOPs which describe how to manage a patient in a given clinical situation or specified point on including guidelines June 17 7 neonatal critical care services
where relevant. the pathway. Some guidelines may be common to all three types of unit; others will be specific to only one or two depending on their levels of care. Ref: NICE guidelines for Jaundice, Early onset sepsis, hypoglycaemia E08-17-012 There is a clinical governance process in place Self-declaration There should be a multi-disciplinary clinical governance process in place to monitor the quality of care including: joint perinatal mortality review with maternity services joint neonatal mortality review process with other services of shared cases joint perinatal morbidity review with maternity services including: term admissions, babies admitted below gestational threshold, babies admitted with HIE review of clinical incidents and dissemination of actions / learning points within Trust and the ODN outcomes of extreme preterm babies at 2 years of age Parent/ Carer Experience E08-17-201 Parent/Carer feedback is reflected in service development Self-declaration The NNU should have undertaken an exercise during the previous two years to obtain feedback on parents/carers experience of the services offered. The exercise and actions taken as a result should have been presented to, Annual report including actions agreed June 17 8 neonatal critical care services
agreed and discussed with the unit, relevant trust governance group, and the network governance body, and shared with parents/carers E08-17-202 There is information for parents and carers Self-declaration The NNU should have written information for patients covering at least the following: the service offered local unit information including o Accommodation o Parking o Public transport o Food for families financial help support services information about the baby s care within the network setting breastfeeding/expressing hand-washing and infection control how parents can be involved in the care of their baby The NNU written information should be provided within 24 hours of admission to the unit. It is recommended that the information is available in languages and formats understandable by patients including local ethnic minorities and people with disabilities. This may necessitate the provision of visual, audio and digital material. examples of information should be available for a review visit 08-17-203 There are facilities for families Self-declaration There are dedicated facilities for families of neonates which should include: overnight accommodation for parents (1) arrangements for secure and readily accessible storage of parents personal items; non-secure storage for personal items (e.g. baby clothes); private breast feeding/ expressing facilities; a parent sitting room; (1) As specified in the Toolkit for high quality neonatal services (DH 2009) June 17 9 neonatal critical care services
a kitchen with hot drink and snack-making facilities, a toilet and washing area; a changing area for other young children; a play area for siblings of infants receiving care; access to a telephone and internet connection within the hospital; a room set aside and furnished appropriately for counselling free parking facilities E08-17-204 The NNU undertakes an audit of family centred care Self-declaration The NNU should undertake an audit of family centred care using the Bliss Baby Charter Audit Tool, develop a plan and implement actions for improvement. Annual report including action plan Clinical Outcomes / Quantitative Indicators Introduction The data for the following quantitative indicators will be obtained directly from the relevant data source. Categories: This section s key feature is that the indicators are quantitative, rather than qualitative, measures of processes or proxies for outcomes. A few can be considered as quantitative structural parameters, which are of contextual interest. Interpretation issues If a parameter is outside the control of the service under review, although it may be very influential on its outcomes, it is a contextual parameter which can t be legitimately used in the direct judgement of the quality of care of the service but may be of great interest. Some parameters are partly under the service s control and partly outside it, making for difficult interpretation. Number Indicator Data Source Descriptor Notes E08-17-101 Retinopathy Screening SSQD Unit, Clevermed Percentage of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g who receive specialist neonatal care and undergo retinopathy screening in line with national guidelines on timing. June 17 10 neonatal critical care services
E08-17-102 Line-associated bloodstream infection SSQD Unit, Clevermed Proportion of babies with positive blood culture after 72h of age standardised to a rate per 1000 catheter days. E08-17-103 Admission Hypothermia SSQD Unit, Clevermed Proportion of new-born babies born at less than 34 weeks of gestation admitted for neonatal care from delivery suite who have an admission temperature of less than 36C. E08-17-104 Birth Place of Extremely Premature Network Babies SSQD Unit/network, Clevermed Proportion of babies born at less than 27+0 weeks of gestation (or multiple pregnancies < 28weeks) who are born in a hospital with a NICU, in the Network. E08-17-105 Mortality rates MBRRACE UK The data in the annual MBRRACE UK Perinatal Mortality Surveillance Report is shown for the relevant commissioning and service delivery organisations, with the mortality analysis based on the mother s address at the time the birth occurred and the place of birth, respectively. There are separate maps for stillbirths, neonatal deaths, and extended perinatal deaths. The 2017 Annual Report (due to be published 22 nd June 2017) is based on the births in 2015 calendar year E08-17-106 Neonatal Network Report - Care Location Exception Summary Badgernet (network reports) List of babies who breached a care location exception, by identified exception criteria, within selected date range. E08-17-107 Nurse staffing / Activity Badgernet (network reports) E08-17-108 NNAP Audit 2017 NNAP (2014,2015,2016) Shows the percentage of shifts staffed to DH Toolkit standards (based on number of staff required against the acuity of patients on the NNU at the time) and the percentage of shifts with a team leader. Also a national average comparison against units of a similar level of unit, within a selected date range Shows the performance of each NNU against 17 NNAP audit questions in 2016 compared to set audit standards (where these exist), averages by level of NNU and national average too. Outlier analysis is also provided for a small number of June 17 11 neonatal critical care services
the audit questions (3 in 2015) June 17 12 neonatal critical care services
Appendix Patient flows between NNUs June 17 13 neonatal critical care services