Embedding Transitional Care Services in London - PowerPoint Presentation

Embedding Transitional Care Services in LondonA Resource for London maternity & neonatal services Compiled by:-Clare Capito – Deputy regional maternity lead for LondonMichele Upton - Head of Maternity and Neonatal TransformationProgrammes, NHS ImprovementJenni Jagodzinski - Pan London Lead Nurse, Quality Improvement, London Neonatal Operational Delivery NetworkSuzanne Sweeney – Network Director, London Neonatal Operational Delivery Network

Keeping mothers and babies together should be the cornerstone of newborn careTransitional Care (TC) supports a mother to remain beside her baby as the primary care giver, supported by healthcare professionals to provide care for her baby who has additional care requirements, in excess of normal newborn care, but not requiring admission to a neonatal unit (NNU) 

National Drivers for TC 2017 – Progress and Next Steps

Definition of Transitional Care (as per Maternity Incentive Scheme NHS Resolution December 2018)Transitional care (TC) is not a place but a serviceIt can be delivered in any of the following settings:In a separate dedicated transitional care areaWithin the neonatal unitPostnatal ward settingPrinciples of transitional care are that there:-Is a multi-professional approach between maternity and neonatal teamsAre appropriately skilled & trained workforceIs data collection in relation to TC activityIs agreed criteria as per HRGXA04 for admission to TC and has defined pathways into community paediatric services

CNST Maternity Incentive Scheme – Year 2 (NHS Resolution December 2018) Safety Action 3: Avoid Term Admissions Into Neonatal units (ATAIN) Programme and develop transitional care servicesEvery maternity service has a TC & can demonstrate / have in place the following:- Pathways of care for admission into and out of transitional care have been jointly approved by maternity & neonatal teams with neonatal involvement in decision making and planning care for all babies in transitional careExplicit staffing model for a TC serviceA data recording process for transitional care is established, in order to produce commissioner returns for Healthcare Resource Groups (HRG) 4/XA04 activity as per Neonatal Critical Care Minimum Data Set (NCCMDS) version 2 An action plan has been agreed at Board level and your Local Maternity System (LMS) and Operational Delivery Network (ODN) to address findings local ATAIN reviews & that there is an audit trail of thisProgress with the agreed action plans has been shared with your Board and your LMS & ODN

Meeting CNST Action 3: Can you demonstrate that you have transitional care services to support the Avoiding Term Admissions Into Neonatal units Programme?Deadline for reporting to NHS Resolution is Thursday 15 August 2019 at 12 noon

Meeting CNST Action 9: can you demonstrate that the trust safety champions (obstetrician and midwife) are meeting bimonthly with Board level champions to escalate locally identified issues?Deadline for reporting to NHS Resolution is Thursday 15 August 2019 at 12 noon

Transitional Care Competency Requirements for Care of the Baby Criteria (XA04Z) Midwife Neonatal Nurse Nursery Nurse /support worker Nutrition Support of mother’s choice of feeding √ √ √ Care of baby requiring NGT feeding √ √ √ Able to administer medication via NGT √ √ x IV fluids (e.g. Care of an intravenous cannula and associate assessment and documentation) √ √ √ Ability to calculate intravenous fluid therapy & administer via an infusion device √ √ X Risk of infection   Ability to recognize the signs and symptoms of infection √ √ √ Able to correctly calculate, prepare, and administer IV antibiotics according to local guidance and medicine management policies √ √ X Stoma care   √ √ √ Neonatal Abstinence Syndrome Define and discuss causative factors for NASRecord and interpret the NAS scoring system – as per local guidelinesIdentify strategies to help minimize symptoms √√√Administer oral treatment according to local medicine management policy √√XJaundice √√√Thermoregulation care√√√Hypoglycaemia√√√Respiratory √√√Care of an indwelling catheterUrethral or suprapubic√√√Preparation for discharge √√√ Suitably trained staff (registered or not) should be caring for babies in TC This list is not exhaustive – for a more detailed list please access:

