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Showing results for tags 'NICU/SCBU'.
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Diagnostic uncertainty was relatively common in critically ill children admitted to the paediatric intensive care unit (PICU), an AHRQ-funded study in Critical Care Medicine concluded. Diagnostic uncertainty is the subjective perception of clinicians of their inability to provide an accurate explanation of a patient’s health problem. Researchers aimed to identify the frequency and factors associated with diagnostic uncertainty among critically ill children admitted to PICU. They reviewed the medical records of 882 patients admitted to one of four PICUs. Diagnostic uncertainty at admission was observed in 228 out of 882 patients. They also found a significant association between diagnostic uncertainty and diagnostic error. Researchers highlighted the need for more research and better strategies to address diagnostic uncertainty.- Posted
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untilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. For every 1000 babies born, 1-2 need assistance (2-10% of these need intubation). In this webinar we will explore learnings following a review of hypoxic ischaemic injuries (HIE) or early neonatal deaths (ENND). Register for the webinar -
Event
untilThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. MNSI has completed over 3500 independent safety investigations, using system focused methodology, into maternity events, including direct and indirect maternal deaths in pregnancy and up to 6 weeks postpartum. This webinar will explore learnings following maternal deaths secondary to HLH and consider learning points for future clinicians and investigators. Speakers: Dr Charlotte Frise Dr Bethan Goulden Dr Louise Page Clare Luby Register for the webinar -
Content Article
This article in JAMA Internal Medicine looks at the impact of language barriers on healthcare safety and quality in the US. Research shows that language discordance between patients and healthcare professionals worsens health outcomes, especially when there are no available, affordable and adequate interpreter services. The article describes the case of a mother who tried to raise concerns about her newborn baby's breathing and had her concerns dismissed, likely because she was unable to speak English and therefore could not communicate sufficiently with midwives and doctors. The author, Tamara Huson, a doctor in Ohio, describes how she had to convince the NICU unit to take the baby in for observation. On arrival at NICU, the baby's condition quickly deteriorated and she was intubated to save her life. This near miss illustrates the impact of language discordance, and the author argues that statutory requirements for translation service in the US are not being fulfilled by healthcare providers which receive Medicare and Medicaid funding.- Posted
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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.- Posted
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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. Key findings Babies born to the richest 20% of families are the least healthy. They are more likely to be born premature and at a low birth weight, two key risk factors for medical complications early in life. This is because their mothers are more likely to be older and to have twins (which are more common with the use of fertility treatments). However, even with those early risk factors, these babies are the most likely to survive both their first month and first year of life. Rich and poor mothers were equally likely to have high-risk pregnancies, but the poor mothers were three times as likely to die—even within the same hospitals. Maternal mortality rates were just as high among the highest-income Black women as among low-income white women. Infant mortality rates between the two groups were also similar. Babies born to the richest Black women (the top tenth of earners) tended to have more risk factors, including being born premature or underweight, than those born to the richest white mothers—and more than those born to the poorest white mothers. -
Event
Neonatal Quality Improvement study day
Patient-Safety-Learning posted an event in Community Calendar
untilThis 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 -
Event
untilEast 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- Posted
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Published in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.- Posted
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HQCA: Patient Experience Awards 2019
Patient Safety Learning posted an article in Implementation of improvements
For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience. The following four initiatives were selected to receive the HQCA’s 2019 Patient Experience Awards: NowICU Project, Neonatal Intensive Care Unit (NICU), Misericordia Community Hospital Rapid Access, Patient Focused Biopsy Clinic; Head and Neck Surgery, Pathology; University of Alberta Hospital Edmonton Prostate Interdisciplinary Cancer Clinic (EPICC), Northern Alberta Urology Centre Transitional Pain Service, South Health Campus Take a look at their presentations and find out more about these great initiatives.- Posted
