Report from the Vermont Oxford Quality Improvement Congress Chicago, September 2018
September 20th was the beginning of the 2018 Vermont Oxford Congress and, through the generosity of our charity, Simpsons Special Care Babies, five members of staff from the Simpson Neonatal Unit and one from the Special Care Baby Unit at St John’s Hospital were able to participate in this incredible, neonatal specific event.
The main themes of the Congress were:
Using the NICU Wisely
Follow-Through: Care Beyond the NICU Walls
Artificial Intelligence and You
The Developing Brain
Remarkable stories of improvement were documented in over 300 abstracts by teams from around the world. Supporting the main events were pre and post conference workshops on Jump Starting Quality Improvement, Genomics, and Writing for Publication. For the first time, families played a key role in organising the Congress, as well as being equal members of improvement teams.
Each year VON’s Global Neonatal Database and volunteer program is dedicated to supporting health care providers in global resource-limited communities to enable sustainable data-driven quality improvement. This year it was dedicated to providing clinical mentoring, medical care, and quality improvement training for NICU nurses and physicians at Tikur Anbessa Hospital in Addis Ababa, Ethiopia.
Here are the reflections of our experiences.
Using The Nicu Wisely/Who Really Needs Nicu Care?
What we learned:
Bigger (Full term) babies occupy more beds – Less HD, more special care
Most of the cost of having a baby in NICU happens in the first few days of life (surfactant, CPAP, TPN etc)
Majority of money is spent on a greater volume of ‘less sick’ babies opposed to smaller volumes of ‘more sick’ babies
Our practice has a direct affect on length of stay and, in turn, cost of care. Ensuring that we are only admitting babies who need to be in the NICU and ensuring they stay only as long as they need greatly affects families, providers and cost.
It made us think about several topics, including;
Who really does need NNU care? and,
Are we really doing our best to keep mums and babies together?
Could we potentially be focusing our resources on the smaller sicker babies?
We need to think about the impact of admission to the NNU and the length of stay on both us and the families.
The impact on us
Cost to the unit and the NHS
Ability to provide safe and effective care
Availability of resources (equipment and/or staff)
Closed units due to overcapacity
Impact on families
Exposure to potential errors
Breast feeding interference
Impact for extended family, e.g. siblings
Potential exposure to unnecessary tests and investigations
At one of the break-out sessions, we heard from a parent who summarised these impacts when telling us of the journey she and her daughter went through after she was born at 23 weeks. This was very inspiring as her daughter was now 20 years old, and she too spoke in front of us all. It was fascinating to see the journey and the outcome for their family and gives me hope for all the extremely premature infants and the positive futures these babies can lead. Although we are all aware of the impact that having a baby on the unit can have, hearing it first-hand from a parent who was visually distressed and upset about sharing her thoughts and feelings was very powerful. Listening to her experience of an NNU made me think about the following;
What can we do? and,
Is there anything more I can change?
NICU utilisation varies in differences of admission/discharge and length of stay:
What drives these variations?
Decrease in numbers of very preterm babies with less admissions of babies’ < 34 weeks gestation with longer stays
Increased admissions of normal and larger birth weight babies and term babies with shorter stays.
Exposure to risk (i.e. infection or medical error).
Overuse of opportunities, tests or treatments (i.e. use of antibiotics, anti-reflux medicines).
Benchmarks (i.e. use of diagnostic imaging MRI, CXR).
NICU is a place to deliver the best therapies possible with best possible outcomes.
Holistic care and not just a medical intervention, to give effective family centred care with outcomes that can be measured.
A baby’s admission to NICU impacts on the whole family.
Costs of NICU hospitalisation is not just financial it has long term social and psychological effects on families. Mother and infant separation can affect attachment process with adverse effects on maternal mental health and baby’s development.
Maternal and paternal health varies through the chaos of NICU and dictates the care and discharge of baby.
Give families what they need when they need it.
Support parents and empower them by giving them a voice and time to listen.
Access to services and what is available to them.
Aiming for best practice: the right length of stay for each baby.
As a non-medical prescriber I feel a huge responsibility surrounding antibiotic stewardship, the risk of over-treating babies and anti-microbial resistance. I was therefore very interested in the presentations regarding the use of auto-stops to help prevent antibiotic courses being prolonged when there is no clinical benefit. I was pleased to hear that there has been an average of a 34% decrease in the use of antibiotics in neonatal units within the VON partnerships. An antibiotic resistance challenge event has been launched. This event is part of United Nations activities. There have been 100 commitments from around the world, with VON being one of these. VON aims to decrease antibiotic use by 45% by 2020.
Many NNU use a sepsis risk calculator. There was wide variation in the use of this calculator vs wait and watch. Why do we not use this? This is a discussion I must have with our consultant body.
