Neonatology

Improve neonatal ODN effectiveness through development of a more consistent and equitable funding model, and strengthen relationships with key stakeholders. a Develop an agreed requirement for national core network funding (relative to network activity) to ensure all networks have sufficient and equitable resource to be able to operate effectively across all areas of their remit. Arrangements must be futureproofed for changes to funding models and the move to ICSs. A national neonatal ODN service specification is needed which reflects these core funding requirements. b Put arrangements in place to allow for substantive appointments to network posts. c Strengthen commissioning relationships with neonatal ODNs. Strong commissioning leadership must be present to develop the business case for service change and subsequently support any reconfiguration / re-designation of services. d Ensure parents play an integral part in all aspects of network activity including representation on the network board. e Share ownership and joint working where neonatal ODN and LMS/LMNS work plans align. Planning guidance to LMS/LMNS for 2021/22 makes it clear that they must take responsibility for working with neonatal ODNs on implementing the findings of the NCCR. f Develop closer relationships with paediatric clinical networks, embedding paediatric sub-specialty input into antenatal and postnatal pathways within networks. g Strengthen neonatal ODN relationships with LMSs/LMNSs and Fetal Medicine Networks (FMNs). The footprints for these organisations should be aligned as much as possible together with a similar collective ICS footprint. An overarching regional high risk perinatal group allows streamlining of joint maternity and neonatology objectives.

Regional neonatal transport services must meet national service specification standards and the requirements of neonatal ODNs. a Ensure network risk registers include service specification response times and capacity benchmarks when they are consistently not met. Include current mitigations and an action plan. Urgent action is required where there is major disruption to patient flow. b Confirm funding for transport services including ambulance provision, particularly where these services are integrated with NICUs. Capital funding for equipment should be included within funding allocations; charitable funding should not be the primary funding source. c Ensure consultant (tier 3) staff are always available 24/7 to perform transfers if clinically required. Where this is not currently possible, this issue should be on the trust and network risk register and include current mitigations and an action plan. d Analyse the likely impact of changes to network pathways or configuration on transport service capacity and responsiveness.

Significant investment in additional cots is required to implement optimal care pathways as recommended in the Neonatal Critical Care Review (NCCR). a Clarify the amount of capital funding available in the NHS Long Term Plan for additional cot capacity. Any critical gaps with no identified funding commitment will need to be escalated through regional specialised commissioning teams and ICSs for national review. b Clarify how the capital funding model within NHS England is changing and how additional cots will be funded as the neonatal intensive care footprint is larger than the ICSs. c Where neonatal ODNs and regional teams identify a clear need for increased capacity within a trust, there must be an action plan for implementation including current mitigations and escalation plans if difficulties are encountered.

Optimise antenatal and postnatal patient pathways and reduce unnecessary mother-baby separation. a Ensure all network hospitals and cardiac and surgical service providers understand the importance of minimising mother baby separation and avoiding early postnatal transfer. Clarification of birthing hospital for high-risk surgical and cardiac conditions likely to require transfer in first 48 hours of life will help to address this. b Commit to joined up working between LMSs/LMNS, FMNs, neonatal ODNs, transport service providers and paediatric subspecialties to review all exceptions to the preterm designated antenatal and postnatal transfer pathways as well as for babies with congenital anomalies requiring urgent surgery. Feedback should be given to all clinicians across the relevant specialities regarding any learning outcomes including potential to improve antenatal diagnoses. For congenital anomalies, exception reporting and review is recommended for any infant requiring an intensive care transfer from a unit that is not the designated surgical birthing centre, to a surgical centre in the first 48 hours of life. c Consider, where capacity permits, adjusting gestational age for in-utero transfers in low volume LNUs (<1,000 IC/HD per year) to under 29 weeks gestation and under 1,000g, to reduce known risks associated with transfer for this high-risk group pending any decisions regarding re-designation. d Expedite plans for high-volume LNUs that do not meet BAPM staffing standards for Tier 1 and 2 rota separation to meet these standards. If it is likely to take some time, consideration should be given to temporarily adopting the adjusted thresholds suggested for low volume LNUs, network capacity permitting. e Expand neonatal outreach services across all neonatal services to support earlier discharge of neonates from neonatal units, transitional care, and postnatal wards. This should include the ability to support short-term nasogastric tube feeding for preterm infants and access to AHP services. This may require network and commissioning involvement to develop services across the footprint of the network. f Consider maternity unit size, and projected changes to maternity activity alongside socioeconomic factors when evaluating whether an LNU or a SCU is more appropriate for the local population. g Continue to work on strategies to reduce term admissions into neonatal units, particularly units with above average term admissions, including development of transitional care in line with BAPM Framework, and adherence to existing guidance (ATAIN) and CNST requirements.