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A three-year programme launched in February 2017 to support improvement in the quality and safety of maternity and neonatal units across England - formerly known as the Maternal and Neonatal Health Safety Collaborative. NHS Improvement aim to: improve the safety and outcomes of maternal and neonatal care by reducing unwarranted variation and provide a high quality healthcare experience for all women, babies and families across maternity and neonatal care settings in England contribute to the national ambition, set out in Better Birthsopens in a new window of reducing the rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 20% by 2020. The web page includes resources on: Improving the proportion of smoke-free pregnancy. Optimisation and stabilisation of the very preterm infant. Detection and management of diabetes in pregnancy. Early recognition and management of deterioration of mother or baby. -
Content Article
Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. This toolkit, produced in the US, includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.- Posted
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A fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.- Posted
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Abbie experienced a high-risk pregnancy with her twin girls. They were born at 27 weeks gestation and weighed in at just 677g and 500g. After 150 nights in Neonatal Intensive Care Unit (NICU), both of Abbie’s daughters came safely home. In this blog, Abbie highlights the importance of building a trauma-informed, clinical network around women whose babies have spent time in NICU. Drawing on her own experience and insights, she offers suggestions for how midwives, GPs and health visitors can support their mental health postnatally. The post-partum period is important. A mother recovers and heals physically from birth, but it also is a strong influencing factor on the long term physical and emotional wellbeing of both mother and baby. I want to consider a quote I saw recently, ‘Remember to hold the mother, not just her baby.’ Whilst I welcome society recognising that women shouldn’t be forgotten once their baby has been born, my immediate thought was - but what if the mother isn’t even holding her baby? What if the baby hasn’t left the hospital yet? Who holds the mother then, and ensures she feels safe, heard and supported? We know that parents who have experienced time on a NICU Unit are 80% more likely to experience psychological distress, than parents who haven’t. Care for a woman during and after, needs to be trauma-informed, supportive and personalised; their mental health must be prioritised. As the data demonstrates, the contacts during the postnatal period, affect the weeks, months and even years that follow. Frequent, open communication asking how she is throughout, will ultimately support her wellbeing safety. Here’s are some of my thoughts on how midwives, GPs and health visitors can help support women who have had babies in NICU… Community midwives It is important that women whose babies remain in NICU, feel considered and counted too. We once were the patient too. Never let women fall down a gap in accessing their postnatal care, because their baby was not discharged to home, when they themselves were discharged. These appointments provide important opportunities to talk postnatally about maternal mental health. Women may be feeling frightened and scared about their baby in NICU. They may also be feeling guilt about their baby being early or sick. Acknowledge that these feelings are all entirely normal for the circumstances they are in. Acknowledge that it is hard and difficult. Acknowledge that the separation between mum and baby, rather than both home together, is not how it should be. Ask what she needs. These early days can often feel fast, and our minds have not caught up yet. Be prepared to sit with silence as she starts to process what is happening. Hold that space open to listen. Take early opportunity to refer or signpost for support where appropriate. Early identification can often avoid crisis. General practitioners Ensure that postnatal follow up is completed at 6-8 weeks post birth. It is not exclusive to those whose babies are home and able to also attend this appointment. Access to this must be equitable for all women. It may be an initial telephone appointment, or have to be considerate of time that the woman wishes to spend on the NICU. A degree of flexibility is needed here to achieve access, as the surrounding circumstances are different to the regular postnatal check up alongside baby. Continue the dialogue about postnatal mental health. Be considerate of language here too. I know I personally found phrases such as, ‘still in NICU’, or ‘at least they’re in the right place,’ difficult. Support us by knowing NICU can feel like a marathon and all we want too, is for our baby to come safely home with us. Normalise talking about postnatal maternal mental health in primary care, from the beginning. Trusting relationships are built this way, and women will feel safer reaching our to their GP if they are struggling. Whether that’s in the first few weeks, or even a year down the line, GPs can empower women postnatally and equip them with choice regarding support. It is important to know support exists and that other mothers have needed this too. Health visitors Often it is after the much yearned for hospital discharge, there is more time to reflect and consider what happened in the immediate postnatal period. This can be when women start to really feel the effects of spending time in NICU. Balancing this processing of events, with the demands of raising your baby, and adding in more sleep deprivation on top, can often lead to the perfect storm. Babies who have spent time in NICU usually