In Colorado during each ward round they have an antibiotic “time out” pause, where decisions are made regarding the treatment - parents are also encouraged to speak up at this time. I feel that we should be empowering our parents whenever we can, and I like this idea of them being more involved in the decision making. In Colorado antibiotics are stopped at 24 hours. They report that almost all blood cultures were positive by 24 hours, therefore antibiotics were stopped at 24 hours if there were no concerns about the clinical condition at blood culture was negative. There was no discussion about the use of CRP results as a basis for this.
We heard about the very interesting concept of “Prescribing NICU care”, almost in a way of prescribing a therapy, with lots of benefits but also numerous side effects, in the talk: Who Really Needs NICU Care? by D. Goodman. Mentioned the trends that we see in our ITU/HDU, that majority of admissions are short term admissions of large term babies. Not to say that all are unnecessary but in spirit of keeping babies with their mothers, increasing cost of ITU /HDU admissions and potential for adverse effects – drug errors, HAI etc we really should review the necessity of each individual admission. This is in keeping with our own project within the Best Start initiative to promote Transitional Care and to keep mums and babies together. This also ties up with more Family centred care for the families where admission is unavoidable.
It was highlighted that the longer the NICU stay the longer you are exposed to risk (developmental risk, medical error). Therefore, we should be trying hard to decrease the length of stay our babies have in the NNU.
At the RIE we have implemented “Keeping Mums and Babies Together”. This addresses the highlighted issues of the cost of late preterms, as we aim to keep this group of babies with their mums on the postnatal ward with minimal neonatal input. Whilst our NHS structure makes cost not such a transparent concern, we should worry about the “cost” to the babies and families of admitting them to the NNU - breastfeeding, attachment, etc.
We listened to John Chou discussing telemedicine and parental bonding in the NNU. This is using cameras (visual only with no audio) so parents can see their babies. It is highlighted - which we have discussed at the RIE - that this can sometimes increase parental stress as they can see venepuncture, apnoeic episodes etc from home. John Chuo advocates the use of a parental stress scale in these situations.
Follow-Through: Care Beyond The Nicu Walls
I believe that, as a unit, we could utilise our community team more than we do at present whilst still maintaining patient safety. We should see the community outreach team as an extension of the care we deliver on the unit. Do we always consider the potential harm that we may be doing when unnecessarily keeping or admitting a baby to the NNU. Could we adopt an admission pause, e.g. Is the NNU the best environment for this baby? And a daily pause on ward rounds asking the same question?
And finally, something that I think we should ask ourselves, could there be times when a baby might receive better care from the parents?
Artificial Intelligence And You
Artificial Intelligence seemed as very unlikely topic for discussion on QI in the NICU, where we find so many basic issues that need our attention, yet it turned out to be fascinating. Probably charismatic Professor Max Tegmark helped the matter a lot with his enthusiastic but very scientific talk on the basics of artificial intelligence. Working in an environment full of automates and alarming machines makes us all think about the future. Are we going to have to put up with even more alarms, machines and independent systems or will it all be more integrated, streamlined and less demanding on our rapidly exhausting decision making capabilities. The world that Tegmark helps to create seems like nice place to be a Neonatologist. AI will take over – apparently whether we want it or not- it is just a matter of human decision how we will implement this in our life. The science is trying to describe the direction of changes so there is more servo-automated responses and those responses are less and less straightforward, and take into account more and more complex issues. Although this session did not inspire any of my own QI based projects, it gave me a lot of food for thought in expectation of the new generation of self-regulating Ventilators, responding to changes in pO2 and pCO2.
I found the Artificial Intelligence seminars very interesting with regard to where the future of NICU care could be. The presentation talked about how cameras could be installed to allow parents to log in and see their baby. This idea has some extremely positive consequences to help bonding, reduce anxiety and improve contact between long distance family members. However, I feel that this has the potential to reduce physical visiting with some families if they can see their child via video link. In the same presentation the idea that the possibility of future communications via video call could happen, therefore connecting multidisciplinary agencies much quicker and with better effect. An example of this was used in relation to the resuscitation and subsequent ventilation of a baby where a video call was able to link staff in different hospitals which were able to offer expertise and advice.
The Developing Brain
‘Every interaction with a preterm baby is an opportunity for brain protection’
Procedural Pain and the Brain
Prof Grunau presented very compelling evidence that procedural pain – skin pricks mainly - have tremendous impact on brain development, so great that it can be quantified by quality of the brain tissue. In babies of 24-32 weeks gestation a single heel prick causes profound changes in brain chemistry that can alter neurone development. Babies of this gestation are not designed to be dealing with this, and the adverse effects can be reduced by carrying out procedures alongside skin to skin as the physiological response to pain is reduced.
This lecture inspired me a lot to continue work on limiting the amount of unnecessary blood tests, grouping blood tests and, more so, aiming for more procedures to be done while baby is breastfeeding, where possible, or having Kangaroo care with skin to skin. Apart from routine use of sucrose, those techniques seem to have protective action on the adverse effect of pain and brain development.
