Vacancies ranged between 5.26 whole time equivalents to 8.63 whole time .... There is a medical staff room with information technology facilities and office.
INDEPENDENT REPORT ON NHS LANARKSHIRE NEONATAL SERVICES, WISHAW GENERAL HOSPITAL MAY 2014
INDEX Summary
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Introduction
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Background
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Regional and National context
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Terms of reference
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Methodology
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Profile of Nursing/Midwifery Staffing
Profile of Medical Staffing and Advanced Neonatal Nurse Practitioners 15 Neonatal Unit facilities
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Clinical summary of the three babies who died
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Findings from staff interviews
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Findings from family interviews
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Communication
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Data
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Conclusions
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Recommendations
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Appendix 1 Membership of Independent Review Group
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Appendix 2 Vermont Oxford Risk Adjustment methodology
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Appendix 3 BAPM levels of care
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Appendix 4 Relevant literature
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SUMMARY The Independent Review Group were privileged to meet members of the three bereaved families whose babies had been highlighted by the Press. We admired their courage in talking with us about their babies’ short lives. The Group was also impressed by the openness and professionalism of the Wishaw General Hospital Neonatal Unit staff who met with the Group and who gave their views about their team and the tasks they performed on a daily basis. We thank them both. In 2013 and 2014 there was no epidemic of infection. The infection control precautions and hygiene measures of the Wishaw General Staff were of a high standard. Babies born very prematurely are at risk of developing infections, and sadly some of these do not survive. The three babies died in Wishaw General Hospital Neonatal Unit between August 2013 and February 2014 and infection was a contributory factor in all three. In the view of the Review Group, all three were managed to a high clinical standard, with close involvement of senior nurses and consultants. There is little doubt that the Wishaw General Hospital Neonatal Unit is busy. The physical space available to the Unit is small and the Group makes recommendations about how this might be improved.
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In the opinion of the families interviewed, the nursing staff and the Review Group, the recruitment of Qualified in Specialty Nurses should be an ongoing priority. In addition the on‐call Consultant Staff numbers should be increased. A Family counselling room should be created within the Neonatal Unit so that private discussions may be conducted with dignity. The Review Group listened carefully to the opinions of parents of babies who had died, but also to those whose babies had gone home after being cared for in the Neonatal Unit. In general, all had the highest praise for the medical and nursing staff. The staff were courteous and inspired confidence. A number of parents however drew the attention of the Review Group to a small minority of staff who should develop a more welcoming personality while caring for the families in the Neonatal Unit. The Neonatal Unit has coped well under difficult circumstances. Periods of high workload can occasionally coincide with times of staff sickness. During these times the stress of working in a Neonatal Unit can be very great. Parents notice when the care of their babies is shared between those babies of other families, and they recognize that nursing staff are sometimes stretched to the limit. The current report has produced 23 recommendations. The Review Group expects that these recommendations will be studied not only in Lanarkshire but also by all the Neonatal Units of Scotland. As a result of the views expressed by parents, it is to be hoped that improvements may be made in the facilities available to these most vulnerable babies and their families.
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INTRODUCTION This report was written in May 2014 at the request of the Chief Executive Officer of NHS Lanarkshire. It was stimulated by negative accounts in the Press in early April 2014 regarding alleged poor outcomes in the Neonatal Unit of Wishaw General Hospital. The Press reported three babies had died in the Neonatal Unit, and implied that low staffing levels had been a contributory factor. It is not clear where the Press had obtained such allegations, but one theory is that a member of the Wishaw General Hospital staff might have approached them. In response to the disturbing news coverage, and in order to obtain clarity about the quality of care in the Wishaw General Hospital Neonatal Unit, the Chief Executive Officer of NHS Lanarkshire commissioned an Independent Review Group (see Appendix 1) to visit the Neonatal Unit, interview staff, interview families, study all available data and provide a report to inform future managerial directions for the Wishaw Neonatal Service. BACKGROUND Neonatal mortality in Scotland is approximately 2.6 per thousand (see Relevant Literature Appendix 4). Specifically this means that 2 to 3 babies of every thousand born alive will die in the first 28 days of life. The commonest causes of
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this mortality include extreme prematurity (being born before 28 weeks gestation), infection, and congenital abnormalities incompatible with life. Every Neonatal Unit in the world experiences deaths in the newborn period, and all aim to prevent these wherever possible. REGIONAL AND NATIONAL CONTEXT In the 21st century there have been a number of initiatives in Scotland to improve care of the newborn. There has been a recognition that outcomes are better in large Neonatal Units where staff have extensive knowledge of Neonatal care, all modern equipment is readily available, and the staff are dealing with imperilled infants on a regular basis. Simply put, staff tend to carry out tasks well if they do them frequently. This philosophy has been given extra credence in 2014 by a report published in Archives of Diseases in Childhood by Marlow et al (see Relevant Literature, Appendix 4). The Scottish Government Maternity Services Action Group (MSAG) made a number of recommendations to coordinate and improve Neonatal care in Scotland. These included 1) the development of clinical standards 2) the establishment of Managed Clinical Networks at a regional level 3) the development of consistent pathways of care 4) the development of safe transport systems
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5) the assurance of appropriate staffing for neonatal care From this important work there was commissioned a multidisciplinary, national Neonatal Expert Advisory Group to make recommendations about Neonatal services throughout Scotland. Three Managed Clinical Networks were created to coordinate care in three major Regions: The North, The West, and The South and East. These Managed Clinical Networks came into being in 2010. They sought to coordinate care for neonates in each Region. They studied data from Managed Clinical Networks in England and emulated some of their managerial constructs. A Report, written in collaboration with the three Managed Clinical Networks entitled “Neonatal Care in Scotland: A Quality Framework. Scottish Government 2013” was published, and has been the template for progress in Scotland over the last two years. The three Regions have worked very closely together. The three Managed Clinical Network Managers and three Neonatal Managed Clinical Network Clinical Leads have met on a regular basis to learn from each other and to ensure that solutions to problems and challenges throughout Scotland have been thoroughly discussed and consistently addressed. The number of Neonatal Intensive Care Units in Scotland has been reduced, in order to maximize the quality of care that the most vulnerable babies receive. Many of these most vulnerable babies are premature and of very low birth weight. In keeping with the research carried out by Professor Marlow, the largest Neonatal Intensive Care Units in the West Region are led at all times by
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trained Neonatal Consultants. These three largest Maternity Units, Southern General Hospital, the Princess Royal Maternity Unit and Wishaw General Hospital, provide much of the Neonatal Intensive Care carried out in the Region. The Review Group recognizes that, in the West Region, Ayrshire Maternity Unit also offers long term Neonatal intensive care, and other Neonatal Units offer short‐term intensive care. For the large majority of babies born in the United Kingdom, care is routine and does not involve admission to a Neonatal Unit. Approximately 11% of babies born are admitted to a Neonatal Unit for further care. This care may be Special Care (where babies are not very unwell but need support from trained staff). There is High Dependency Care where babies need care of an increased level. Intensive Care is required by a small but important minority: this level of care is the most critical. The precise definitions of the levels of care are complex, and are captured in a recent publication (2011) of the British Association of Perinatal Medicine. (See Appendix 3). TERMS OF REFERENCE The scope of the review was to
Measure the neonatal service against the national policy context of the British Association of Perinatal Medicine Service Standards for hospitals providing neonatal care (2010) and Neonatal Care in Scotland: A Quality Framework, (2013).