leave with an array of outpatient appointments and there can be a theme, that they remain the patient and centre of support beyond. Developmental assessments, ‘milestones’ and even birthdays, can all evoke the feelings we had in NICU right at the start. Often our feelings of fear, guilt, and even a grief regarding the path we thought antenatally, we would follow, re-emerge. Anxiety regarding baby’s development and their continued health can be at the forefront of our mind because of the experiences we have had. The health visitor is such a valuable continued contact here in these following months for mother and baby. Rather than viewing their NICU experience as simply in the past, let mothers know there is space to talk about it postnatally. Demonstrate an understanding that a mother’s experience of NICU, is not simply left at the NICU doors when discharged. Listen and validate the feelings that come up, do not dismiss them. Tell them about the support choices available. Approaching appointments or contacts like this will really help mothers feel able to speak openly and ask for support if and when they need it. Final thoughts Spending time in NICU with your baby is traumatic. Whether your baby was there for a day, a few weeks or even months. Building trusting, listening relationships that validate how women are feeling postnatally, can empower them with choice and information about support they can access, at the right time for them. It recognises that whilst the trauma cannot be erased, care can go a long way to mitigate the experiences postnatally. Related reading Women who experience high-risk pregnancies are too often forgotten when their babies are born My Black Motherhood: Mental Health, Stigma, Racism and the System (by Sandra Igwe) Racial disparities in postnatal mental health: An interview with Sandra Igwe the Founder of The Motherhood Group Patient safety and maternal mental health during covid Neonatal herpes: Why healthcare staff with cold sores should not be working with new babies Leading for safety: A conversation with Jane Plumb, Founder of Group B Strep Support -
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. I’m Abbie Mason-Woods and in late 2021/2022, I experienced a high-risk pregnancy with my identical twin girls. The girls were born at only 27 weeks plus 5 days gestation, weighing in at just 677g and 500g, and spent 20 weeks in a Neonatal Intensive Care Unit (NICU). On paper, I had my career as a Designated Safeguarding Lead and qualified Family Worker in Education, a First-Class degree in Childhood Studies, and a confidence to always advocate for the right support, at the right time for families. However, the cloak of vulnerability that fell upon me when I found myself pregnant with twins and navigating a high-risk pregnancy, pre-term birth and twenty weeks in NICU, was beyond paralysing. Beginning to process and reflect Clarity. The journey to bringing home my pre-term twins had in fact started long before I walked through the NICU doors for the very first time, as their mother. I realised I had once been the patient too. A ‘high risk’ pregnant woman who had been told at 22 weeks pregnant that it was very possible my pregnancy could end in stillbirth because of its complications and difficulties. Weeks followed of careful considerations about options and expectant management of the pregnancy, the tertiary care miles from our local hospital, multiple scans, and too many bloods and blood pressure checks to count. Pre-eclampsia led to pre-term birth and early delivery at 27 weeks with an emergency caesarean section, a blood transfusion, a week’s stay in hospital, and my babies now separated and in two different hospitals. Only one remaining in the same hospital as myself. Quite the list of events. And then I was discharged. From patient to ‘NICU mum’ I took up watch now at the side of my girls’ incubators instead. It was all I could do as a ‘NICU Mum’. Watch on as between them they endured extended periods of mechanical ventilation, emergency and planned surgeries, including lifesaving surgery for a bowel perforation, a stoma reversal, laser eye surgery for retinopathy of prematurity (ROP), blood and platelet transfusions, episodes of sepsis and many other clinical events. They now were the high-risk patient, and I was simply the patients’ mother. Helpless as they fought for their lives. I’d never ‘mothered’ before. As a first-time Mum, I wasn’t acutely aware at this time of how different all of our ‘firsts’ were in those first few months, but I did feel like I had been mis-sold ‘motherhood’ somewhat. I hadn’t had a term baby, who had been placed immediately upon my chest, no car seat photo as we all left the hospital together within a few days, no family being able to rally round us in a ‘baby bubble’, as we soaked up newborn snuggles. NICU was my third and my fourth trimester. It certainly didn’t feature in a leaflet in an antenatal clinic. I spent many hours hoping they would live and eventually come home. Photo shows Abbie holding one of the girls in NICU. Forgotten but needing support Disconnect. I noticed that I had existed in two very different clinical systems and played two very different roles. Once I had been the patient and then I became the person giving consent for the patient to receive care and treatment. Maternity and neonatal existed in isolation from each other. Maybe partly due to my babies being in a NICU that wasn’t at the hospital I gave birth in, or maybe each thinking the other would ‘catch’ us, there was a striking realisation that there was no connectedness between the two. I was