Improving brain outcome is impacted by hygiene and prevention of infection, neonatal pain management, mother’s milk, warmth of the incubator, noises, talking, light – we, NICU staff, have a lot to improve. On the other hand – there is also the work of educating parents regarding continuous impact on their child’s brain development which is part of my normal work in Follow Up.
The Developing Brain session touched on more concrete issues around ... developing brain. Steven Paul Miller is Paediatric Neurologist with profound understanding of the intricacies of the developing preterm brain. His talk referred to brain plasticity and the importance of wide spectrum factors modifying brain development – from pain, environment and parental influence. It seems that there is not a single ‘static lesion’ but a very dynamic process in which the preterm brain needs to navigate to achieve its final function. There were a few fantastic quotes from this talk, but my favourite has to be:
‘Every contact with preterm baby is an opportunity to improve their brain outcome’
The Developing Brain presentation is very relevant to our QI ‘Brainiacs’ group, which is looking at neuroprotection and follow up and we are always looking for ways to improve infant’s outcomes. This presentation also ties in with our QI Families group, of which I am also a member. It was reassuring that we have already adopted many of the strategies that are being used, but there is definite room for improvement in some areas, especially around developmentally supportive care and Family Integrated Care. There was a very inspirational talk from a teenage single mum of preterm twins who talked about follow up and the things she valued and would have liked more help with, such as attending appointments, but also more help with child care as she wanted to go back to study to be a physical therapist, but until the twins are at school there is no way to for her to do this. We are more fortunate in this country, and not many of our families struggle to come to appointments. We have streamlined the clinic to make the appointment valuable and worthwhile attending and trying to minimise duplication and unnecessary appointments.
There were lots of poster presentations on follow up and Bayley outcome data, which was really good to see. However, the best thing about it was that we are way ahead of anything presented there with our follow-up programme and the quality of our data.
“Understanding the ‘everyday’ provides new opportunities for better outcomes”
This was my take home message from the VON conference, that everything we do on the unit is an opportunity to improve outcomes for our babies and improve the families’ experience.
There were many interesting points made in presentations and further considered at the panel discussion sessions where questions from the audience were answered. Many professionals from around the world shared their expertise and knowledge on the topics above, but the one thing that impressed me the most was the courage and candid experiences brought by a few parents of NICU ‘graduates’. One mother spoke about her troubles regarding her stay in NICU with her twin boys and how difficult life was for her being a single parent living with her elderly grandmother. This was extremely valuable as it enabled an unedited and uninterrupted view into NICU care from the parent’s perspective. It allowed me to truly appreciate the job that I and all clinical staff do, and the impact this has on the experience and outcomes for the families we care for.
I feel that I can improve my own practice by,
Continuing to act as a role model in promoting keeping mums and babies together
Challenging decisions and making alternative safe suggestions in the care of our babies
Continue promoting transitional care on postnatal wards
Early referral to the
Community Outreach Team
Changing culture and mindsets
Sharing information I gathered from the Von conference
Learning from both good experiences and bad
Measuring success and failure
Exploring the introduction of an admission pause with colleagues
Finally I feel that the Von conference is a must for neonatal nurses and Doctors, as it is a great opportunity to network with others; and through the talks and poster sessions, I feel that it has opened my mind to all the great changes that can be made through quality improvement.
I would like to thank Simpson’s Special Care Babies for the funding to allow me to attend the conference. It would have been an opportunity which wouldn’t have materialised without this funding, and I am grateful for the extension of this to St. John’s hospital this year.
These talks and discussions made me realise that we are doing a great job in our unit:
We support and nurture parents and are partners in care with them. We provide support and guidance with our community outreach service after discharge, and monitoring of progress and milestones with our neurodevelopmental clinics.”
We now have a ‘families’ working group looking at supporting parents on the unit with different events, and new facilities for parents are hopefully being installed in the near future.
Best Start: keeping mums and babies together, a Scottish Government Initiative is changing the way we care for preterm babies over the next 5 years. Scottish Government have also introduced a scheme to provide parents with financial assistance as long as their baby is in NICU.
All good but we need to continue to improve, which is why QI initiatives are so important.
To be the best whatever that looks like.
I particularly enjoyed the talks about ‘Using The Nnu Wisely’ and ‘Length Of Stay Too Short Or Too Long?’ as these topics overlap with the Best Start strategy. I hope that I can share my experience with others and encourage more people to attend and think about ways to improve the quality of care on our unit.
It is impossible to report on the whole conference in a short note that I promised to complete at return and do justice to the rich and diverse experience. Since we now have access to online handouts and some lectures, I would love to compile a ‘mini Chicago’ event in nearest future to share inspiration with all my medical and nursing colleagues.
It would be great to feedback with a small slide show running in the seminar room with maybe a couple of slides from each of us. Also, the ‘kick starting QI’ pack is very good, with lots of information which I am sure is available through the NHS, but here it is all in one place – as a non-QI expert, it made the process much clearer to me.