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Undertake case reviews for the babies reported in the media.
Seek the views of parents including those reported in the media regarding the care provided in the Neonatal Unit.
Seek the views of staff working within the Neonatal Unit.
METHODOLOGY The Independent Neonatal Review Group met to discuss the programme of work and details of confidentiality. Two members (IL and PF) carried out an in depth examination of the case records of the three babies whose deaths had led to the negative media coverage. Four members (IL, PF, MP and YB) met the three bereaved families: one couple chose to come to Wishaw General Hospital, while the other two families chose their own homes for the meeting. JM attended two Paediatric Outpatient Clinics to interview parents of graduates of the Neonatal Unit to discover whether their views concurred with those of the bereaved families. The Review Group were provided with data on performance, quality issues, Neonatal Unit structure, and medical and nursing/midwifery rotas. The Review Group interviewed the following members of Wishaw General Staff (in order of availability):
A health care support worker,
Two domestic staff and their supervisor,
A ward clerkess, 9
A senior Neonatal consultant,
Two registered Neonatal Nurse/Midwives,
A Neonatal Unit coordinator and senior charge nurse/midwife,
An Advanced Neonatal Nurse Practitioner,
A Maternity Coordinator,
An infection control nurse,
The Consultant Microbiologist,
The three named consultant Neonatologists who had administrative care of the three deceased babies,
A Paediatric medical trainee,
The Clinical Service Manager Women and Children,
The Senior Midwife Women Services,
The Clinical Lead of the Neonatal Unit
The Bereavement Specialist Midwife.
The Group were also welcomed into the Neonatal Unit and had an opportunity to study the Intensive Care Unit, High Dependency Unit, Special Care Unit and Transitional Care Area facilities. In addition the storage and cleaning areas were inspected. The Review Group carried out a search of the relevant literature, with a particular focus on Neonatal Services in Scotland. The data were analysed and conclusions and recommendations were agreed unanimously.
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PROFILE OF NURSING/MIDWIFERY STAFFING Appropriate nurse/midwifery staffing levels are key to delivering safe, high quality care to babies and their families within the Neonatal Unit. Equally important are the specialist levels of education and experience. British Association of Perinatal Medicine recommendations The British Association of Perinatal Medicine ‘Service Standards for Hospitals Providing Neonatal Care’ August 2010 recommendations are based on the numbers of nursing staff available on each shift. They recognise that minimum staffing recommendations may vary at times for example at nurse break times or over an acute care period. Intensive Care ‐ The ratio of neonatal nurse Qualified in Specialty should be 1 nurse: 1 baby. The nurse should have no other managerial responsibility but may support a less experienced nurse working alongside her in caring for the same baby. High Dependency Care ‐ The ratio of neonatal nurses Qualified in Specialty should be 1 nurse: 2 babies. The more stable less dependent babies may be cared for by a nurse not qualified in specialty but under direct supervision and responsibility of a neonatal nurse Qualified in Specialty. Special Care ‐The ratio of nurses looking after special care should be at least 1 nurse: 4 babies. Registered nurses and non‐registered clinical staff may care for these babies under direct supervision and responsibility of a neonatal nurse
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Qualified in Specialty. Staffing should ensure that there is adequate support of parents and discharge planning is properly organised.
Nursing/Midwifery Establishment in the Wishaw General Hospital Neonatal Unit The Neonatal Unit at Wishaw General Hospital has 29 cots of which 8 are designated for intensive care, 10 for high dependency care and 11 for special care. The 8 intensive care cots and 4 high dependency cots are located in one room with the remaining high dependency cots and special care cots being accommodated within 4 cot rooms. There are in addition 3 single rooms and a family room. Neonatal Care in Scotland: A Quality Framework recommends that neonatal nursing establishments are calculated against activity with an uplift of 22.5% to accommodate expected leave (annual, sick, maternity, paternity, mandatory training and continuous professional development), based on an 80% occupancy level. The current funded establishment at Wishaw General Hospital is 77.46 whole time equivalents of which 68.54 whole time equivalents provide direct patient care with an approximate skill mix of 90% registered staff: 10% non‐registered staff. When staffed to establishment this would equate to the unit being staffed to British Association of Perinatal Medicine recommendations at 80% occupancy. The funded establishment in relationship to skill mix exceeds the standards described in Neonatal Care in Scotland: A Quality Framework which advise
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minimum of 70% (in level 1 units) and 80% (in level 2 and 3 units) of the workforce establishment holding a current Nursing and Midwifery (NMC) registration.