Improve attainment of key optimal start metrics for preterm infants. These include the following core items: • born in NICU; • antenatal steroids; • antenatal MgSO4; • antenatal antibiotics; • Optimal cord management; • normothermia on admission to NICU; and • colostrum within 24 hours. a Review available benchmarking data to develop formal annualised QI plans at trust and neonatal ODN level to support improvements in optimal start interventions (and other interventions where planned). Trust-level plans should be submitted to their network. b Utilise national QI resources e.g. BAPM/ MatNeoSIP to improve optimal start metrics. Sharing of resources, data analyst support and shared practice will reduce the burden on individual units and provide a supportive structure for improvement. c Increase perinatal working, with close maternity and neonatal collaboration at network, transport and unit level to improve optimal start metrics. d Establish a joint review by LMSs/LMNSs and neonatal ODNs of preterm babies <27 weeks who received higher levels of resuscitation (cardiac compressions and/or adrenaline) to review outcomes and determine any common themes or actions to improve perinatal care.

Maintain skills and confidence for all neonatal clinical staff, particularly those working in LNUs and SCUs, managing emergency situations which occur infrequently outside the NICU setting. a Provide education and simulation training, at least annually but ideally bi-annually, for the entire workforce to ensure confidence and skills are maintained in early preterm stabilisation and other emergency scenarios requiring neonatal emergency procedures, such as exchange transfusion and chest drain placement. b Offer supernumerary time for LNU/SCU staff to spend in NICUs to increase exposure to intensive care. c Look at ways to improve rapid access to expert clinical advice during stabilisation and intensive care support, including use of new technologies such as telemedicine.

Implement NICE guideline NG124 specialist neonatal respiratory care for babies born preterm. a Develop local guidance for preterm infant respiratory support in delivery suites to minimise use of mechanical ventilation. b Provide guidance and training in use of minimally invasive techniques for administering surfactant. c Provide guidance and training on use of synchronised volume-targeted ventilation. d Support units to develop business cases for purchasing ventilators that are able to deliver synchronised volume-targeted ventilation. Consideration should be given to purchasing the same ventilator across LNUs and SCUs within a network to simplify training and potentially reduce cost (see also recommendation 21).

Improve early access to breast milk and sustaining numbers of preterm babies receiving breastmilk during their entire stay in the neonatal unit. a Use the BAPM Breastmilk Toolkit to improve the numbers of preterm babies receiving breastmilk during their entire stay in the neonatal unit. b UNICEF Neonatal BFI accreditation is strongly recommended, and funding sources should be sought at local and national level. Funding is on offer for maternity services to support UNICEF Maternity BFI through the NHS Long Term Plan and there is a strong case for central funding for UNICEF Neonatal BFI accreditation. c Improve network guidance to support equal access to donor breastmilk across the region for the most high-risk infants.

Reduce unnecessary transfusion of blood components, donor exposure and adverse outcomes of transfusion in neonates. a Locally adapt and implement network-wide guidance on transfusion for neonates based on national best-practice guidelines. b Provide appropriate transfusion training to all staff prescribing and administering blood components for neonates, including reviewing key educational messages from paediatric reports in the national haemovigilance system (SHOT). c Audit blood testing practices with the aim to eliminate unnecessary tests and minimise blood volumes taken. d Conduct further research trials to improve safe and effective transfusion practise in neonates and neonatal units should be encouraged to participate in approved trials.

Improve the pathway for babies presenting with bilious vomiting to reduce unnecessary transfers and reduce delays in access to surgical review and upper GI contrast study. a Develop a National Framework for Practice for babies presenting with bilious vomiting with involvement of a multidisciplinary working group. b Form a cross-party working group, including service user representation, to develop standards for radiology / radiography services needed in NICUs, LNUs and SCUs. c Review pathways for babies with bilious vomiting and work with surgical NICUs, transport services and all service providers to improve the pathway, including minimising mother-baby separation. Consideration should be given to developing “drive-through” pathways for well infants.