in a transitional state. I wasn’t ready to be discharged and become ‘just’ the parent. It became clear to me that the overwhelming feeling of paralysis as I stepped through NICU with the girls for twenty weeks was because the cortisol rushing through my body had long run out. The fight or flight mode I was in was exhausting and the lethargy I felt entirely overwhelming. My body trying to repair after major surgery and a complicated pregnancy, whilst travelling miles to my babies, expressing breast milk, remembering to eat and drink, and watch on as they fought for their lives. Navigating the twists and turns of NICU with very small neonates, the future was entirely unknown. Each hour unpredictable, it all cumulatively took its toll. Whilst my mind was often still trying to process the clinical decisions that I needed to make at just 22 weeks pregnant, my body stood next to my baby being mechanically ventilated and requiring 1:1 nursing. So, was this abandonment intentional? No. Each clinician, from the tertiary Hospital I gave birth in to the NICU did their absolute very best to ensure I gave birth safely and our girls made it home. Nobody intended to ‘forget’ about me; however, systemically, I had been forgotten. Complicated paths such as this can lead to cumulative trauma and to mitigate this support must be built in at each stage of the pathway. Supporting women who spend their post-partum period in NICU Safety netting for high-risk pregnant women, through birth and beyond must be robust and rigorous. These are life changing moments for parents, carried with us forever. Without considerate and informed care and support, patient safety can be compromised both physically, mentally and emotionally. The specific needs of women whose post-partum period is spent in the NICU must be considered. For example, care for the physical aftereffects of birth, such as checking stitches or blood pressure, often means having to walk back into a maternity unit surrounded by pregnant women and women who are able to take their baby home immediately. This can be incredibly painful emotionally which could prevent some women going back. They may also not wish to leave their baby while they receive aftercare. My GP surgery at home had no understanding of what was happening in the Level 3 Surgical NICU unit my daughters were in. Despite receiving my discharge paperwork from the hospital I gave birth in, when they called to arrange our ‘6 week check-up’, a receptionist advised me that if the babies were home it would be with a GP. They repeatedly asked me when the babies were going to be discharged. When I said I didn’t know, trying to swallow the lump in my throat, the receptionist had to ask a colleague and told me that if there were no babies to check it would be a healthcare assistant ‘to check your stitches.’ Thus, demonstrating the lack of connectedness and understanding between the settings and assuming each post-partum woman fitted into a one-size-fits-all care plan. Cumulative trauma builds at a significant moment in our lives and diagnoses of an array of maternal mental health conditions, such as postpartum depression or post-traumatic stress disorder, may follow. It is important to consider not only the experiences parents and caregivers have with their own baby, but also vicarious trauma, from the other events you witness and experience during time spent on NICU. Parents who have experienced time on a NICU Unit are 50% more likely to experience psychological distress, than parents who haven’t. The care provided should ensure that protective steps of support are in place universally to minimise the effects of this. Embedding protective factors Universal but tailored support I don’t think there can be an ‘ideal’ as such. Each situation and circumstance is different. We as individuals differ too, notably my husband’s experience of NICU and his feelings differ greatly to mine. Care is required to be personalised, trauma informed and intuitive. There are multiple contact opportunities with high-risk pregnant women owing to care and appointments being more frequent. These should provide support, signpost to appropriate information and, ultimately, ‘catch’ the patient. I think it is important that we acknowledge that support should be universal here, not just for those who may have been identified as ‘vulnerable’ because of a particular factor, such as a previous mental health condition. Universally providing support means that the patient feels empowered with knowledge. There is also great comfort in knowing that clinicians recognise that medical events or experiences can be challenging physically and/or mentally, and that there is support for you if you need it. Without this, patient experience is minimised, and clinicians can appear de-sensitised. The patient can be left feeling that they should be coping and that this is the shared expectation. Photo shows Abbie's husband's hand on one the babies while in an incubator in NICU. Kind and compassionate communication For parents who experience NICU there is a continued need for offers of support throughout their child’s stay. Kind and compassionate language, care that is sensitive to a family’s needs and pathway to the ‘here and now’, opportunities to ask questions or gain a deeper understanding of what your child needs or is experiencing, collaboration and involvement in your child’s care, and decision-making opportunities. All examples of protective factors that can be implemented and that also offer the parents some control back within an uncontrollable situation. A shared understanding between clinicians