Midwifery Rotation Internal rotation of registered Midwives to transitional care takes place twice a year. Neonatal Nurses/Midwives are also included in this rotation. Vacancy During the time period when the three babies died August 2013 to March 2014 the unit had an average establishment in post of 62.18 whole time equivalents. Vacancies ranged between 5.26 whole time equivalents to 8.63 whole time equivalents in March 2014. These vacancy figures include 1 whole time equivalent Advanced Neonatal Nurse Practitioner and 1 whole time equivalent discharge planning nurse. At the time of the Review, recruitment to vacancies had been actively managed and interviews had taken place for 8.63 whole time equivalent nursing/midwifery replacement posts for the Neonatal Unit. Seven of these whole time equivalent posts are permanent. Qualification in Specialty At the time of review approximately 80% of the registered nursing/midwifery staff are Qualified in Specialty with a further 7 registered nurses currently undertaking specialty courses.
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Sickness Absence Sickness absence amongst the nursing/midwifery workforce has undoubtedly been a significant pressure within the Unit. From August 2013 to March 2014 there was an average sickness absence of 11.56%, ranging from 9.02% to 14.16%. All staff have a return to work interview. Short and long term sickness absences are robustly managed according to NHS Lanarkshire Attendance Management Policy. Planned Leave/Unplanned Leave
From August 2013 to March 2014 planned leave, which would include annual and study leave, accounted for 16.33% against establishment. During March this peaked at 20.24% due to staff returning on a phased return programme following long term sick leave. Unplanned leave includes special leave and carers’ leave, and averaged 0.83%. Nurse Bank/Additional/excess hours Identified shortfalls in nursing/midwifery rotas are covered initially by realignment of shifts, followed by the use of nurse bank staff; and finally midwifery staff are redeployed from maternity to support the Unit. The nurse bank staff contributed 5.19 whole time equivalent bank hours, utilised over the 8 month period. Excess and overtime hours averaged at 0.28 whole time equivalents.
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PROFILE OF MEDICAL STAFFING AND ADVANCED NEONATAL NURSE PRACTITIONERS At senior level, there are 4.2 whole time equivalent consultants leading the care of the infants. They are on call in a 1 in 4 rota. At middle grade there are two Advanced Neonatal Nurse Practitioners (1.3 whole time equivalents), three resident consultants and 3.6 whole time equivalent middle grade trainees. The Advanced Neonatal Nurse Practitioners are invaluable in providing roles previously ascribed to medical registrars. The junior tier of staff comprises 3 General Practitioner trainees, 3 “foundation” medical trainees and 5 Advanced Neonatal Nurse Practitioners. The numbers of such trainees are good, and provide a robust “first response” rota. Grand Rounds on Wednesday mornings and an Audit meeting on Thursday afternoons are opportunities to exchange clinical ideas. NEONATAL UNIT FACILITIES British Association of Perinatal Medicine Guidelines 2004 (see Appendix 4)
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Neonatal care should be planned on an average requirement of 0.75 cots per 1000 births population for intensive care, 0.7 cots per 1000 births for high dependency care and 4.4 cots per 1000 for special care. With the creation of the three Managed Clinical Networks in Scotland, there is greater partnership than ever before between the Neonatal Units of the West Region. Unit design should be flexible, because a baby’s requirements may change between intensive care and high dependency care and the preference would always be not to move the baby. The Neonatal Unit at Wishaw General Hospital has 29 cots: Intensive Care Unit ‐ 8 cots High Dependency Unit – 10 cots Special Care Unit – 11 cots The Unit is situated adjacent to the main maternity and theatre suite and alongside the adult critical care unit (accessible for fathers through a connecting corridor). There is a secured door entry system in place at all entrances. The first impression includes a peaceful atmosphere with child‐friendly murals painted on walls of all corridors. Intensive care/High dependency Room‐ There is one large room within the unit where the 8 intensive care cots and 4 high dependency cots are located. Access to the main Intensive Centre Unit is via a door at either end of the room. Each cot space is supported by a pendant with appropriate supplies of medical gases, electrics, and monitoring equipment. The high dependency cots are equipped to the same specification as the intensive
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care cot spaces. The area has 4 hand wash sinks with automatic sensors. The cot spacing within the room appears adequate. There is shelving for supplies at one end of the room. High Dependency/Special Care‐ High dependency care not provided in the main room takes place within one of four smaller rooms (4, 5, 6 and 7) within the Neonatal Unit. Out with the main intensive care area all rooms have sinks with elbow taps. Two of these (rooms 6 and 7) are occasionally used for High Dependency Care when the High Dependency cots in the main room are full. These four rooms are more commonly used for Special Care. The cot spacing within these rooms does not meet recommended guidance British Association of Perinatal Medicine 2004). All the rooms contain a refrigerator for the storage of breast milk. In addition there are three single isolation rooms; one is used as an outpatient admission room. This room is well equipped to accommodate babies requiring assessment up until day 14 following birth. There is also a family room equipped with adult twin beds, a wardrobe and en suite facilities. Parent Facilities There is a parent’s waiting room with soft chairs, coffee table and reading materials at the entrance of the unit. Lockers are available for parents and
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visitors with separate toilet facilities located next to waiting room. There are also facilities available within the unit for parents to make hot or cold beverages. The breastfeeding room contains equipment for expression of breast milk. Soft chairs and screens for privacy are available. There are facilities for cleaning and sterilising equipment and refrigerated storage. Equipment Cleaning Room This is a small room equipped and appropriately ventilated for the purpose of cleaning. This room is also used weekly for outpatient allied health professional consultations. Medical staff room There is a medical staff room with information technology facilities and office equipment. There is also a Seminar room with telemedicine facilities. Equipment Storage Storage facilities, inadequate for amount of equipment present. Storage process using dust covers noted. Additional storage out with the unit was identified while the review team were on site. Senior Nursing Staff Office
There is a shared office for the senior charge midwife and Neonatal coordinator. Sterile supplies and sundries
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Supplies are stored in three separate areas Reception There is a central administrative desk with information technology equipment, telephones and security door access equipment. Linen room Linen is stored within appropriate cupboards. However it was noted that there were some extraneous items also stored with the linen. Staff Facilities There is a staff rest room with facilities for eating and drinking. This includes a refrigerator, microwave and television. There are Staff changing facilities with small lockers, coat and shoe racks and a supply of theatre “scrubs”. Waste disposal There is a sluice area for disposal of waste fluids including bath water. CLINICAL SUMMARIES