Governance and mortality review processes at local and network level must conform to national recommendations and include clear structures for escalation of risk. a Implement a clear governance and communications structure from neonatal ODNs to specialised commissioning. b Review neonatal risk registers quarterly at both network and trust level. There should be clearly outlined processes for escalation of risk within the trust, from trust to network and from network to region. c Coordinate an approach to maternity and neonatal governance at both local and regional level. Whilst recognising that particular issues may require more in depth focus at specialty level, there must be appropriate overarching structures for both governance and mortality review. d Standardise the neonatal death review process within the network. All deaths should be reviewed at network level and include LMS/maternity representation. Networks should have oversight of local trust mortality review and PMRT outputs and the networks should be involved in neonatal Child Death Overview Panels to provide a more robust mortality review framework.

Governance and mortality review processes at local and network level must conform to national recommendations and include clear structures for escalation of risk. (continued) Governance and mortality review processes at local and network level must conform to national recommendations and include clear structures for escalation of risk. a Develop a national set of neonatal standard infusion concentrations to reduce the risk of errors occurring when babies are transferred between units; increase viability of commercial production of the required medication strengths; and improve consistency for education and training. b Increase the use of ready-to-use standardised concentrations of drugs and infusions, prepared in pharmacy aseptic services or by external suppliers, and reduce local drug preparation in neonatal units. c Adjust, where applicable, trust or network-developed drug calculators to ensure they are updated against MHRA advice and can be used across networks. Existing drug calculators should not be removed until a safer sustainable alternative is in place. d Ensure standardised parenteral nutrition (PN) bags are available for both initial and maintenance PN in all NICUs and LNUs and consider network-wide standardisation (see also our recommendations about procurement). PN bags should comply with national nutritional recommendations for neonates as well as safety standards, including mechanisms to avoid accidental lipid over-infusion.1 e Ensure all neonatal units have access to a pharmacist with competence to provide advice for prescribing and monitoring of PN to complex patients. f Enable staff in all units to regularly practise preparing drugs and infusions commonly used in neonatal intensive care. g Prioritise rolling out suitable electronic prescribing systems for neonatal care. These require a high level of involvement from neonatology teams and neonatal pharmacists to ensure the design is fit for purpose. Where the existing trust prescribing system is not deemed safe for neonatal use, it must be suitably adapted, or an alternative product used. h Implement smart pump technology in conjunction with advice and recommendations found in HSIB smart pump report94 and audit the impact on medication errors in neonates.

Improve prompt recognition, diagnosis and treatment of conditions commonly screened for or assessed in the neonatal period, which are more likely to result in significant clinical harm. a Review the evidence for pulse oximetry screening and work together to support role out of pulse oximetry screening (POS) across all networks. b Reconsider inclusion of pulse oximetry screening as part of the national screening programme given the increasing number of neonatal units already undertaking universal screening that results in significant regional inequity in identification. c Ensure all hospital and community services have access to transcutaneous bilirubinometry (TcB) in line with NICE guidance. d Implement clearly agreed antenatal and postnatal pathways for managing infants at high risk of needing an exchange transfusion in the neonatal period. Delivery should be planned at a site where the neonatal unit has appropriate staffing and expertise on site at all times. e Training for staff performing newborn infant checks must include information regarding anorectal anomalies and the fact they may be more likely to be missed when meconium is passed through a fistula. f Raise awareness of signs consistent with spinal cord anomalies in the newborn period and establish network-wide protocols for initial management and referral pathways. This should be done jointly between paediatric neurosurgical services/networks and neonatal ODNs as part of a wider collaboration between the two networks with regards to neurosurgical pathways (see GIRFT’s Paediatric Neurosurgery report). g Review NICE guideline: Neonatal Infection (NG195), and HSIB’s national learning reports on group B streptococcus (July 2020) and neonatal collapse (Aug 2020) recommendations and amend local guidelines and education material accordingly. h Optimise evidence-based infection reduction strategies and submit accurate verified infection data to NNAP.

Reduce litigation costs by application of the GIRFT Programme’s five-point plan. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. b Clinicians and trust management to discuss with the legal department or claims handler, the claims submitted to NHS Resolution in the data set, to confirm correct coding to neonatology as claims for neonates can occur in neonatology, paediatrics (including paediatric subspecialties), paediatric intensive care or maternity, all claims for infants <28 days old at the time of the incident, should be reviewed by the respective teams to ensure accurate assignment of the claim to the correct team. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk Note: Coding of claims to neonatology commenced in April 2020. c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious incidents (SI) and where a claim has not already been reviewed as SI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with networks and all front-line clinical staff in a structured format at departmental / directorate meetings (including multidisciplinary team meetings, morbidity and mortality meetings and regional service meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.

