Antenatal Optimisation in Preterm Infants <34w: - PowerPoint Presentation

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Antenatal Optimisation

in Preterm Infants <34w:

A Quality Improvement Toolkit

British Association of Perinatal Medicine In collaboration with the National Neonatal Audit ProgrammeSeptember 2020

To be used for staff education in conjunction with the Antenatal Optimisation Toolkit

For all references see Antenatal Optimisation Toolkit

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The Perinatal Optimisation Care Pathway

 

The Quality Context

 

The Perinatal Team The Perinatal Optimisation Care PathwayCounselling of parents and shared decision-making

 

 

Key optimisation timepoints

Elements of the BAPM Antenatal Optimisation Toolkit

Other BAPM Optimisation Toolkits

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Purpose of toolkit

To facilitate delivery of key antenatal optimisation measures known to improve preterm outcomes. To support clinicians leading and participating in QI in maternity units by providing practical resources in the form of a toolkit and supporting materialsThis toolkit will:Provide the evidence base for effective interventions Facilitate units in interrogating their own data and processes in order to undertake selected quality improvement activities suited to the local context

Assist units in interpreting and monitoring the results of their QI activityProvide and signpost resources to facilitate QI in the area of improving antenatal optimisation in the preterm infant

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Rationale for AO

1 fewer baby with CP for every

37 women treated <30w

1 more baby surviving for every

8-10 women treated <26w 1 more baby surviving for every 20 women transferred

1 fewer baby with infection for 9 GBS+ women treated in PTL

For all references see Antenatal Optimisation Toolkit

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Evidence and professional recommendations

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Prediction of preterm birth

Preterm birth history alone: 10-57% of pregnant women with a PTB history will give birth preterm. Most women who give birth preterm do not have a history of preterm birth.QUiPP App: Using a 5% chance of birth, predicts PTB in next 7d in women <37w and avoids 90% of admissions

qfFN: Predicts PTB <30w in singleton/multiple pregnancy Combination of Cervical Length and qfFN:

Addition of cervical length refines predictive ability of qfFN and may save €480 per patientPlacental growth factor and sFlt-1/PGF ratio: Rules out pre-eclampsia within the next 7d in women with suspected pre-eclampsia <35w

For all references see Antenatal Optimisation Toolkit

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For all references see Antenatal Optimisation Toolkit

SteroidsA complete course of steroids reduce death by 30% in infants less than 34w, including those <25w where mortality effect is greaterSteroids also reduce RDS, IVH and NEC including in extreme preterm gestationsOptimum timing is within 7d of birth with course completed 24h before birth (only 22% of women who give birth <34w receive steroids in this timeframe)

Benefits of steroids do not exceed 7dMortality benefit remains for steroids given 6-12h before birthRepeat courses reduce respiratory morbidity but do not reduce mortality and may impact fetal growth  Focus should be on more accurate prediction of birth to inform more precise timing of antenatal steroids rather than a repeat dosing strategy

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For all references see Antenatal Optimisation Toolkit

MagnesiumGiven within 24h before birth at <32w reduces the risk of cerebral palsy and death without risk to mother or fetus Similar effects across a range of gestations including extreme preterm infants

Optimum level is at least 4h after loading dose Benefit remains if given <4h where birth is imminentAntibiotics

Preterm prelabour rupture of the membranes and preterm labour are associated with early onset neonatal infection with GBS

Antibiotics given at least 4h before birth reduces the risk of GBS sepsis tenfold

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For all references see Antenatal Optimisation Toolkit

Place of birthIf birth of an extreme preterm infant occurs in a high volume, neonatal intensive care setting, Mortality is reduced by around 50%There are reductions in NEC, IVH and PVL

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Optimising Place of Birth

 

 

  

  In utero transfer to NICU setting if: <27 weeks singleton  <28 weeks multiple 

<800g

• If these maternal interventions are not achieved before birth, the opportunity for benefit is lost •

Overall

Aim

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The drivers for preterm Antenatal Optimisation

within the UK

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What does best practice in Antenatal Optimisation look like?

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*

in some situations, such as remote distance from a NICU at extreme preterm gestation, a lower

QUiPP threshold may be appropriate in prompting transfer. These decisions should be clinician-led.

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Best Practice in Delivery of Antenatal Optimisation Interventions (1)

GeneralIt is recommended that each unit should establish: Obstetric, Neonatal and Midwifery leads for Antenatal Optimisation

A ‘Perinatal Team’ culture with shared goals and responsibilities A maternity triage system such as the Birmingham Symptom-specific Obstetric Triage System to expedite assessment of women presenting acutely with symptoms of PTLA preterm birth guideline to support the delivery of the key elements of Antenatal Optimisation A rolling training package including simulation to ensure staff awareness of both the benefits and the need for timeliness in delivering the elements of Antenatal Optimisation. Situational awareness training using the Situational Awareness Programme for Everyone (SAFE) Toolkit may be valuable

Auditable standards and a system of exception reporting where interventions are not achieved Pharmacological interventionsTo ensure prompt administration of medication, consider the value of prescription templates, pre-made administration packs, stickers and checklists. Where available, practice should align with PReCePT.

