MCQIC Re-Engagement Webinar Maternity & Neonates

MCQIC Re-engagement Webinar Maternity & Neonates 3pm – 4.20pm Wednesday 30 September 2020

Thank you for joining us today - the meeting will begin shortly

Improvement Hub Enabling health and social care improvement Dr Colin Peters MCQIC Neonatal Clinical Lead Healthcare Improvement Scotland Meeting participation

During the meeting please have your microphone on mute and video turned off to avoid distraction for you and also to minimise the likelihood of slowing down the technology.

To take part in discussions use the chat box or raise your hand and wait to be invited to speak, please then: • unmute your mic • after speaking please re-mute This meeting will not be recorded. Meet the Team

Angela Cunningham Colin Peters Elaine Mackay Damian Boyd Midwifery Clinical Lead Neonatal Clinical Lead Project Officer Associate Improvement Advisor

Alan Cameron Jo Thomson Sula Kirkpatrick Dagmara Lukowiec Obstetrics Clinical Lead Improvement Advisor Administrative Officer Senior Project Officer Jo Thomson MCQIC Improvement Advisor Healthcare Improvement Scotland MCQIC Reactivation

Where we are:

• Re-engaging with stakeholders • Team capacity • Recognition of possible further COVID 19 developments

Priorities we will support in the short term:

• Stillbirth (and associated process measures) • Neonatal Mortality (Preterm Perinatal Wellbeing Package), Term Admissions • Developing a package of measures around reducing BPD • Looking at data on Stillbirths during COVID • Early development work around C Sections NHS Borders Kirsteen Guthrie & Gill Lunn NHS Borders

How did COVID-19 affect work?

• At the end of March 2020 there were concerns regarding COVID 19 within the hospital ,the transmission of this via the vertical ventilation system. This had the potential to compromise patient and staff safety and our antenatal/postnatal ward was re located to another area within the hospital with a smaller foot print. • With a reduced amount of antenatal beds the obstetric staff reviewed our current induction of labour policy. • After discussions with other health boards it was decided to use the Cooks Cervical Ripening Balloon as an alternative form of induction of labour for appropriate women. • Advantages of the Cook Cervical Ripening Balloon at NHS Borders – Using the Cook balloon for women wishing a VBAC to help reduce intervention and emphasise patient experience – At the beginning of lockdown there was no visitors or partners allowed to visit, which led to increased anxiety for women having to stay in hospital – Most women were keen to spend as little time as an inpatient as possible at this time – The Cook balloon costs around £80 compared to the cost of an overnight stay on the ward NHS Borders

Lessons learned?

• Communication with all staff concerned regarding change of practice • Cook Balloon has usually been performed by medical satff • Induction of labour at term in low risk pregnancy has historically been a midwifery procedure • A standard Operating Procedure has been adapted from NHS Lothian to allow midwives to perform the procedure • We need to look at outcomes of the new process with data collection to see if there can be any quality improvements made NHS Borders

What will we do differently?

• A SOP has been written with training devised so that midwives can perform this procedure • We will gather feedback from women and staff • Email in box [email protected] • We have a COVID face book page NHS Borders

What would you ask other Boards?

• What is the uptake rate of using the Cook balloon in other boards? • Do midwives in other boards insert the Cook balloon? • Do you have any other education in place? • Do other boards have patient experience feedback for the Cook balloon? Q&A Amanda Gotch NHS Grampian NHS Grampian

Area of focus: Reviewing adverse events – deep dive into perinatal adverse outcomes

How did COVID-19 affect work? Lessons learned? What will we do differently? •We were successful in keeping ALL of our services working •Staff adaptation to rapid change We are still working that out! •Emphasis on safety and dissemination of •We need to keep our eye on the ball! information •Building resilience in the system Creating more opportunities to build a •Redeployments of colleagues/students •Compassionate organisational stronger QI foundation •Reduction in face-to-face communication leadership •Rapid change – responding to this system •Change fatigue and disengagement Promoting shared empowerment: wide •Investment in QI is vital to motivate Shifting from command and control •All consuming nature of change • •Environment changing on a daily basis Investment in people •Changing whilst keeping services Shared ownership functioning - SAFELY What would you ask other Boards?

