Diana Aguirre

OBJECTIVES: To evaluate the continued impact of pulse oximetry screening (POS) in a regional neonatal unit (NNU) and identify trends in screening outcomes in comparison with our previous experience. DESIGN: Retrospective review of admissions between April 2013 and March 2019 (the current study) and comparison with previously published data (the 2014 study). PATIENTS: All infants >34 weeks completed gestation admitted to NNU as a result of positive POS. OUTCOME MEASURES: Indication for admission, diagnosis, investigations and management. RESULTS: There were 49 375 livebirths and 253 NNU admissions as a result of positive POS (0.5% of livebirths; compared with 0.8% in 2014). 247/253 (97.6%) of those admitted had a significant diagnosis requiring medical intervention (compared with 79% in 2014) and the proportion of healthy babies (with transitional circulation) admitted decreased from 21% to 2.4%.22 (9%) babies admitted as a result of a positive POS were found to have a previously undiagnosed congenital heart defect (CHD) of which eight were critical CHDs (CCHDs). This accounted for 73% of all undiagnosed CCHD undergoing POS. The antenatal detection rate of CCHD was 75% compared with 46% in 2014. No baby died or collapsed on the postnatal ward during the study period. The proportion of babies with CCHD identified before discharge improved from 94% to 99%. CONCLUSIONS: Routine POS, in addition to antenatal screening and postnatal examination, continues to contribute to the improvement of our overall CCHD detection rates. We have demonstrated an overall reduction in the admission of healthy babies and therefore workload following a positive test.

Background: Kangaroo Mother Care (KMC) was introduced in the 1970s to keep premature babies warm after birth. There has been growing evidence of multiple benefits including physiological autoregulation, reduced stress, positive attachment, enhanced neurocognitive development, breastfeeding and psychological well-being. Delivery Room Cuddles (DRC) was introduced 15 years ago in Norfolk and Norwich University Hospitals as an extension of KMC. Other units have since reported the successful introduction of the process [1]. Anecdotally in our Neonatal Intensive Care Unit (NICU) parents were not routinely offered skin-to-skin contact with their infant early in their neonatal journey. Aim: The aim of the study was to safely introduce DRC as standard practice in our NICU. Method/design: We obtained feedback on parental and staff experience with DRC. A Failure Mode and Effects Analysis (Figure 1) was then carried out to break down the DRC process into steps, highlight potential risks and mitigation strategies. Information was synthesized into a standard operating procedure (SOP) and checklist. The use of a transport incubator to mobilize premature infants was not common practice in our NICU at the start of the project; therefore, a parallel SOP was developed for this. Staff training was then carried out using a video simulation and workshops. DRC was formally introduced in April 2021 (Figure 1). Figure 1: FMEA Implementation outline: Before implementation, 54 medical and nursing staff completed the survey, rating statements on confidence from 1 ‘strongly disagree’ to 5 ‘strongly agree’. Confidence was higher in non-intubated infants 32–34 weeks’ gestation (33/54 rated 5) and lowest in intubated infants <27 weeks’ gestation (10/54 rated 5). Staff reported anxieties around equipment failure, delaying care and adverse events. Thirty-nine parents completed the questionnaire. Thirty-four babies were born locally. Only five babies had DRC, of which four had no respiratory support. Time to first skin-to-skin contact ranged from 2 hours to 17 days (mean of 5 days). DRC is becoming routine practice in our NICU with no adverse events to date. Anecdotally staff and parents report great satisfaction with DRC, although formal outcome assessment is outstanding. Introducing DRC is feasible with adequate process planning and staff training using video simulation and workshops. DRC is cherished by families, rewarding for staff and sets infants up for a positive start in the neonatal journey. With examples of successful DRC practice and emerging safety outcome data, DRC is likely to become routine practice. Using this model of process design and training, other units will also be able to safely introduce DRC.