and families of the feelings associated with spending a third and/or fourth trimester in a NICU is important too. Fear, helplessness and guilt are some of the ‘normal’ feelings associated with experiencing a NICU stay. There is definitely a feeling of safety knowing what you are experiencing is ‘normal’ for the situation you are in. Primary post-partum care Beyond hospital care, primary care has its role to play too. Navigating trauma and its after-effects does not always happen immediately and this needs to be recognised. Trauma-informed care throughout all settings means that appropriate support can be provided at a time that is right for the individual; it is never too late to be given the choice to receive support. This will demonstrate that the experience is not simply compartmentalised within each setting but that the pathway is connected throughout. This pathway should also include robust follow up for post-partum physical care. Using patient insight for change I think that too often, patients can feel that if they provide feedback and reflection on what they wished for, or needed but didn’t receive, during their care, it may lessen the gratitude towards clinicians. It doesn’t. Our insight can shape care for the better, making it more efficient and safer. Patients should be telling their story just once and the pathway actively listening, responding to patient choice, working collaboratively and intuitively based upon individual needs and wishes. This will empower patients and their families. Universal, unconditional, trauma-informed care and connectedness provides universal safety. Photo shows Abbie Mason-Woods -
News Article
Trust suspends treatment for premature babies after several deaths
Patient-Safety-Learning posted a news article in News
A national study is examining whether a treatment for premature babies could cause harm, amid concerns about the deaths of four infants last year, it has emerged. HSJ has learned a national study into the use of prophylactic low-dose hydrocortisone steroids, also known as “premiloc”, is being carried out at the Neonatal Data Analysis Unit, part of the Imperial College London Medical School. Meanwhile, University College London Hospitals Foundation Trust confirmed that four children died in January and February 2023 last year, having been transferred from UCLH to nearby Great Ormond Street Hospital, after receiving the treatment. They had been given hydrocortisone steroids at UCLH to reduce the risk of developing a lung condition called bronchopulmonary dysplasia. UCLH said its own internal investigations “did not confirm a direct link” between the deaths and the drug, “but concern remained” so they were reported to the regional neonatal network. UCLH noted that the national study at Imperial was now under way, although the Imperial team told HSJ it was not specifically aware of the UCLH/GOSH deaths last year. A report from GOSH’s safety team last year, seen by HSJ, said: “In all four deaths the mortality review group identified modifiable/potential modifiable factors around the administration of premiloc prior to admission to GOSH. Administration of premiloc (hydrocortisone steroids) to these babies may have been associated with the subsequent perforations. A series of incidents of perforations was flagged to the UCLH neonatal unit who reviewed data and have stopped the administration of premiloc.” Read full story (paywalled) Source: HSJ, 5 June 2024- Posted
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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. -
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. Findings The assessment of visual signs of jaundice in newborn babies is subjective and more challenging with babies who have black or brown skin. Stakeholders have differing opinions about the reliability of visual signs to detect jaundice in newborn babies. Some neonatal units have introduced safety measures to mitigate the risk of reliance on visual signs of jaundice. National guidance does not recommend routinely measuring bilirubin levels in babies who are not visibly jaundiced. National guidance for jaundice in newborn babies maybe more applicable to term babies (those born after 37 weeks of pregnancy) than those born prematurely. National guidance does not contain information on how to address the challenges of detecting jaundice in newborn babies with black or brown skin. Some universities providing education to NHS students on the detection of jaundice are seeking to ensure that teaching aids and literature represent the diversity of the population. Levels of bilirubin can vary according to the gestational age of a baby (how long the baby was in the womb). Laboratory staff do not calculate the gestational age of a baby and therefore whether their bilirubin level is within the expected range. Laboratory practice varies in terms of whether they set specific reference ranges for bilirubin in newborn babies; whether they have a defined threshold for communicating results to neonatal units; and whether the telephone alert limit (the level of bilirubin that triggers laboratory staff to report the result to clinical staff by telephone) reflects the thresholds in national guidance. Neonatal staff may be unaware that laboratories analyse blood samples to see if they are icteric (indicate jaundice). These staff will not know to look for a comment about this on blood test reports. Safety recommendations HSIB recommends that the National Institute for Health and Care Excellence reviews the available evidence and updates its guidance if appropriate, regarding: the