Do you think the global pandemic has affected adverse outcomes? If so, what makes you think this? The real power in leadership is in encouraging and creating more leaders. Q&A NHS Lanarkshire Lorna Lennox & Augusta Anenih NHS Lanarkshire

Area of focus: Term Admissions to Neonatal Unit

How did COVID-19 affect work? Lessons learned? What will we do differently? • Maternity Unit reverted to LDRP setup. • Centralisation of services to one single • Systems thinking in making change • Retain the labour ward, AN /PN area. • Rapid PDSA cycles are achievable! ward set up. • Non essential work suspended i.e. • Consider rapid testing all pregnant BLISS, QI, MCQIC • Importance of behavioural science women on admission • Staffing (reorganisation of staff, • Patient Safety remained a priority • Utilise technology for teaching shielding, self isolating) while maintaining quality • Restricted Visiting. • Digital technology for care • Redeployment of 2nd /3rd year student • Digital technology for staff training and • Be proactive in real time rather midwives. client care than reactive now • Homebirths suspended • The “retroscope” gives us clarity

What would you ask other Boards? • Have you seen an increase in Term admissions especially those requiring respiratory support with no known underlying risk? • Does your data tell a different story? March – August 2019 March – August 2020 Difference %

Total deliveries 2212 2060 -152 6.87% less

Term (≥ 37weeks) 2027 1923 -104 5.13% less

Late Preterm (34 – 36+⁶ wks.) 127 90 -37 29.1% less

Preterm (<34wks) 58 47 -11 19% less

Total Term Admissions 130 141 +11 8.46% more

% Term admissions 6.41% 7.33% 0.92 14% higher

A run chart showing rate of term admissions admitted to the neonatal unit 300 (from Dec 14 to Aug 20 atin the NNU University Hospital Wishaw)

250

200 PDSA - NEWTT escalation 150 pathway PDSA 1 - Theatre Temp Covid-19 Lockdown 100 Coorie In Project

50 neonatalper1,000 unit

Jun… Jun… Jun… Jun… Jun… Jun…

Oct… Oct… Oct… Oct… Oct…

Apr… Apr… Apr… Apr… Apr… Apr…

Feb… Feb… Feb… Feb… Feb… Feb…

Dec… Dec… Dec… Dec… Dec… Dec…

Aug… Aug… Aug… Aug… Aug… Aug… rate ofrateterm admissions admittedtothe Reason for Term admissions to NNU - March - August 2019 35 100% 90% 30 80% 25 70% 20 60% 50% 15 40% 10 30% 20% 5 10% 0 0% ? Infection / Ventilated / Other Issues Respiratory colour Change Feeding Jaundice / Cooling Neonatal Hypoglycaemia Covid-19 Antibiotics CPAP conditions issues phototherapy Abstinance suspected syndrome

Reason for Term admission to NNU - March - August 2020 (since Covid-19 restrictions) 45 100% 40 90% 35 80% 30 70% 60% 25 50% 20 40% 15 30% 10 20% 5 10% 0 0% Ventilated / Respiratory Other Issues Hypoglycaemia ? Infection colour change Cooling Jaundice / Covid-19 Neonatal Hypothermia CPAP conditions /Antibiotics phototherapy suspected Abstinance syndrome Reason for short stay Term admissions March - August 2019 (n:112) 70 100% 60 80% 50 40 60% 30 40% 20 20% 10 0 0% Cannulation / Observation Respiratory Other Feeding/ antibiotics conditions reasons vomiting • Lower numbers in 2020, 79% reduction.