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As part of the Clinical Review, two of the Group (IL and PF) studied the case records of the three babies where infection was thought to be at least a contributory factor to their death. The three babies in question were cared for in Wishaw General Hospital in the time period August 2013 to March 2014. Birth weights were 860g, 950g and 1485g. Gestations were 25 weeks + 3 days, 28 weeks + 1 day and 28 weeks + 6 days. One baby had external evidence of a congenital abnormality, although this alone would not normally be expected to contribute to the baby’s death. Infection was rightly suspected in all three cases. In one baby, there was E. coli grown from blood cultures and also from the tips of the umbilical venous and arterial catheters. This baby had an umbilical arterial catheter and an umbilical venous catheter inserted under sterile precautions as a routine part of baby’s treatment. It is possible, but not certain, that this was the portal of entry of the E. coli into the blood stream. Another possibility is that he had E. coli released into the blood stream from an inflamed section of bowel, as a complication of necrotising enterocolitis (NEC). Another baby had a clinical picture strongly suggestive of necrotizing enterocolitis (NEC), which is a well recognized complication of being born very prematurely. Necrotising enterocolitis sadly carries a high mortality. The bowel becomes inflamed and bacteria can be seeded into the blood stream and can cause overwhelming sepsis and death. Throughout the world, very preterm
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babies develop this condition, and prevention and treatment remain uncertain. Group B beta‐haemolytic Streptococcus and Methicillin Sensitive Staphylococcus aureus (MSSA) were isolated in a throat swab, at approximately two weeks of age. The third baby grew E. coli from the tips of the endotracheal tubes which had been inserted, and this may have reflected a ventilator associated pneumonia, perhaps exacerbated by milk aspiration into the lungs. The E. coli however did not grow on blood cultures in this baby. A blood culture on the last day of this baby’s life grew Staphylococcus capitis, but it is doubtful that this contributed to the baby’s sad demise. It is difficult to see a connection between the deaths of these three babies. Certainly they do not reflect an outbreak of infection within the Unit. Two examples of excellent practice should be highlighted. Firstly there is ample evidence of very close engagement of senior medical and nursing staff in the care of all three babies. The consultant Neonatologists were holding the reins of the care in a very commendable way. Secondly, there are recurrent, clear indications of high quality, sensitive and detailed communication with the parents. The case records of all three babies demonstrated that investigations for suspected infection were carried out timeously. There was good communication with senior staff in Microbiology. The antibiotics were at all times started appropriately and clear evidence documented of discussion with consultant staff.
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Senior Medical staff did request of the families that an autopsy be carried out on all three babies to clarify the complete causes of death. It is a matter of considerable regret that consent was not obtained. Such an examination might have clarified whether there were any further congenital abnormalities internally, and in particular whether necrotizing enterocolitis (NEC) was key to the death of one (or perhaps two) babies. FINDINGS FROM STAFF INTERVIEWS The Review Group interviewed 22 members of staff in 17 separate formal interviews. The Group were impressed by the openness and professionalism of the staff. All of them were supportive of the Neonatal Service, enjoyed their work and were proud of the team. The Neonatal Unit coordinator and Senior Charge Nurse have a demanding workload, including administrative duties and clinical cover for breaks within the Unit. Sickness absence is an ongoing problem, particularly with long‐term sickness. Sickness levels have been actively managed down from 14.8% in December 2013 to 7% at the time of this report. Maternity leave rate is 8% currently. There is heavy use of “The Bank”, even though the skills available are in general limited to caring for Special Care babies. Rotation of Midwives through Transitional Care, Labour Ward and Postnatal Wards is seen to have the advantage of flexibility, but the disadvantage of taking
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Midwives who are also Neonatal Qualified in Specialty away from the Neonatal Intensive Care Unit and High Dependency Unit. Safety briefs are now well embedded in the ethos of the Unit and no longer require to be audited. There is no dedicated Neonatal Risk Management Meeting. There is however a combined Obstetric and Neonatal Management meeting: this occurs monthly and is run by the Risk Manager. It is recognized that only some incidents receive a Datix entry, and staff are frustrated that they do not get feedback from incident reporting. Managers are now trying to improve the quality of the data entry so that more meaningful interpretation can be achieved. A more informative risk sheet has been developed and this has recently been launched, and cannot yet be assessed. The “traffic light system” has been used to inform the Maternity Unit of the state of openness of cots in the Neonatal Unit. This “traffic light system” has been of benefit for communication in the maternity service as a whole. Occasionally babies require to be transferred from Wishaw Neonatal Unit to another Neonatal Unit in order to accommodate a particularly ill newborn baby. Nursing staff feel that they have limited professional development during times of peak activity and/or nurse staffing pressures. They would like to go to joint meetings with Medical staff but they have no time because of the demands of
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clinical care. It is not appropriate that trained staff are taken away from clinical duties to empty bins, help with cleaning, and stock shelves. The following list captures further comments made by staff during interviews with the Review Group.
There is one family room. If it is occupied, there is no dignified facility for counselling parents.
In theory the premature babies get a “journal” soon after their arrival. Parents and nursing staff are encouraged to write in it daily as a memory for the parents of their child’s stay in the Unit.
The Advanced Neonatal Nurse Practitioners find the Consultants very supportive, especially when the Nurse Practitioner is the most senior member of staff resident in the Neonatal Unit overnight.
The Neonatal Unit has embraced the Scottish Patient Safety Programme (SPSP) principles of care bundles.
There is a handover sheet between shifts, and includes details of some babies in Special Care Unit or even the postnatal wards.
Consultants very good at updating parents, especially at the end of ward rounds.
There is a nursing desire for more experienced staff, more teaching and education.
The “huddle” involves Maternity Coordinator, Consultant Anaesthetist, Consultant Obstetrician, Clerkess, Midwifery staff and Neonatal nursing staff. The nurse in charge of the Neonatal Unit attends the “huddle” and feeds back “usually but not always” to the Neonatal medical staff.
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After incidents, there is peer support but no formal debriefing.
