Great Ormond Street Hospital NHS Foundation Trust’s (GOSH) Neonatal Nurse Advisor and Consultant Neonatologist led a project in collaboration with the GOSH Quality Improvement (QI) team. The QI project focused on improving the quality and safety of core care for neonatal patients across the whole Trust, which included: Jaundice care, New Born Bloodspot screening and fluid therapy. These improvements would complement the focused specialist care provided across the Trust and improve patient care and outcomes in line with national guidance.
Where to look
The quality standard for specialist neonatal care requires that the physical, psychological and social needs of babies and their families are at the heart of all care given. An integrated approach to provision of services is fundamental to the delivery of high quality care to babies in need of specialist neonatal services (NICE, 2010).
GOSH is a tertiary specialist paediatric hospital with no dedicated maternity or neonatal wards. As care is provided in different clinical specialties across GOSH, neonatal patients are admitted to different wards across GOSH dependent on their physical health needs, ensuring that GOSH provide the focused specialist care they require. Due to the specialist care focus, neonatal patients can be located across 22 different wards, so neonatal care must be coordinated across wards to deliver the care every newborn baby needs, in addition to the specialist input they receive for their condition.
The QI project was initiated in response to clinical audit work which focused on all aspects of neonatal care carried out by the Neonatal Nurse Advisor, Consultant Neonatologist and Clinical Audit Lead. The audit results highlighted unwarranted variation in core care requirements across the wards that received neonatal patients, particularly those that did not frequently care for this patient cohort. Three key areas for improvement were identified, which led to the initiation of a Trust-wide QI project. The areas for improvement were: Jaundice care, Newborn Bloodspot screening and intravenous fluid therapy.
What to change
Jaundice Care – The audit work highlighted unwarranted variation, identifying incidences where neonates requiring jaundice care were not always being well managed. The project aimed to change this by ensuring that all cases of neonatal jaundice were being managed in line with NICE guidelines for recognising and managing the condition (NICE, 2014).
Intravenous Fluid Therapy – The Neonatal Nurse Advisor and colleagues from the project team identified that Intravenous fluid therapy required improvement in several areas. They identified the need for a standardised approach for neonates. To improve care, they set about developing and implementing a guideline to improve fluid management in neonates. The key priorities for implementation to improve patient safety for children and young people having IV fluid therapy in hospital are set out in “Intravenous fluid therapy in children and young people in hospital” (NICE, 2015).
Bloodspot Screening – The Trust had also been identified as a national outlier in compliance by the Newborn Bloodspot Screening programme. Public Health England (PHE) (2018) Newborn blood spot (NBS) screening enables early identification, referral and treatment of babies with 9 rare but serious conditions. The programme helps to improve their health and prevent severe disability or even death. For each condition, the benefits of screening outweigh the risks.
NBS screening tests use a blood sample that is taken from a baby’s heel and spotted onto a special card containing the baby’s and mother’s details. The sample taker sends the blood spot card to a regional newborn screening laboratory for testing. The internal GOSH audit found that bloodspots were not always being completed within the 5-8-day timeline, and the rate of avoidable repeat screenings was 30%. Audit data also showed that the most common reason for these repeats was missing patient information on the blood spot card, including NHS number and Date of Birth. It was also found that blood spot cards were returned due to improper technique in taking the sample, which can result in an increased likelihood of false-positive and false-negative results. Making changes would ensure all eligible babies would have a successfully completed Newborn Blood Spot test within the appropriate time.
Standardising Neonatal Care – The audit highlighted that some core neonatal processes were overly reliant on the Neonatal Nurse Advisor, with a clear variation in the data when the specialist nurse was on leave, demonstrating a need for improved access to standardised guidance and education across all the wards and professional clinical groups. A staff survey was carried out across all wards to identify training needs and current levels of understanding in neonatal care. Highlighting variable levels of knowledge and confidence across the wards, particularly those that did not regularly care for neonates. The project set out to address the issues identified by the clinical audit and staff survey by standardising neonatal care at GOSH.
How to change
The Neonatal Nurse Advisor worked with the QI team throughout the project and developed and led the changes through testing, seeking feedback from staff, engaging and educating.