<h3>Background</h3> Heart murmurs are commonly detected at the Newborn Infant Physical Examination (NIPE). Routine use of antenatal and pulse oximetry screening means isolated murmurs are unlikely to be due to missed critical Congenital Heart Disease (CHD). We have developed a local guideline for assessment and follow up of these babies and share our experience of this service. <h3>Aim</h3> To assess the outcomes of neonatal heart murmurs detected on routine NIPE and review utilisation of neonatal and PEC (Paediatrician with Expertise in Cardiology) clinics. <h3>Methods</h3> All babies with murmurs on NIPE over one year (July 2015–June 2016) were retrospectively identified from the NIPE Smart system. Data was gathered from electronic and paper hospital records. All babies had follow-up outcomes for minimum 6 months. Babies with antenatal CHD diagnosis or having NICU admission were excluded. <h3>Results</h3> Out of about 6000 deliveries, 139 patients had murmurs detected (50.4% Male). 96 murmurs were noted at &lt;24 hours of life. 132 babies (95%) had pulse oximetry, of which 3 were abnormal. 134 (96%) had inpatient middle-grade/consultant review. All ECG (5 patients) and CXR (2 patients) were normal. Five patients had in-patient echocardiograms (three normal and two showed Ventricular Septal Defects [VSD]). 53 patients (41%) had murmur at discharge, of which 51 were referred to neonatal clinic, seen at average 5.5 weeks from discharge. Of these 51 patients, 13 still had murmur in clinic; Five had murmur resolution under neonatal follow-up, three are under neonatal follow-up with persisting murmurs (two had echocardiogram showing small muscular VSDs) and five were referred to PEC clinic. These five patients were seen in PEC clinic on average 11 weeks from referral. Three were discharged following normal echocardiograms, one referred to paediatric cardiology and the 5th remains under PEC follow-up. <h3>Conclusion</h3> Most murmurs in neonates with normal pulse-oximetry are innocent, only 4% diagnosed with underlying CHD. CXR and ECGs have little role in the routine investigation of isolated neonatal murmurs. The current department referral pathway is working well with only 10% of referrals to neonatal clinic requiring PEC clinic referral, thus optimising PEC clinic utilisation.

Background: Infant abductions are rare distressing events. The Care Quality Commission recently highlighted inadequate protective measures in other trusts as a cause of major concern [1]. In April 2020, the security system in our Neonatal Intensive Care Unit (NICU) was updated, with a new baby tag system. A tag is placed onto each baby in NICU, and if this tag is within close proximity of an exit door, an alarm sounds and the door locks. Aim: The aim of the study was to test our existing patient safety system in a real-life situation looking at human factors and equipment functionality. Method: An activated baby tag was placed on a mannequin which was then put into a pram. A member of staff in disguise (the ‘abductor’) pushed the pram out of the neonatal unit by ‘tailgating’ another member of staff so that the doors would not automatically lock, replicating a potential real-life scenario that exploited a known risk. The aim was to see whether the mannequin could leave the hospital. The ‘abductor’ was eventually stopped from leaving. A detailed timeline of events was recorded and analysed. Safety was ensured and participants were individually debriefed as emotions were high. Results: Our simulation highlighted points of excellence including a quick and calm response, the use of the panic button and appropriate persistent challenge of the ‘abductor’ without aggression. Important human factors were highlighted. There is no security staff in the hospital. The ward clerks called the porters directly, rather than dialling 2222 and saying ‘lockdown’, which triggers a lock of all doors out of the hospital. There were several system failures. The baby tag system did not alert the front of house. The panic button was broken, and a set of doors out of the hospital did not lock. Implications for practice: Simulation is an effective tool to identify system failures and patient safety risks. This scenario highlighted deficiencies in our system and a lack of established procedures and training. A detailed action plan has been put in place. The panic alarm, door locking mechanism and system linking the baby alarm system to the front of house are being addressed. The option of an automatic lockdown on activation of the baby tag alarm system is being explored. Finally, a standard operating procedure is being written and learning disseminated in the department. We are planning to run this simulation in other areas of the hospital to optimize patient safety.