reliability of visual signs to detect jaundice in newborn babies, particularly in babies with black and brown skin risk factors for jaundice identified by this investigation, including prematurity. HSIB recommends that the Royal College of Pathologists works with stakeholders to understand current practice and make any appropriate recommendations to promote the adoption of an icteric threshold at which a bilirubin test may be cascaded or reported. HSIB recommends that the Royal College of Pathologists works with stakeholders to understand current practice and make any appropriate recommendations on neonatal specific reference ranges for total bilirubin and thresholds for direct communication of these results to clinicians. Safety observations HSIB makes the following safety observations: It may be beneficial for regulators of pathology services to consider the findings of the investigation and amend their guidance if necessary. It may be beneficial to develop a national standardised Early Warning System track and trigger observation chart for use in neonatal unit settings.- Posted
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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.- Posted
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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. -
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. The report looks at the following issues: To what extent are maternity services affected by staffing shortages? What impact are staffing shortages having on antenatal care? What impact are staffing shortages having on labour and birth? What impact are staffing shortages having on postnatal care? What impact are staffing shortages having on neonatal care? What impact are staffing shortages having on the quality and/or safety of bereavement care? What impact are staffing shortages having on learning from incidents? What impact are staffing shortages having on the morale and wellbeing of maternity staff? What impact are staffing shortages having on the training and development of maternity staff? What impact are staffing shortages having on the recruitment and retention of maternity staff? What measures are necessary to address staffing shortages in the short term? What measures are necessary to address staffing shortages in the medium to long term?- Posted
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- Workforce management
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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. HSIB was notified about potential patient safety issues by Sarah, who was concerned about the care she had received when her babies were delivered. The investigation used interviews, observations of the maternity unit and reviews of guidelines and organisational documents in order to understand the system-wide factors that contributed to Sarah’s experience and the decisions made by staff. The evidence suggested that the process of decision making in the context of Sarah’s care was relevant to this investigation, so the investigation has summarised the key factors that appear to have influenced the decision making associated with her care and the delivery of her babies Findings There are currently no proven treatments available to reduce the risk of preterm labour for twin pregnancies. There are gaps in scientific knowledge and challenges to completing research in the field of preterm labour and birth. This creates a challenge for the development of detailed guidelines to support clinical decision making. Guidelines and equipment recommended for managing and monitoring singleton (one baby) and full-term pregnancies are used to assist with clinical decision making about preterm twin pregnancies; some interventions within the guidelines are unproven for use in preterm twin pregnancies. Research and national improvement initiatives, such as the British Association of Perinatal Medicine perinatal optimisation care pathway and NHS England and NHS Improvement ‘Saving babies’ lives care bundle version two’ and the Maternity and Neonatal Safety Improvement Programme are improving the standardisation and implementation of evidence-based interventions. Intelligence from national data gathered by maternity units can support the learning on preterm labour and birth in twin pregnancies. Safety observations It may be beneficial if further research aimed to generate additional knowledge to predict and prevent preterm labour for twin pregnancies among different groups of women/pregnant people. It may be beneficial to increase awareness among the public and healthcare professionals of the limitations of interventions for the prevention of preterm labour of multiple births. It may be beneficial to regularly analyse data on multiple births so the interpretation of this data can inform learning and research. Safety actions Following stakeholder feedback received during an update of the guideline for preterm labour and birth, the National Institute for Health and Care Excellence decided to delete the recommendation relating to milking the cord and amend the subsequent recommendation on clamping of the cord to wait at least 60 seconds before clamping the cord of preterm babies unless there are specific maternal or fetal conditions that need earlier clamping. -
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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. -
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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. -
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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.