Medical trainee felt that Wishaw was the best unit for support and teaching. He praised the Consultants and Advanced Neonatal Nurse Practitioners in this regard.
There is a good induction programme over 2 days for the most junior medical tier.
Healthcare support workers are key to the smooth running of the Unit. There are usually 2 on Thursdays when re‐stocking occurs. At rare times of sickness there may be no healthcare support workers. There is concern that Qualified in Specialty Nurses are being taken from clinical care to perform tasks such as emptying bins, assisting with stock taking and helping with cleaning.
The consultant microbiologist and infection control nurse have an excellent relationship with the Neonatal Unit. They have no current concerns about infection control measures. The infection control nurse carries out an annual audit according to hospital acquired infection (HAI) principles. She routinely undertakes quality assurance audit and can increase the frequency of visiting and audit if concerns arise. There is no evidence of lateral spread of organisms in the Neonatal Unit. The infection control nurse attends the Wishaw General Hospital Clinical Governance Team meeting, and provides an infection control update, including any problems that might be identified in the Neonatal service. The Senior Midwife for Women’s Services represents the Neonatal Unit at this
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meeting. Currently there are no identified problems relating to infection control in the Neonatal Unit. Domestic staff are well informed about their duties and work very well with the domestic supervisor. Their governance is robust, including procedures for dusting, wiping, cleaning floors and sinks, re‐stocking the hand towels, emptying clinical bins, running taps (against Pseudomonas infection). The work is subjected to audit by two auditors from outwith the Neonatal Unit, and the Neonatal Unit regularly scores 95.5 to 100% in these surveys. Healthcare support workers should normally be three in number, but one has left and one is on long term sick leave. There is a very large workload. One task is to clean incubators: there may be up to 8 requiring this at the beginning of the shift, each taking 40 minutes to clean thoroughly. Duties also include taking phone calls, interaction with parents, monitoring stock levels, removing dirty linen, helping with tea relief and feeding babies. The appointment of a further daytime healthcare support worker or housekeeper would enhance the Unit significantly. The ward clerkess is frequently the member of staff who first greets visitors. There is a team of three who work tirelessly answering telephones, responding to the doorbell, filing laboratory results, and arranging labels for each baby’s case records and laboratory specimens, They also telephone established members of nursing staff to request that they do extra shifts at times of staff illness. The ward clerkess interviewed took a great pride in the Unit and
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emphasized the good working relationship with secretaries, as well as medical and nursing staff. One of the many strengths of Wishaw General Hospital is the post of Bereavement Specialist Midwife, who cares for families after miscarriages, stillbirths, traumatic births, or death of a baby. She may be involved at the diagnosis of a fetal abnormality, during palliative care or the withdrawal of care, post‐termination counselling, and infertility counselling at Monklands Hospital. She is not involved in counselling bereaved families in the early months after a baby’s death. Posters and leaflets informing families of her existence are planned but not yet available. FINDINGS FROM FAMILY INTERVIEWS Messages from meeting Bereaved Parents. The Review Group were full of admiration for the courage of the three bereaved families, all of whom agreed to a face‐to‐face meeting with the Review Group. The Group wishes to express its condolences and profound gratitude. The following points raised concentrate on the comments about neonatal care and follow up, and do not include comments about care prior to the delivery of their baby.
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Press involvement had clearly increased the sense of anxiety experienced by the families. One couple felt “betrayed” by the hospital on the assumption that a member of staff had gone to the Press about perceived deficiencies in care.
Parents stated how difficult it was to criticize staff at the time, because they wanted to maintain good relationships with their baby’s caregivers. Examples included worries over the nappy covering the umbilicus: would this not increase the likelihood of contamination from baby’s bowels? One father was concerned about trauma to his baby’s right leg caused by friction with the urine bag, and he believed the cut was not adequately cleaned.
When they left at night, they felt that their baby was in safe hands.
Some nurses are excellent at communicating. If a consultant Neonatologist is summoned, it might take an anxious hour before his/her arrival.
Many nurses were welcoming, but some were “grumpy” including senior members of staff.
One family stated that the Staff social agenda sometimes felt more important than safety of the child. Another family however felt that it was important to have social interaction with the nursing staff.
One mother had the traumatic experience of being summoned urgently from home to her baby’s cotside only to witness, without warning, the terrifying sight of her baby’s resuscitation. She felt strongly she should have been greeted and properly prepared for the major upset.
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One baby had had an episode of bleeding from the umbilicus on removal of an umbilical artery catheter. (The episode was well managed and the baby did not come to harm). The parents, however, were not told about this episode and discovered only after the death of their baby.
They did not always receive the baby “journal” at the beginning of their stay.
Parents expressed the belief that there was not enough follow up support after discharge.
Hand washing for parents and relatives is well taught.
Not enough nurses, especially at break times. Parents perceived that a nurse/midwife might be caring for 3 or even 4 babies during the 20 minute breaks. “Breaks are a big issue”.
There is occasionally a problem of meticulous precautions between babies. E.g. not all staff wear aprons as a baby is handed from one nurse/midwife to another.
Messages from parents of babies who graduated home from the Neonatal Unit Parents of 9 babies were interviewed from two clinic sessions held on a Friday afternoon and Tuesday morning in Wishaw General Hospital. Gestation of babies at birth ranged from 28 weeks +1 day to 38 weeks. Time in the Neonatal Unit ranged from 1 week to 14 weeks.
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All parents gave positive comments about the staff of the Neonatal Unit who were described as supportive, friendly and helpful. Staff were “sensitive” and good at communicating with each other.
Parents believed that the nursing/midwifery staff were overstretched in terms of their work commitment
Parents would have wished for comfortable seats when holding/feeding baby.
They were concerned that they could be alone in the rooms 4, 5, 6 or 7 when alarms were activated on the monitors.
They were concerned that there was a lack of a counselling room.
Parents would have wished for more continuity of carer when in the “side rooms”.
Parents believed that hand and forearm hygiene was less rigorous in the “side rooms” although it was excellent in the main Intensive Care Unit room.
Parents were happy with updates regarding their babies care. Communication was generally good.