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Best Practice in Delivery of Antenatal Optimisation Interventions (2)

ParentsInformation for parents about the risks of PTB, NNU admission and the benefit of interventions. PReCePT, Bliss and the BAPM Extreme Preterm Framework: Helping parents to understand extreme preterm birth have useful resources

Where a woman is expected to give birth before 27w, parental discussions should be led by senior members of the paediatric and neonatal teams and should be based on the BAPM Extreme Preterm Framework for Practice: Communication Guidance for professionals consulting with families at risk of extreme preterm deliveryParent-held passports may aid information-sharing about interventions between different unitsIn utero transferTo ensure efficient and effective referral and transfer processes, networks should work to establish:

A network-wide combined maternity and in utero transfer policy including reciprocal transferA central referral hub with defined turnaround time (auditable) for requestsDecisions about appropriateness of transfer being made by senior clinicians and supported by risk assessment tools using details of maternal and fetal wellbeing and progression of labourRemote support for clinicians in LNU/SCUs by those in NICU settings

NICU and associated Maternity Unit policy of ‘auto-acceptance’ of in utero transfersGuidance about staff resource and experience required to accompany in utero transferGuidance for Ambulance Service Partners about time critical nature of transfer

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The Improvement Journey

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Phase One: Define the Problem

Understand your local data, both now and in recent past

Consider data in context of national standards/benchmarkingUse one or two of the following tools to understand your data:

Forcefield analysisFishbone diagramCase reviewProcess mappingPareto chartDevelop an improvement plan using a driver diagramLearn what works by talking to high performing unitsListen to parents

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Phase Two: Develop a Shared Purpose

1. Engage your teamObstetric, Midwifery and Neonatal project leads Parent representation Multidisciplinary representation includingObstetricians Labour Ward and Theatre representatives

MidwivesNeonatologists/paediatriciansNeonatal nursesPeople with QI expertise +/- a data analyst

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Phase Two: Develop a Shared Purpose

2. Engage your stakeholders: Which teams need to be reached to make your project successful?Parents

Senior and junior obstetriciansMidwivesNeonatal nursesObstetriciansTheatre staffTransport teamPharmacistsSonographers

Prioritise us

Understand usInform us

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Phase Three: Plan and Implement Changes

Construct a Project Charter: Detail your proposed improvement, including the resources required and the potential benefits to patients Formulate, prioritise and test solutions using established QI methodology, e.g:Model for Improvement and PDSA cycles

LEANSix Sigma

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Phase Four: Test and Measure Improvement

1. Collect the best data for your needsOutcome measures: reflect the impact on the patient e.g. mortality, CP, IVH

Process measures: the way systems and processes work to deliver the desired outcome e.g. number of women receiving steroids or Mg; number of extreme preterm infants born in a NICU; measures of parental satisfactionBalancing measures: this is what may be happening elsewhere in the system as a result of the change e.g. Place of birth: number of women transferred but who do not give birth; number of women who give birth during transfer; number of low risk women who are transferred out from their primary choice of place of birth for capacity reasons; measures of labour ward and neonatal unit capacity

Antenatal steroids: number of women who receive steroids but do not give birth within a week; number of women who receive steroids but deliver at termAntenatal magnesium: number of women who receive Mg but who deliver at term; number of delayed inductions or low risk women transferred out due to lack of labour ward capacity.

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2. Use well-described methods to analyse and display your data:

Phase Four: Test and Measure Improvement

Run chartStatistical Process Control Chart

Days between chart

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Phase Five: Implement, Embed and Sustain

Spread:

Dissemination: formal

eg

presentationsDiffusion: informal eg word of mouthException reporting: Case review for noncompliant casesBarriers and loss of motivation:Understand Talk to key individuals Observe clinical practice in actionUse a questionnaire to survey staffBrainstorm with a focus group Find solutionsRe-examine your change ideaUse impactful parent storiesUse lessons from high performersRe-market your messageUse incentivisation to engage

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QI tools and templates

BAPM Quality Webpages

Specific BAPM resources at

https://www.bapm.org/qimadeeasy

Planning your QI projectInvestigating your current practice Planning your change idea Interpreting your dataOther QI resources at BAPM QI Signpost: https://www.bapm.org/signpost-qi-resources

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Organisational standards, guidelines and initiatives

NNAP Online. National Neonatal Audit Programme: Royal College for Paediatrics and Child Health

Maternity and Neonatal Safety Improvement Programme: NHS Improvement

Maternity and Children’s Quality Improvement Collaborative- Scottish Patient Safety Programme

Saving Babies Lives’ Version 2. A care bundle for reducing perinatal mortality: NHS England; 2019 Neonatal Service Quality Indicators: Standards relating to structures and processes: British Association of Perinatal Medicine; 2017 PERIPrem Care Bundle: West of England Academic Health Sciences Network 2020 Preterm Perinatal Wellbeing Package: Maternity and Children Quality Improvement Collaborative, Scottish Patient Safety Programme. Health Improvement Scotland; Implementing the Recommendations of the Neonatal Critical Care Transformation Review: NHS England; 2019 [updated 2019. PReCePT Resources: PReCePT Programme. The AHSN NetworkPreterm Labour and Birth: National Institute for Clinical Excellence; 2019 Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation (Green-top Guideline No. 73): Royal College of Obstetricians & Gynaecologists; 2019 [Available from: