atain insights from the national programme

Atain – insights from the national programme Michele Upton Head of Maternity and Neonatal Transformation Programmes NHS Improvement

21st February 2018

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• What is Atain?

• Political context – spotlight on maternity

• Why this is important

• Reducing term admissions to NNU

• Complexities (and opportunities)

• Findings

• Influencing for improvements

• The programme in 2017

• Your role in Atain

Presentation

Atain – insights from the national programme

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Acronym for

Avoiding Term Admissions Into Neonatal units

Programme of work initiated under patient safety to identify harm leading to term admissions

Current focus on reducing harm and avoiding unnecessary separation of M&B

What is Atain?


The journey to a national maternity safety ambition

2010

2013 – NAO

Report on maternity services

2016 – Better Births

2010 - NHS Mandate & Outcomes Framework

2015 – Kirkup Report

2015 – National Ambition

2016 – Safer Maternity Care

Action Plan

National Maternity Ambition

To reduce the rate of

stillbirths, neonatal and maternal deaths, and brain injuries occurring during or soon after birth by 50% by

2030; and 20% by 2020

Maternity Transformation Programme

A cross-system programme

set up to implement the vision set out in the National

Maternity Review. From April, NHSI is leading

workstream 2 ‘Promoting good practice for safer care’.

Maternity Transformation Programme

6

Key themes

Overarching

communications

strategy which

supports all activity

Improving safety of care

Empowering women

Work streams

1. Supporting local transformation

2. Promoting good practice for safer care

3. Increasing choice and personalisation

4. Improving access to perinatal mental health services

5. Transforming the workforce

6. Sharing data and information sharing

7. Harnessing technology

8. Reforming the payment system

9. Improving prevention

Aim of WS2 Five themes

Deliverables

Make measurable

improvements in safety outcomes for women, their

newborns and families in

maternity and neonatal

services, as set out in Better

Births.

Reduce the rate of stillbirths

neonatal death and brain injuries occurring during

or soon after birth by 20% by

2020 and 50% by 2030

Teams

Innovation

1. The appointment of two National Maternity Champions: Jacqueline Dunkley-Bent ad Matthew Jolly

2. Clinical Network Champion in every MCN

3. Local obstetric and midwifery safety champion, as well as a board-level champion in every trust

4. Saving Babies Lives Care Bundle

5. Avoiding Term Admissions Into Neonatal Units (Atain)

6. Rapid Resolution and Redress

7. Perinatal Mortality Review Tool

8. Annual report detailing progress against the National Ambition

9. £8m MDT training fund

10. National Maternal and Neonatal Health Safety Collaborative

11. £250k Innovation Fund

Leadership

Learning and best practice

Data

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2010 - NHS Mandate & Outcomes

Framework

National perspective Seen as a signal of sub-optimal care during antenatal, intrapartum or post natal period – few fully grown babies should need neonatal services Signal that avoidable harm might have been caused Significant but avoidable cost to NHS and families Maternity and neonatal teams long recognised as an issue – will to resolve

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• Mothers and babies have a physiological and emotional need to be together: hours and days following birth.

• The first hour of life outside the womb is the time when a

family is formed. A once-in-a-lifetime experience to be cherished and protected.

• Important for physiological stability of baby and beginning of

maternal infant interaction

• The benefits of skin-to-skin care extend beyond birth. The mother learns about her baby’s needs and how to care for, comfort and soothe her newborn.

Why is this important

Current initiatives for improving safety for newborns

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Why is this important

There is overwhelming evidence that separation of mother and baby so soon after birth interrupts the normal bonding process, which can have a profound and lasting effect on maternal mental health, breastfeeding, long-term morbidity for mother and child. This makes preventing separation, except for compelling medical reason, an essential practice in maternity services and an ethical responsibility for healthcare professionals.


Reducing term admissions

2010 - NHS Mandate & Outcomes Framework

2013 First

meeting to

consider issue

Feb 2014 Analysis of

primary RfA NNRD

58% of all babies in NNU = term 1. Resp 2. Infection 3. Hypoglycaemia 4. Jaundice 5. Asphyxia

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Complexity


Which term babies?

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Complexity


Which term babies? Data collection system – accuracy of data entry Data on place of admission - TC Different commissioning arrangements across networks and even within trusts - variation in TC Incentives for admission – income via Neonatal services Local variation: clinical practice/admission policies…. Midwifery skills/resource Maternal morbidity Early discharge / transfer Fail safe decision-making + inexperience of junior doctors Some term admissions are entirely appropriate

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• CQUIN

• System-wide engagement

• Identified enthusiasts

• Plan and development of model for system wide improvement

• Move to NHS Improvement April 1 2016

• 5 working groups set up

• Priorities for each group identified

• Agreed as deliverables

Next steps

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Deliverables

Current initiatives for improving safety for newborns

Respiratory 33% of all admissions for respiratory symptoms Elective C/S <39 weeks Hypothermia Antenatal steroids

Asphyxia Role of the LW coordinator MDT training – LW Leaders workshops: aviation, RCM/RCOG Safety huddles and handovers LWC - supernumerary status

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Jaundice


Analysis of data Publish findings Thematic review of litigation claims

Promote use of TCB in the community Make a film Education and training to address the gaps found in the

analysis Prospective audit of practice – publish Parent involvement in recognising

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Hypoglycaemia


Data analysis and publish Prospective audit of practice Analysis of litigation claims and publish FfP with UNICEF and BAPM – standardise Education and training Parental involvement NHS Resolution flyers

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Findings

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Term live births in England (2011-2014) 3.6%


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Care days for term admissions ( 31%) (>60%)


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136 036 babies care analysed: 2013 – 2015:

• >8% of all live births resulted in a L1,2 or 3 NNU

admission

• Additional 10,000 care days delivered for term babies in

2015 compared to 2011

• Increase predominantly in Special Care category

• ~20% - 30% of admissions were avoidable - intervention

received did not warrant admission

• 20% = 27 207

• 30% = 40 810

What we know


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• Unnecessary intervention

• Risk factors not identified

• Evidence based guidance not followed

• Babies born at 37-38 weeks twice as likely to be admitted to neonatal services as those born at 39-42 weeks gestation

• Snapshot of findings

What we know


Mode of delivery of babies admitted

with respiratory symptoms

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

37 38 39 40 41 42 43

N/K

All VD

El CS in labour

El CS not in labour

Em CS in labour

Em CS no labour

Temperature of babies admitted with

respiratory symptoms

274, 1%

1770, 5%

5792, 18%

21977, 68%

2237, 7%

440, 1%

<35

35-35.9

36-36.4

36.5-37.5

>37.5

n/k


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• Babies born by CS were over represented, accounting for 48% of all hypoglycaemia admissions

• 44% of all admissions for hypoglycaemia were directly from birth room or theatre.

• This increased to 71% among those admitted before 4 hours of age

• 39% low risk infants (Mat/Obstet problems; BW and Apgar)

Hypoglycaemia


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• 30% admitted <4 hours of age (normal period of transient hypoglycaemia)

• of which half were <1hour of age (LW/OT)

• 86% of infants of diabetic mothers admitted from LW/birthing room before 4 hours of age – of which

• 41% had admission blood glucose above the operational threshold

• 86% of infants of diabetic mothers admitted within an hour of birth did not ever need an IV glucose infusion.

• Suggests prophylactic admissions

Hypoglycaemia


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• These babies generated >76,000 care days, ~80% in special care category

• The financial cost of these admissions was £25 million over 3 years

• More importantly, there were >76,00 days of mother and baby separation

Hypoglycaemia


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• 6% of term infants admitted for jaundice (3000/annum)

• Most common reason for admission from home (approximately 20% each year )

• infants admitted from home statistically significantly later – median age is 1.7 vs 3.9

• Majority received phototherapy only

• Admission more likely in babies born at 37 weeks, male babies, those of Asian ethnicity or who were one of a multiple birth

Jaundice


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20% – 30% of all babies admitted to L1, 2 or 3 care

received no intervention which could not have been

delivered by keeping them with their mothers n = 34 000

31% of babies were admitted for <48 hours and

received no high dependency or intensive care

intervention

Role for Transitional Care facilities

Babies born at 37-38 weeks were twice more likely to be

admitted to Neonatal services compared to those born at 39-42 weeks gestation = increased vulnerability

Overall data findings


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National Drivers


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National Drivers


2017 SofS Safety strategy

CNST

Incentivisation scheme

Opportunities for Transformation

33

Key themes

Overarching

communications

strategy which

supports all activity

Improving safety of care

Empowering women

Work streams

1. Supporting local transformation

2. Promoting good practice for safer care

3. Increasing choice and personalisation

4. Improving access to perinatal mental health services

5. Transforming the workforce

6. Sharing data and information sharing

7. Harnessing technology

8. Reforming the payment system

9. Improving prevention

23 I Atain – insights from the national programme

Transformational approach to reducing term

admissions

Frontline maternity and neonatal teams:

Perinatal collaboration crucial

Identify Atain leads – mat and neo

Undertake in partnership with your CN and ODN

Review/audit of admissions

BadgerNet and MSDS +review to understand

contributory factors for admissions

Draw on atain findings to inform audit questions/review

Rigour, transparency

Involve your maternity safety champions

Transformational approach to reducing

term admissions

Frontline maternity and neonatal teams:

Implement FfP

Undertake Atain eLfh programme

Consider use of Bobble Hat bundle or similar

Admissions for IVAB

NEWTT for monitoring on postnatal ward and TC

TC – virtual or integrated – staffing numbers and skills

Use the MNHSC to turn plans for measurable

improvements to local services.



term admissions

Commissioners:

Implement NHS England Improving Value scheme:

Work with clinical colleagues to address requirements

identified from audits

Focus on quality

NICU staffing and capacity addressed in part if babies in

right place at right time

Improved outcomes

TC – virtual or integrated – staffing numbers and skills

Co-commissioning



term admissions

ODN and MC Networks:

• Support to implement NHSE IV scheme

• Address as a joint MCN/ODN/PSC network priority

• Appoint Atain leads in every unit – mat&neo

• Baseline using BadgerNet data to understand local admission rates and issues

• Draw on national guidance and regional work to address relevant issues

• Consider model of transitional care and ensure staffing and skills appropriate


Atain as part of a national programme

April 17

Formal deliverable within WS2 of the MTP

PS Alert Mandated

action August 17

NHS England

Improving Value

Scheme

HEE, RCM and RCOG to support

overcoming barriers to

implementation

NMPA Resources for implementing

TC E-Learning programme

2016 – Safer

Maternity Care

Action Plan

Unthinkable not to have service and

staffing models which

keep M&B together

↓ trajectory

of ATAIN

2017 SofS Maternity safety strategy

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