Suggested staffing configurations for TCMidwivesBAPM recommends that there is 1 midwife to 5 to 8 women depending upon complexity. Maternity complexity tends to be higher for mothers of newborns who require TC This can be offset in part by healthy low risk women who are self-caring but their babies require TC careIf a midwife lone working in TC area then consideration should be made for a meal breakNeonatal nursesDesignated neonatal nursing lead (Band 7) for TC – to determine discharge plans back into the community and to arrange community outreach for babies if requiredTo collaborate with midwifery team (hospital and community midwifery services), health visitors, paediatric team as well as safeguarding teamBAPM recommends that including midwifery staffing input that ratio of nursing staff to babies receiving TC should be 1:4Support workers / Nursery nursesSuitably trained support workers / nursery nurses provide invaluable support to staffing and families within TC.Once received the appropriate training this group of staff may take responsibility for an individual baby and / or mother and reporting to the relevant midwife / neonatal nurse in TC (see basic skills competency list) Baby support worker – purpose to deliver care to families receiving transitional care wherever they are e.g. labour ward, postnatal ward or paediatric ward – they liaise with families, neonatal services and maternity to ensure that plans of care are robust and delivered effectively MedicalAll babies in a TC must have a named paediatric / neonatal consultantClear and agreed local arrangements to be in place for the named consultantDirect input on a day to day basis by same level of seniority for babies receiving care in NNU.Daily review of babies in TC may be undertaken by appropriately supervised trainee medical staff or advanced nurse practitioner

No.London’s Top 5 reasons for ATAIN admissionsExample of actions resulting from term case reviews 1.Respiratory NEWTT tool Red hat initiative - high risk babies TTN - Review of observation period / senior review prior to admission Avoidance of IV fluids if blood glucose normal 2. Hypoglycaemia Guideline review/amendments/updates and alignment across neonatal & maternity service Introduction of Glucogel Programme to raise awareness of hypoglycaemia (& hypothermia) prevention – ‘warm, sweet & pink’ Red hat initiative shown to reduce admissions for hypoglycaemia & hypothermia by around 50% 3. Jaundice Introduction of Transcutaneous jaundice meter (TCM) Review of guidelines 4. Observations Use of NEWTT tool Red Hat initiative/assessment tool for high risk babies Standardisation of care for ‘monitoring/observation’ admissions reasons across site 5. HIE Fetal well-being/CTG mandatory training sessions Helicopter view / fresh eyes review of CTG ( hrly ) CTG huddle Revised fetal monitoring/CTG guideline CTG workshops 6. Other actions Use of TC ward /revised TC SOP Use of ATAIN e-learning module Focus on thermoregulatory care & skin-to-skin Introduction of heated mattress in theatres recovery area Introduction of checklist for managing babies with weight loss due to poor feeding New post-natal neonatal notes implemented across site Review of infant feeding policyReview of admission criteriaNew guidance on milk bank use which includes use on post-natal ward

ATAIN Action Plan Item No Link to ATAIN admission criteria (e.g. Respiratory, Jaundice, Hypoglycaemia, HIE, Observation, Poor feeding ) Recommendation identified following case review Action plan to achieve compliance with recommendation (SMART) Lead Responsible Expected date for completion RAG rating Compliance with CNST Date when discussed at LMS board meeting Compliance with CNST Date when discussed at ODN Board meeting Compliance with CNST Date discussed at Trust board Progress/comments / further action required                                                                           Example template Resources to support the identification and management of ‘At Risk Neonatal Infants’ ATAIN https://www.e-lfh.org.uk/programmes/avoiding-term-admissions-into-neonatal-units/

Resources to assist in developing a Transitional Care serviceNational guidance from BAPM – A Framework for Practice : www.bapm.org/sites/default/files/files/TC%20Framework-20.10.17.pdf Health Education England “Exploring New Ways of Working in Neonatal Services” HRG costings for Transitional Care Sample documents for collecting non electronic Transitional Care data & codes used (may require adjustment to suit local need) London Transitional Care admission criteria

Case StudiesCo-located TC serviceVirtual TC service Stand alone TC ServiceReflections from Hillingdon TC