Parents found the Intensive Care Unit room quite relaxing in atmosphere but the side rooms could appear less well supervised. Two sets of parents had been concerned about care in the Special Care Unit rooms when a midwife, rotated in to cover the Unit, had stated “My job is to deliver babies not to look after them afterwards.”
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Five sets of parents were asked the question “Did you feel welcome to at all times?” Three mentioned that one person had been abrupt and it was a different person in all three cases. Parents of graduates of the Neonatal Unit were happy that there was good social interaction with the nurses/midwives and did not feel that their baby’s care was compromised by this. COMMUNICATION Parents and families
Parents noted that regular updates by medical staff were informative and readily available.
Communication skills by a small number of staff gave the impression of lack of professionalism.
The baby’s daily journal, when used, was highlighted as a positive means of communication although a number of parents were unaware of this resource.
Patient confidentiality and sensitive information discussions were often undertaken in areas not fit for purpose.
Neonatal Staff : Medical, Nursing and Midwifery The following are examples of current professional interactions.
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Daily safety brief discussed with all staff.
Daily hand over meetings between medical staff.
Medical Staff have weekly meetings held within the seminar room in the neonatal unit, and telemedicine facilities are accessed regularly
Consultant Neonatologist attends the directorate monthly risk management meeting.
Senior Charge midwife attends the directorate daily “huddle”
Nursing Staff attend biannual meetings held with the occasional attendance of a Consultant Neonatologist.
A communication book is available in all cot rooms and Intensive Care area. Staff signatures are documented at the time of reading.
Perinatal mortality meetings are occasionally attended by nursing staff.
Routine simulation training is provided fortnightly and led by a Consultant Neonatologist.
A nursing and midwifery staff training log is maintained and monitored by the neonatal coordinator.
Regular communication links between the maternity coordinator, infection control team and facilities management teams.
DATA Data available showed that in 2012 there were 1034 admissions, resulting in 968 intensive care days, 2705 high dependency days and 3828 special care days. In 2013 two babies were transferred out to receiving Neonatal Units on the basis that the Wishaw Unit was at capacity. Also in 2013 four babies were transferred
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in to the Wishaw Neonatal Unit from other Neonatal Units, three from Forth Valley and one from Paisley. The Review Group was supplied with details of Neonatal deaths in Wishaw General Hospital since January 2009. There was no evidence of a significantly increased mortality among the neonatal population cared for in Wishaw General Hospital . Neither was there any evidence that infection played a higher than expected contribution to mortality in the last 4 years. Wishaw General Hospital Neonatal Unit showed an exceptional commitment to quality assessment of the standard of their care. This was the first Neonatal Unit in Scotland to join the Vermont Oxford Network (VON). The Vermont Oxford Network is an international collaboration of health care professionals established in 1988. The Network is comprised of over 950 Neonatal Intensive Care Units around the world. The Network provides data to allow Neonatal Intensive Care units to benchmark their own outcomes against those of the rest of the developed world. The Network maintains a Database including information about the care and outcomes of high‐risk newborn infants. The Database provides unique, reliable and confidential data to participating units for use in quality management, process improvement, internal audit and peer review. Wishaw Neonatal Unit has in recent years been forwarding data (non patient‐identifiable) to the Network and receiving feedback based on the outcomes quoted by the Neonatal Unit. The data from Wishaw are for babies of birthweight 401‐1500g, and gestation 22
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weeks to 29 weeks plus 6 days. Analysis of data for Wishaw General Hospital can be compared to the entire Network (which is weighted towards figures from the USA) or to similar units within the UK and the Republic of Ireland. It is important to recognize that populations vary, and the babies may have a greater level of illness on admission to each Neonatal Unit. Important scientific methods to adjust for initial condition of the baby have been developed, and these allow the Network to quote “risk adjusted” figures (see Appendix 2). Some of the data benchmarked by Wishaw General Hospital are excellent, including the outcomes of visual capabilities of surviving babies: specifically Wishaw General Hospital have a commendably low incidence of retinopathy of prematurity. When the Wishaw Neonatal Unit data are adjusted for risk, the Unit demonstrates an incidence of infection which is average compared to the international outcomes quoted by the Vermont Oxford Network. There is a strong internal drive to improve the data so that the Unit’s figures are better than the average. Every year the Clinical Lead of Wishaw Neonatal Unit circulates Vermont Oxford Network key performance data principally to the consultant body. He also gives a verbal presentation to all Neonatal Unit staff. This event is used as an opportunity to reinforce hand and forearm hygiene measures, and to encourage staff to look critically at all aspects of prevention of infection. The Review Group noted with interest the ongoing pursuit of quality in the Neonatal Unit. Staff are exploring the potential use of a system called HeRO,
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which may identify the onset of infection before it can be detected by clinical staff. This depends on an algorithm which monitors heart rate variability. Trials in the USA suggest that there might be a reduction in mortality of Very Low Birthweight babies by 20% and of 25% in Extremely Low Birthweight babies. Dr Ibhanesebhor is keen to embark on a multicentre trial, perhaps with Swansea, Liverpool and Units in London, to see whether these results might be replicated in the UK.
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CONCLUSIONS The Wishaw General Hospital Neonatal Unit is one of the major 6 Neonatal Units in Maternity Units in Scotland. The workload is high. The Unit is built on a small footprint, and this affects the Special Care rooms in particular.
Wishaw General Hospital Neonatal Unit is a modern, active service with high workload, which receives babies principally from the West Managed Clinical Network Region.
There is a strong corporate spirit.
There is high quality leadership.
There are good working relationships between Nursing and Medical staff.
There is clear evidence of an excellent spirit of open constructive criticism.
The quality of hand and forearm hygiene is high.
The decisions taken in the care of the three infants were of high quality.
There is strong evidence of close involvement and leadership from Consultants in the care of the three babies.
Documentation in the case records is clear and appropriate.
There is no evidence that inadequate staffing contributed to the deaths of any of the three babies.
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There is no evidence that the baby who was transferred to an outer room (6 or 7) for High Dependancy, and then returned to the Intensive Care Unit next day came to harm from that transfer. On the strong balance of probabilities, the baby’s sad deterioration would have happened had he remained in ICU throughout.
