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Found 30 results
  1. Content Article
    In this long-read article, Abbie Mason-Woods talks about her experience of having a high-risk pregnancy, pre-term birth and two baby girls in a Neonatal Intensive Care Unit (NICU). Abbie shares her deep insights as a patient and parent, highlighting the importance of trauma-informed, person-centred care throughout the care pathway, and the risk in forgetting the mother. 
  2. Content Article
    The aim of this study in the journal Pediatrics was to explore the impact of rudeness on the performance of medical teams. Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by three independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing and help-seeking. The authors concluded that rudeness had adverse consequences on the diagnostic and procedural performance of NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.
  3. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff. Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin. The reference event for this investigation was the case of baby Elliana, who was born at 32 weeks and 1 day via a forceps delivery and then transferred to the Trust’s special care baby unit (SCBU). Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby and a routine blood sample was taken from around two hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team. The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon. Another blood sample was taken when Elliana was two days old and was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon. Over the next two days, Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well. When Elliana was five days old, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken which showed she had a high level of bilirubin in her blood and treatment was started accordingly. Elliana’s bilirubin levels returned to within acceptable levels over the next three days and she was subsequently discharged home.
  4. Content Article
    This video from the Irish Health Services Executive (HSE) tells the story of Barry, a paediatric nurse who made a medication error when treating a critically ill baby. Barry describes how the incident and the management response to it affected his mental health and confidence over a long period of time. He also describes how he had to fight to ensure the family were told the full story of what had happened, and the positive relationship he developed with the baby's mother as a result. The baby received the treatment they needed and recovered well.
  5. Content Article
    This paper, published by the National Bureau of Economic Research (NBER) aimed to explore how parental wealth and race affect maternal and infant health outcomes in California. The authors used administrative data that combines the California birth records, hospitalisations and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide new evidence on economic inequality in infant and maternal health. The paper also used birth outcomes and infant mortality rates in Sweden as a benchmark, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.
  6. Content Article
    Pain and trauma experienced as a preterm baby in the NICU have been linked to lasting psychological injury, altered brain development and individuals' ability to regulate emotions later in life. In this blog, Vox's Science and Health Editor Brian Resnick looks at how scientists are investigating how to treat pain in babies who can’t tell you when it hurts.
  7. Content Article
    Preventable harm continues to occur to critically ill premature babies, despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. This article in the Journal for Healthcare Quality describes the introduction of a robust process improvement (RPI) program at a NICU in a US children's hospital. Leaders, staff, and parents were trained in RPI concepts and tools and given regular mentoring for their improvement initiatives, which focused on central line blood stream infections, very low birth weight infant nutrition and unplanned extubations. The authors conclude that implementing the RPI program resulted in significant and sustainable improvements to reduce harm in the NICU.
  8. Content Article
    Very preterm infants are at increased risk of adverse outcomes in early childhood. This study in The Lancet Child & Adolescent Health assessed whether delayed clamping of the umbilical cord reduces mortality or major disability at two years. The authors found that clamping the umbilical cord at least 60 seconds after birth reduced the risk of death or major disability at two years by 17%, reflecting a 30% reduction in relative mortality with no difference in major disability.
  9. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
  10. Content Article
    This report by Bliss, the UK’s leading charity for babies born premature or sick, found that young parents are often underprepared and under-supported when their babies are in neonatal care. Research by Bliss found that more than half of young parents felt they were not as involved in caregiving or decision-making as they wanted to be when their baby was born premature or sick. It also highlighted contradictory messages that young mothers are given throughout their pregnancy that their youth will be a protective factor, despite an increased risk of prematurity and neonatal mortality for babies born to mothers aged under 20. This myth leaves many young parents feeling unprepared, enhancing their feelings of shock and disbelief if their babies are born unwell.
  11. Content Article
    This nationwide study of over 1 million births in the English NHS between 2015 and 2017, published in The Lancet, has found large inequalities in pregnancy outcomes between ethnic and socioeconomic groups in England. The findings from Jardine et al. suggest that current national programmes to make pregnancy safer, which focus on individual women's risk and behaviour and their antenatal care, will not be enough to improve outcomes for babies born in England. The authors say that to reduce disparities in birth outcomes at a national level, politicians, public health professionals, and healthcare providers must work together to address racism and discrimination and improve women's social circumstances, social support, and health throughout their lives.
  12. Content Article
    In this podcast, Gill Phillips speaks to Nadia Leake and Rachel Collum, parents of premature babies who had long stays in neonatal care after birth, about the importance of Family Integrated Care. Gill developed Whose Shoes?® as a tool to allow people to 'walk in other people's shoes'. Through a wide range of scenarios and topics, Whose Shoes?® helps groups explore many of the concerns, challenges and opportunities facing the different groups affected by the transformation of health and social care.
  13. Content Article
    The NHS Race & Health Observatory (RHO) has published a rapid review into ethnic health inequalities across a range of areas. This report is the first of its kind to analyse the overwhelming evidence of ethnic health inequality through the lens of racism. The NHS has longstanding problems with ethnic inequalities in terms of access to, experiences of, and outcomes of healthcare. These issues are rooted in experiences of structural, institutional and interpersonal racism. The review focussed on priorities set by the RHO relating to ethnic inequalities in: mental healthcare maternal and neonatal healthcare digital access to healthcare genetic testing and genomic medicine the NHS workforce.
  14. Event
    This online study day from the East of England Neonatal Operational Delivery Network will be led by Sara Davis, Neonatal Practice Development Lead. Using a blend of theory and guided workshops, you will have the opportunity to see worked examples, ask questions, share ideas and receive support in the first stages of planning your own project. It will include: Action planning for learning and improvement using human factor science and QI methodologies, Audit as a tool for assurance and improvement and team effectiveness. The cost of this study day is: £10.00 per person for delegates attending from within the East of England Network £20.00 per person for delegates attending from outside of the East of England Network. Book a place
  15. Event
    East Midlands and West Midlands Patient Safety Collaboratives will be hosting a webinar on appreciative inquiry (AI). Hosted by Appreciating People, it will focus on ‘what works’ and the existing strengths and assets of people, team and organisations. The pandemic and current working challenges has shown how resilient and creative the maternity and neonatal workforce has been, so this workshop aims to support you to build upon your current knowledge and experiences. The webinar will share tools to focus on levering and amplifying strengths, and there will be time for reflective conversation with colleagues. AI helps build psychological safety and is extensively used by many NHS trusts who are part of Learning From Excellence. Register for the webinar
  16. Content Article
    When critically ill premature infants require transfer by ambulance to another hospital, they frequently require mechanical ventilation. This observational study investigated acceleration during emergency transfers and looked at whether they result from changes in ambulance speed and direction, or from vibration due to road conditions. It aimed to assess how these forces impact on performance of neonatal ventilators and on patient-ventilator interactions. The authors found that infants are exposed to significant acceleration and vibration during emergency transport. Although these forces do not interfere with overall maintenance of ventilator parameters, they make the pressure-volume loops more irregular.
  17. Content Article
    Family Integrated Care (FICare) is an approach to neonatal care which aims to involve parents as equal partners in the care of their babies while in the Neonatal Intensive Care Unit (NICU). FICare aims to minimise separation, support parent-child bonding and promote parental decision-making. In this blog, Katie Cullum, Lead Nurse for Innovation and Quality Improvement at East of England Neonatal Operational Delivery Network, talks about the proven benefits of Family Integrated Care and why all NICUs should be implementing the model to improve outcomes.
  18. Content Article
    This action plan to implement the recommendations of the Neonatal Critical Care Transformation Review outlines how the NHS will further improve neonatal care with the support of funding set out in the NHS Long Term Plan. It includes information on capacity, staffing and support for parents.
  19. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to consider the management and care of preterm labour and birth of twins. Preterm birth—defined as babies born alive before the completion of 37 weeks of pregnancy—is one of the main causes of death, long-term conditions and disability in under-fives worldwide, and 60% of twin pregnancies result in premature birth. The reference event for this investigation was the case of Sarah, who was pregnant with twins and was overseen by an obstetrician during her pregnancy. Sarah was assessed as having a higher-risk pregnancy as she had had previous medical intervention on her cervix and was pregnant with twins. Shortly after having been discharged from a hospital with a specialist neonatal unit following suspected early labour, she went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected and a caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well, but 23 days after their birth a scan revealed brain injury in both babies. The investigation identified several findings to explain the experience of the mother in the reference event, including the lack of scientific evidence or specific guidelines and the uncertainty associated with the clinical decision making in this scenario. This highlighted the need for further research into preterm labour as a recognised risk factor for twin pregnancies. As part of the investigation, HSIB identified that since 2019 a large volume of national work and research in the area of twin pregnancy and preterm birth has been undertaken. The investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge.
  20. Content Article
    This article and video tell the story of Rihan Neupane, a baby born prematurely in Dhapasi, Nepal, who was left in a vegetative state following a series of medical errors including a missed diagnosis of meningitis. His parents had chosen a private international hospital for their maternity care, but were let down by a series of medical errors including Rihan being mistakenly given a massive paracetamol overdose. Although external hospital safety inspectors found the hospital negligent on many counts, the hospital continued to deny any wrongdoing or responsibility for Rihan's condition. Rihan's father Sanjeev Neupane talks about his family's experience in the embedded video.
  21. Content Article
    Neonatal intensive care unit (NICU) admission among term neonates is associated with significant morbidity and mortality, as well as high healthcare costs. This study in the Journal of Clinical Medicine aimed to identify and quantify risk factors and causes of NICU admission of term neonates. The study looked at NICU admission for term babies at a maternity unit in Israel. The authors suggest that a comprehensive NICU admission risk assessment that uses an integrated statistical approach may be used to build a risk calculation algorithm for this group of neonates prior to delivery.
  22. Content Article
    This report draws on data from the National Child Mortality Database (NCMD) to investigate how illness around the time of birth affects the health of children up to the age of 10, and to draw out learning and recommendations for service providers and policymakers. This report aims to understand patterns and trends in child deaths where an event before, or around, the time of birth had a significant impact on life, and the risk of dying in childhood.
  23. Content Article
    Established in 2006, the National Neonatal Audit Programme (NNAP) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and delivered by the Royal College of Paediatrics and Child Health (RCPCH). It assesses whether babies admitted to neonatal units receive consistent high-quality care in relation to the NNAP audit measures that are aligned to a set of professionally agreed guidelines and standards. The NNAP also identifies variation in the provision of neonatal care at local unit, regional network and national levels and supports stakeholders to use audit data to stimulate improvement in care delivery and outcomes. This report summarises the key messages and national recommendations developed by the NNAP Project Board and Methodology and Dataset Group, based on NNAP data relating to babies discharged from neonatal care in England and Wales between January and December 2021.
  24. Content Article
    In this article for The Times, Deborah Ross describes her negative experience of NHS maternity care during and after labour, and how this has put her off having more children. During her 72-hour labour and subsequent hospital admission, she was denied pain relief, did not feel listened to and was not informed as to why her baby had been transferred to NICU.
  25. Content Article
    This joint report by the APPG on Baby Loss and the APPG on Maternity is a culmination of over 100 submissions to an open call for evidence from staff, service users and organisations, on the maternity staffing crisis. It paints a picture of a service that is at breaking point and staff that are over-worked, burnt out and stressed.
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