Leading change

The neonatal practice development nurse and infant feeding midwife at Bedford Hospital NHS Trust led a programme of work to adopt and implement the ‘RAPP’ (Respirations, Activity, Perfusion, Position/Tone) tool (Ludington-Hoe, 2014) in their maternity unit. This programme led to improved outcomes for new-born babies in the unit.

Where to look

In 2014, Ludington-Hoe (2014) published evidence on ‘Sudden Unexpected Postnatal Collapse’, where babies deteriorated unexpectedly. The findings of this research highlighted that the risk of this occurring was at its greatest during the first few hours post-delivery. Whilst reports showed this could occur at any time, there were cases occurring during skin-to-skin contact, possibly due to the airway becoming compromised. In addition, a reoccurring theme in many risk management cases were inconsistencies standardising documentation. At a time when there was a neonatal sudden death at the Trust, the nursing and midwifery leads reviewed skin-to-skin contact practice between mums and babies post-delivery within the Trust and explored opportunities to introduce the RAPP tool to reduce unwarranted variation in practice through standardising new-born assessment.

What to change

The “RAPP” assessment (respiratory, activity, perfusion, and position) tool has been developed to support evaluation of an infants’ physiological condition and position following birth, to reduce the risk of Sudden Unexpected Postnatal Collapse (SUPC). The neonatal practice development nurse and the lead infant feeding midwife identified a need to introduce the tool into practice. They provided education, training and development opportunities.

The nurse and midwifery leads presented the tool to colleagues at the Trust, collaborating with them to localise the tool to meet their requirements, as well as consulting with other members of staff within the maternity unit and incorporating their feedback into tool development and refreshing the process of new-born assessments.

How to change

The neonatal practice development nurse and the lead infant feeding midwife identified the following actions necessary to embed this programme:

• Introduce an assessment tool to be completed at one hour and two hours of age. Staff were required to complete the tool by circling the appropriate box – if a shaded box was circled it prompted the Midwife to respond and document appropriately. The completed tool was then signed and secured in the labour or postnatal notes, along with any necessary follow up plans of care;
• Create reminder prompts on a checklist to be use by the senior midwife whilst undertaking intentional rounding to ensure assessments were completed;
• Prime positioning of posters in every delivery room and in the theatre recovery bay supported parents in how to have skin to skin contact with their baby;
• Education and training delivered to all clinical staff, providing support and engagement with the new process (assessment tool) and guidance how to complete; and,
• Staff information posters to support ongoing awareness.

An audit process was established to monitor the changes made, to demonstrate when the tool and guidance was being used efficiently and effectively, and to ensure any further service development opportunities were identified. The findings from the audit were presented at the Women and Children’s Clinical Audit Meeting.

In response to the audit (results described below), the RAPP tool was incorporated into relevant Trust guidelines (routine post-delivery documentation). A second audit was completed in April 2018 (same sample size as the previous audit) and the compliance result had improved.

Adding value

Better outcomes – Two months post-introduction, the completion of the tool was audited to determine compliance and learning outcomes. One hundred sets of maternal notes were selected at random from this two-month period and reviewed. Correct completion of the tool and adherence to management guidance (at hour and two hours of age) were recorded. Figures revealed 83% of the sample had the tool suitably completed at the first hour, with 66% completing at the second hour. Whilst no babies were identified as displaying risk factors that could contribute to ‘Sudden Unexpected Postnatal Collapse’, completion of the tool did identify other risk factors that may have caused a baby to deteriorate (i.e. grunting) if not recognised or responded to till later. The tool demonstrated there was an improvement in neonatal outcome, whilst encouraging instinctive mothering behaviour with skin to skin contact (UNICEF UK BFI, 2016) and staff were supported to evidence the care they are providing. Figures for ‘unexpected term admissions’ from Delivery Suite to the Neonatal Unit have reduced since implementation of the RAPP tool, suggesting that babies with risk factors are being identified and treated earlier.

Better experience – Staff report feeling increasingly confident in supporting skin to skin contact and monitoring risk factors through using RAPP, which improves mothers’ experiences as they are able to spend more time with their newborn.

Better use of resources – Initial audit information suggests that the implementation of the RAPP tool has supported the prompt recognition and response to deterioration risk factors. This is reducing the need for further intervention by the neonatal team.

Challenges and lessons learnt for implementation

The programme has been incorporated into mandatory training for all midwives, to support understanding and use of RAPP in practice.

Monitoring the impact of a programme is critical; 6 monthly audits to review patient outcomes, with governance monitoring from the departmental clinical audit meetings, has been key.

For more information contact

Esther Tylee
Infant Feeding Team Lead
Bedford Hospital NHS Trust
Esther.Tylee@bedfordhospital.nhs.uk