The three babies who died and became the centre of Press interest had no connection with each other and their case histories stretched from August 2013 to April 2014.
Although infection probably contributed to their deaths, there is no evidence that they shared bacterial pathogens: specifically the bacteria contributing to their deaths were all different.
It is disappointing that none of the three infants had a post mortem examination, especially since there was a degree of uncertainty about the cause of death in all three.
Early support for the bereaved families after they left Wishaw General Hospital was not strong, according to the three families.
When the adverse publicity occurred in April 2014, staff morale was understandably affected. Much support was offered. Peer support was strong. Staff continued to look after their patients with the same high standards as before. Senior staff met with parents of children in the Neonatal Unit to reassure them that the clinical care continued as before.
Wishaw General Hospital Neonatal Unit has the strong benefit of a Bereavement Counsellor who contacts families 4‐6 months after baby’s death.
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With the exception of consultant staffing, “medical” rotas (including the essential contributions of Advanced Neonatal Nurse Practitioners) are satisfactory.
The quality of teaching of hand and forearm washing to staff and parents and other visitors is high.
The footprint of the Unit is small, especially in the rooms designated for high dependency and special care.
There are organizational improvements which can be made in terms of placement and storage of equipment.
There are too few opportunities for Nursing and Medical staff to have joint meetings to discuss governance.
Registered Nursing/Midwifery staff are frequently carrying out tasks which take them away from providing skilled care of the baby.
Staffing of nursing shifts does not always comply with the standards recommended by the British Association of Perinatal Medicine due to vacancies, sickness absence and other planned and unplanned leave.
The rotation system of midwives in the long term may prove to be unsustainable, because the midwives rotating into the Neonatal Unit do not always have the appropriate skills to contribute strongly to the clinical care,.
If staffed to establishment, the Neonatal Unit could be less dependant on Bank staffing. The Review Group recognizes that it is difficult to recruit Qualified in Specialty Nurses. There is an ongoing programme in the Unit to seek such nurses, and also to train more junior nurses towards achieving Qualification in Specialty.
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Conclusions concerning nursing/midwifery establishment The assessment of whole time equivalent nursing requirements for a Neonatal Unit is very complex. Peaks and troughs of activity are unpredictable. A stand‐ alone Unit like Wishaw Neonatal Unit has less flexibility than others e.g. the four Units in Greater Glasgow and Clyde which can rotate trained staff in a more flexible manner. A clear message from interviewing Nursing/Midwifery and Medical staff was consistently that there are currently inadequate numbers of Qualified in Specialty Nurses/Midwives. The funded nursing establishment meets the recommended standards and in fact exceeds them in relation to skill mix. However the lack of availability of nursing/midwifery staff due to the number of vacancies and sickness/absence levels resulted in staffing on some shifts that did not always comply with the British Association of Perinatal Medicine standards. Conclusions regarding Consultant establishment Consultant staffing is currently unsustainable. The on call rota of consultants involves only 4.2 whole time equivalents. There is funding for 5.2 whole time equivalents. This figure should be 7 whole time equivalents (British Association
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of Perinatal Medicine, 2010). A robust on‐call rota might be achieved by promoting consultants from the middle‐grade rota, but only if registrars, specialty trainees or further Advanced Neonatal Nurse Practitioners could be identified and appointed to this rota, where the staff are resident on‐call. The alternative is to advertise for consultants to be appointed directly to the more senior, on‐call rota.
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RECOMMENDATIONS The following recommendations should be seen in the context of a busy unit in which the excellent staff are working in a small footprint. The corporate spirit is evident everywhere and the entire team show a high level of professionalism and commitment. The Review Group wishes to emphasize that many of these recommendations would apply to other Neonatal services in the United Kingdom and are by no means exclusive to Wishaw General Hospital which has demonstrated multiple strengths. 1)
There should be a reduction in vacancy factors by increasing the number of times annually when new nursing staff are recruited.
2)
There should be enough healthcare support workers available to carry out non‐specialist duties, thus allowing Registered Nurses/Midwives to provide direct clinical care.
3)
There should be a robust process for authorizing planned and unplanned leave to ensure leave is provided evenly throughout the year.
4)
The management of sickness absence should continue to be reviewed, including the causes for both short term and long term sickness.
5)
The possibility of creating a West of Scotland Regional Nurse Bank system should be explored so that experienced nurses from the Nursing
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Bank might be available to all the Neonatal Units of the Region, including Wishaw. 6)
The appropriateness of the current midwifery rotation process should be reviewed.
7)
Registered nurses/midwives not Qualified in Specialty require to be directly supervised by a nurse/midwife who is Qualified in Specialty.
8)
Managerial staff should revisit the potential appointment of a housekeeper role in the Neonatal Unit. In the absence of such an appointment it is essential that there be two healthcare support workers on duty during all day shifts.
9)
The quality of discharge planning should be re‐examined with a view to appointing a discharging planning nurse/midwife.
10)
Consultant staffing (on call at home) requires to be expanded from 4.2 whole time equivalents to 7.
11)
A Consultant Neonatologist should attend the daily perinatal pause, “the huddle”, and report back to Neonatal Unit staff.
12)
Medical staff should discuss ways of increasing the percentage of parents who agree to post mortem examination of their deceased baby, particularly where the causes are uncertain or incomplete.
13)
There should be a monthly Neonatal Unit meeting open to all members of the NNU, and at which there is an expectation that Qualified in Specialty nurse/midwives, Consultants and trainee doctors should be present. This meeting would be minuted, and designed and led to discuss corporate problems within the Neonatal Unit.
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14)
In the Neonatal Unit there should be a family room for confidential discussions, appropriately decorated for this purpose.
15)
There should be ongoing identification and education of the small minority of staff who communicate with parents insensitively.
16)
No clinical care should be carried out in the Neonatal Unit corridors.
17)
Consultations where parents attend for babies’ neurodevelopmental assessment should take place in a clinical area not used for equipment cleaning.
18)
There should be a formal process for debriefing clinical staff after an adverse incident.