Facilities for families should allow parents to remain with their baby at all times if their circumstances permit. a Increase the range of services provided within transitional care to reduce mother-baby separation, and where possible to provide more flexibility for partners to also be caregivers. b Urgently address inadequate or poor-quality counselling and bereavement facilities. Seek input from families to determine needs. c Work with families to understand the gap in provision of facilities and address inequities, in line with established guidance.2 Where new units are planned, parent facilities should receive the same priority as clinical space. d Research and determine what tailored support can be made available for siblings.

There must be consistent and equitable financial support for parent travel, subsistence and accommodation requirements. a Benchmark current financial support available to families including parking, accommodation, food and drink and travel costs, making best use of available evidence. b Share network findings with the Neonatal CRG and BAPM to support alignment nationally. c Provide consistent and equitable financial support to families across the network. Ensure families are aware of their statutory entitlements and how to claim. d Provide free, or discounted, parking for all parents of neonatal inpatients for the duration of their stay.

Family Integrated Care must be fully embedded in all neonatal services and networks should ensure family training and involvement in care are the same across different providers in the baby’s journey. a Consider a unified approach across the network to improve the journey for families transferred between providers. This should include development of parent passports to provide consistency for parents to continue care for their baby when they move between sites. b Parents must be considered as essential carers not visitors. Nationally, continue to champion the needs of families in neonatal units during world events that potentially restrict patient access (e.g. the COVID-19 pandemic) in order to reduce the potential neurodevelopmental consequences of these restrictions. c Ensure every provider of neonatal care has a clear action plan for ongoing development of partnership care with families using QI tools such as the Bliss Baby Charter, UNICEF Neonatal BFI (see action 8b) and BAPM Framework for Family Integrated care. This work should have senior nursing and AHP leadership involvement alongside the family voice.

Psychological support services should be accessible to all families during their stay in the neonatal unit, with seamless links to community perinatal mental health services as and when they are appropriate for an individual family. a Benchmark the level of psychological support required against the current standard (BPS Perinatal Services 2016) and the anticipated neonatal standards due to be set by the British Psychological Society (see workforce report recommendation 2b). b Actively address the psychological needs for the whole family throughout the neonatal unit journey and post discharge. There is a major gap in access and provision of Perinatal Mental Health support for these families and this must be addressed. This needs to be taken forward both locally and nationally. c Encourage local and regional links to peer support groups and charities to support improved psychological support. d Raise awareness of the psychological impact of the neonatal experience on families among all professionals but particularly those working in the community who have little exposure to neonatal care.

Robust mechanisms must be in place to include a wide range of parent voices with diverse backgrounds and neonatal experiences in service development and quality improvement across networks and trusts. a Make available Neonatal Parent Advisory Groups/ Neonatal Voices Partnerships or equivalent across all neonatal networks. Links made to MVPs and other parent voice provisions within the local area provide a wide-reaching voice to a diverse population. b Ensure each local provider of neonatal care has a robust mechanism for parent feedback. This may be developed at a network level. c Ensure there is a mechanism for parents to show how their feedback has been actioned and how this has affected change. This should be updated at least biannually.

Ensure seamless and accurate data flow of mandatory datasets for network pathways and flows, national and regional audit, benchmarking, research, pricing and national cost collections (NCC). a Provide sufficient support locally (clinical and administration time) to ensure accurate data collection for the neonatal critical care minimum data set (NCCMDS), NNAP, and NMPA. Include appropriate clinical job planning to support data checking and submission. b Verify data accuracy and completeness in the annual NNAP data returns. c Ensure accurate activity submission to NCC and SUS, and accurate cost submissions to NCC, with use of cost weightings included in National Cost Collection guidance. There should be evidence of clinician involvement in this process. d Ensure, as EPR systems develop, that duplicate data entry is avoided with seamless dataflows for payment, costing, audit and research e Explore development of a national Neonatal Services Monthly Statistics Dashboard along similar lines to the Maternity Services Monthly Statistics Dashboard. f Provide quarterly dashboards for key NNAP and maternity dashboard measures to support improvements in data quality, local benchmarking and improvements in NNAP measures. g Engage with trust level Patient Level Information and Costing System (PLICS) collection for neonatal critical care in line with national timetables. h Agree an amendment to the data flow for SUS to allow linkage of each neonatal HRG bed-day to the location of care to improve accuracy of the data flow to SUS.

Neonatal ODNs to work with local providers and agree procurement models, so consumables and devices used more infrequently are consistent across a network, the GIRFT 3-point strategy should be used to support this process. a Agree a procurement framework across the Neonatal ODN, with a particular focus on parenteral nutrition, neonatal ventilators and equipment for therapeutic hypothermia. b Use sources of procurement data, such as SCS and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. c Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. d Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.