The focused work included:
- Developing, testing and launching neonatal e-learning packages in jaundice and Newborn bloodspots;
- Streamlining admission processes to ensure staff can access the demographic information required to complete Newborn Bloodspot screening;
- Helping develop an automated prompt system that alerts the nursing leads when a baby on their ward is eligible for screening, to help reduce the risk of missing patients who need a bloodspot test;
- Developing a new neonatal care pathway to be used across all wards, prompting staff to deliver neonatal care and screening at the right time;
- Working with the QI Developers to develop a real-time report to identify where neonates are situated in the hospital using data from the electronic patient information system such as weight and gestation. This improved the Nurse Advisor’s ability to provide specialist care to the most vulnerable neonates;
- Developing a Trust guideline for the management of neonatal intravenous fluids;
- Raising awareness of the tenets fundamental neonatal care (British Association of Perinatal Medicine (BAPM) (2010));
- Developing standardised resources and improving access to this information across the Trust, via ward folders and a specialist neonatal intranet hub;
- Funding was also obtained for a dedicated Neonatal Practice Educator, who delivered a comprehensive programme of face to face teaching sessions focusing on the key areas of focus among other aspects of neonatal care. The Practice Educator held ‘Neonatal November’, an awareness raising month, across the hospital to highlight the core aspects of neonatal care and promote the new resources and training opportunities. This was delivered through information stands and drop-in teaching sessions for staff and parents.
Better outcomes – Project outcome measures were established during the clinical audit phase, and measurement continued throughout the project using statistical process control (SPC). The Neonatal Nurse Advisor reviews every case of neonatal jaundice to identify whether it has been managed in line with NICE evidenced based guidelines. There has been a sustained improvement in managing neonatal jaundice, increasing from an average of 62% of neonates managed in line with NICE guidelines to 80% since June 2017 following the introduction of the new education package.
The percentage of eligible babies admitted who have received a bloodspot test within the required timeframe, has increased from an average of 93% to 98%. With a decreased percentage of neonates requiring an avoidable repeat screening from an average of 31% to 11%. Bloodspot screening improvements has reduced the risk of missing or delaying the diagnosis of conditions identified by the Newborn bloodspot screening programme.
Better experience – Increased staff knowledge and expertise around neonatal care has reduced the risk of unwarranted variation and is improving the experience of both patients and staff. The reduced incidences of babies having an avoidable repeat blood spot screening, is reducing stress for both patients and families.
Parents and families were informed of the progress and initial outcomes of the project during the ‘Neonatal November’ awareness week through interactive information stands and a talk in the patient canteen. Positive feedback was received regarding the project work.
A follow up survey of the effectiveness of the bloodspot reminder email prompts as part of the changes had positive feedback from staff:
It’s a great initiative that has proved to be working very well within my unit
I found receiving emails a brilliant idea to keep track and ensure that we don’t miss out on blood spots!
Feedback collected by the Practice Educator on the neonatal teaching sessions included:
Good learning more about neonatal nursing
Will be more thoughtful when looking after neonates
Quotes from the annual GOSH quality report also demonstrate the impact:
The new real-time report of current neonates makes it so much easier for me to see where all the neonatal patients are around the Trust at a glance. Access to additional information such as current weight is especially useful when I am trying to look for premature infants and has helped me ensure they are receiving the care and screening they need.
This work has made a huge difference to the care of the neonatal patient at the hospital. There have been significant improvements in compliance of both the management of neonatal jaundice in line with best practice guidelines and newborn bloodspot screening as a result of the project.
Better use of resources – Improved pathways and training has resulted in improved standard working practices, which are more streamlined and effective. There has been improved efficiency, saving both nursing and laboratory time in processing unnecessary samples. Reducing the risk of avoidable complications in mismanagement of jaundice or intravenous fluids also contributes to better management of resources.
Challenges and lessons learnt for implementation
The project learning highlighted:
- the challenges of education and awareness driven improvements;
- while training was key to the success of the project, this is affected by staff turnover and attrition;
- raising and sustaining awareness and education among junior doctors on rotation was another key challenge;
- the importance of looking for other opportunities to build sustainability into processes;
- drawing up a detailed sustainability plan outlining responsibility for training, reporting and on-going monitoring of data and quality of practice once the project closed and became business as usual;
- communicating and embedding change across the whole Trust was also a challenge; many different approaches were used, including staff newsletters, emails, screensavers, teaching sessions, information stands and attendance at key meetings. It was important to use patient stories and data to engage teams in the need for the work, and identify the key influencers in each area to act as champions;
- ongoing measurement continues to show sustained improvement. A post-project implementation review is currently being carried out to monitor the efficacy of key project interventions. This includes spot audit of the use of the new pathway documentation and staff survey on the new email prompt system. The findings of this and any recommendations will be fed back to the project steering group and wards for action.
Find out more
For more information contact:
- Quality Improvement, Quality and Safety Team, Great Ormond Street Hospital for Children NHS Foundation Trust, GOSH.QI@gosh.nhs.uk