19)
The baby ‘journal” should be consistently available to all parents of babies soon after admission to the Neonatal Unit.
20)
Storage and accessibility for everyday consumables should be rationalized.
21)
Solutions to storage problems should be explored. This might involve visiting other Neonatal Units within the West Managed Clinical Network to stimulate new ideas.
22)
The disposal hold room door should be locked at all times so that it is inaccessible to the general public.
23)
Corridors should be free of any items, including dirty equipment awaiting cleaning.
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APPENDIX 1 Membership of the Independent Neonatal Review Group Ian Laing (Chair) Retired Consultant Neonatologist and retired Clinical Lead of the Neonatal Managed Clinical Network, South and East Scotland. Yvonne Bronsky Local Supervising Authority Midwifery Officer, (LSAMO) South‐east and West Regions of Scotland. Patricia Friel Lead Neonatal Nurse for Greater Glasgow and Clyde Jackie Mitchell National Officer for the Royal College of Midwives Margaret Paterson Parent of extreme preterm baby who graduated successfully from the Wishaw NNU
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APPENDIX 2
Methods of Risk Adjustment on figures scrutinised by the Vermont Oxford Network.
Vermont Oxford Models for Mortality, Mortality Excluding Early Deaths, and Death or Morbidity include the following predictors: Gestational age in completed weeks and its squared term Small for gestational age (SGA, Yes or No), defined as being in the 10th percentile or less for birth weight, given the infant’s gestational age, the maternal race, the infant’s gender and whether the infant was a singleton or multiple gestation. The United States 2007 and 2008 Natality Datasets were used for calculating the 10th percentile values. Multiple gestation (Yes or No) APGAR score at 1 minute (0 to 10) Infant gender (Male or Female) Vaginal delivery (Yes or No) Birth location (Inborn or Outborn) Birth defect severity (Moderately Severe, Severe, Very Severe, Most Severe). The severity categories for birth defects are derived empirically from an analysis of mortality risk for birth defects reported to the database
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APPENDIX 3 British Association of Perinatal Medicine Categories of Care 2011 INTENSIVE CARE General principle This is care provided for babies who are the most unwell or unstable and have the greatest needs in relation to staff skills and staff to patient ratios. Definition of Intensive Care Day • Any day where a baby receives any form of mechanical respiratory support via a tracheal tube • BOTH non‐invasive ventilation (e.g. nasal CPAP, SIPAP, BIPAP, vapotherm) and PN • Day of surgery (including laser therapy for ROP) • Day of death • Any day receiving any of the following o Presence of an umbilical arterial line o Presence of an umbilical venous line o Presence of a peripheral arterial line o Insulin infusion o Presence of a chest drain o Exchange transfusion o Therapeutic hypothermia o Prostaglandin infusion
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o Presence of replogle tube o Presence of epidural catheter o Presence of silo for gastroschisis o Presence of external ventricular drain o Dialysis (any type) HIGH DEPENDENCY CARE General principle This is care provided for babies who require highly skilled staff but where the ratio of nurse to patient is less than intensive care. Definition of High Dependency Care Day Any day where a baby does not fulfil the criteria for intensive care where any of the following apply: • Any day where a baby receives any form of non invasive respiratory support (e.g. nasal CPAP, SIPAP, BIPAP, HHFNC) • Any day receiving any of the following: o parenteral nutrition o continuous infusion of drugs (except prostaglandin &/or insulin) o presence of a central venous or long line (PICC) o presence of a tracheostomy o presence of a urethral or suprapubic catheter BAPM ‐ Categories of Care August 2011 o presence of trans‐anastomotic tube following oesophageal atresia repair o presence of NP airway/nasal stent
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o observation of seizures / CF monitoring o barrier nursing o ventricular tap SPECIAL CARE General principle Special care is provided for babies who require additional care delivered by the neonatal service but do not require either Intensive or High Dependency care. Definition of Special Care Day • Any day where a baby does not fulfil the criteria for intensive or high dependency care and requires any of the following: o oxygen by nasal cannula o feeding by nasogastric, jejunal tube or gastrostomy o continuous physiological monitoring (excluding apnoea monitors only) o care of a stoma o presence of IV cannula o baby receiving phototherapy o special observation of physiological variables at least 4 hourly TRANSITIONAL CARE General principle Transitional care can be delivered in two service models, within a dedicated transitional care ward or within a postnatal ward. In either case the mother must be resident with her baby and providing care. Care above that needed
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normally is provided by the mother with support from a midwife/healthcare professional who needs no specialist neonatal training. Examples include low birth‐weight babies, babies who are on a stable reducing programme of opiate withdrawal for Neonatal Abstinence Syndrome and babies requiring a specific treatment that can be administered on a post‐natal ward, such as antibiotics or phototherapy.
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APPENDIX 4 REFERENCES AND LITERATURE Scottish Perinatal and Infant Mortality and Morbidity Report 25th March 2014 Health for all children 4: Guidance on implementation in Scotland. Scottish Executive, Edinburgh 2005. Getting it right for every child. Proposals for action. Scottish Executive. Edinburgh 2005. Independent review of incidents of Pseudomonas aeruginosa infection in neonatal units in Northern Ireland. Final Report. The Regulation and Quality Improvement Authority 2012. Building a health service fit for the future. NHS Scotland 2005. Review of Neonatal Services in Scotland. 2008. Neonatal Care in Scotland: a quality framework. Scottish Government 2013. The Healthcare Quality Strategy for NHSScotland, Scottish Government 2010
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Laing IA Where should extreme preterm infants be delivered? Crucial data from EPICure. Arch Dis Child Fetal Neonatal Ed 2014;99:F177‐F178 Marlow N, Bennett C, Draper ES et al. Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study. Arch Dis Child Fetal Neonatal Ed 2014;99:F181‐F188 Laing IA et al. Designing a Neonatal Unit. BAPM Guidelines 2004. British Association of Perinatal Medicine. Categories of Care. August 2011 Maternity Services Action Group (MSAG): Neonatal Services Sub Group: Review of Neonatal Services in Scotland May 15, 2009. Maternity Services Action Group: a refreshed framework for maternity care in Scotland, 2011.
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