Reason for short stay Term admissions March - August 2020 • Same top three (during covid restrictions) (n:23) indications. 10 100% 8 80% 6 60% 4 40% 2 20% 0 0% Respiratory Cannulation / Observation Feeding/ Other conditions antibiotics vomiting reasons NHS Lanarkshire

Area of focus: Term Admissions to Neonatal Unit

What would you ask other Boards? • Have you seen an increase in Term admissions especially those requiring respiratory support with no known underlying risk? • Does your data tell a different story? Q&A Dr Colin Peters MCQIC Neonatal Clinical Lead Healthcare Improvement Scotland Bronchopulmonary Dysplasia Reduction Package

• Early effective CPAP by prongs or mask should be utilised as the first line management • Applied within 5 minutes of birth, not intubated within 15 mins of birth. • A Volume Limited strategy should be used in NICU (eg Volume Guarantee, Targeted Tidal Volume) • First ventilated episode in NICU, Volume Limited ventilation used until extubation. • Surfactant in the first 48hrs surfactant should be administered where FiO2 >30% or for a ventilated baby requiring oxygen. • Non-ventilated clinically stable babies after 30mins of minimal handling or any ventilated baby • A Less Invasive Surfactant Administration (LISA) approach should be used when administering in NICU for babies <32 weeks

• PPWP includes elements to reduce BPD eg Steroids, Caffeine, MEBM Alan Cameron MCQIC Obstetrics Clinical Lead Healthcare Improvement Scotland C Section Data - Scotland Jo Thomson MCQIC Improvement Advisor Healthcare Improvement Scotland 2020 Essentials of Safe Care – why?

• Maintaining safety • ‘Essentials’ for every person, in every system, every time • Stakeholder feedback identified three core themes: – Essentials of safe care delivery of safe care in every setting /system for every person – Specific improvement areas resulting from care pathway redesign or change in clinical / operation processes – Learning systems the value and impact of forums to come together to learn and share Principles

• Not a mandated requirement • Complements and supports existing guidance and standards • Combines evidence and existing knowledge • Practical and useable, pragmatic guidance • In Covid context and beyond • Sufficiently generic enough for different health and care settings • Links with other national areas of work, for example Excellence in Care, Health and Social Care Standards Our Engagement So Far

• Mental Health Leads Group • GP Practice Managers Network • Primary Care Leads 2020 Essentials of Safe Care Driver Diagram (draft)

Systems and culture for Person Inclusion and involvement Centred Care are embedded and Workforce capacity & capability Structures & processes that enable safe, person centred support safety for everyone care

Huddles Communication within and To enable the Safety briefs between teams delivery of Safe Structured communication (SBAR) Care for every person within Leadership and Culture of Safety at Prioritisation of safe care at all levels every system all levels Staff wellbeing and psychological safety every time Learning Systems

Operational (Safe Staffing) Safe Clinical and Care Processes Clinical Care Infection prevention and control Angela Cunningham MCQIC Midwifery Clinical Lead Healthcare Improvement Scotland Feedback

• How frequently would you like MCQIC to host Webinars?

• Does 90 minutes feel about right for timing? o Too short? o Too long? [email protected] • What topics relevant to the programme do you wish to see covered moving forward?

• Would your Board be willing to present in future?

Please raise your hand then unmute, use the chatbox or email your responses to New email: [email protected] to be picked up later Mary Davie & Tara Fairley Perinatal Network Damian Boyd MCQIC Associate Improvement Advisor Healthcare Improvement Scotland What’s next?

• Clinical Reference Groups

• Meeting virtually: [email protected]

o MCQIC Quick catch up’s o MCQIC ‘Virtual Visits’

• Data and Self Assessments What’s next? QI Capacity and Capability

ScIL (Scottish Improvement Leaders) For Individuals who need in-depth QI knowledge to support others across their organisation • NES currently recruiting for cohorts 30 and 32 • Applications open from 5th October until 16th October • Targeted recruitment areas are: Lothian, including the State Hospital (Cohort 30) Fife, Borders, Dumfries and Galloway and the Scottish [email protected] (Cohort 32)

Further info / register: https://learn.nes.nhs.scot/1769/quality-improvement-zone/learning-programmes/scottish- improvement-leader-programme-scil/scil-recruitment

SCLIP (Scottish Coaching & Leading for Improvement Programme) For managers coaching and leading teams to improve their services

• 3 national cohorts for SCLIP planned for next year. No dates set for registration Further info: https://learn.nes.nhs.scot/10656/quality-improvement-zone/learning- programmes/the-scottish-coaching-and-leading-for-improvement-programme-sclip Thank you!

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