Involving families in Transitional care

Jay Banerjee Neonatal consultant, Imperial College Healthcare NHS Trust

Hon Senior Lecturer, Imperial College London

Overview

• Admissions to neonatal unit

• Effect of neonatal unit admissions • On service

• On parents and babies

• Integrated family delivered care – Imperial project

Neonatal unit admissions in England Possible reasons for the degree of variation:

• coding

• maternal health

• access to antenatal care / clinical practice

• neonatal clinical decision making

• number of skilled midwives/staff on the postnatal wards

• admission criteria to NNU,

• TC admission criteria and availability

Availability of cots – has an independent effect on medical intervention irrespective of clinical need

Data findings - NHS Improvement

• Despite falling term birth cohort (-3.6%) term admissions are increasing

• Increase across all categories of care but most in SC • Additional 13,000 care days for term babies in 2015 vs 2011 • Increased activity particularly marked in LNU & NICU Increase remains unexplained………variation and change in practice

Data findings - NHS Improvement

• 20-30% of all babies admitted to neonatal care receive no intervention

• 31% of babies were admitted for <48hours and received only SC

• 4% of term admissions are from community /home

• Babies born at 37-38 weeks were more likely to require admission than those born at 39+ weeks

Neonatal CRG - Definition of Transitional Care

HRG XA03Z : Special care HRG XA04Z : Transitional Care = Special Care, with carer resident & caring for baby

Presence of an indwelling urethral or suprapubic catheter Oxygen by low flow nasal cannula Feeding by orogastric, nasogastric, jejunal tube or gastrostomy Care of a Stoma Intravenous medication not otherwise specified elsewhere Receiving Intravenous Sugar +/- electrolyte solutions Receiving drug treatment for neonatal abstinence AND on an observations scoring regimen 4 hourly or more frequently Birth weight ≤2kg for first 48 hours after birth Gestation at birth 35 weeks for first 48 hours after birth Gestation at birth 34 weeks for first 7 days (168 hours) after birth Gestation at birth <34 weeks until discharge from hospital

Preventing separation is essential in providing safe maternity services NHS Improvement focus on 4 areas • Hypoglycaemia • Jaundice • Respiratory problems • Asphyxia ATAIN – avoiding term admissions into neonatal units

ACTIONS 1. Identify how maternity and neonatal teams can improve safety of care and keep mothers

and babies together. 2. To ensure relevant resources are introduced in to practice 3. Staff are aware of factors contributing to admission of term babies

Resources to support PNW normal care and TC • BFI / Kangaroo care

• Family centred care / Family integrated care

• Education and training – Bite sized teaching

– Care bundles

– “Warm Sweet Pink”

• Audit

Existing values at Imperial before our project • Established Multidisciplinary team

available

• Developmental care specialist

• Psychologist

• SLT, Breastfeeding/Lactation consultant

• Dietician

• Physio and Occupational Therapist

• Multidisciplinary team ward rounds weekly with parental attendance

Neonatal Care journey

The Neonatal BFI Accreditation Standards 1. Building close and loving relationships underlies our most loving, creative and moral behaviours and builds who we become later in life 2. Enabling babies to receive breast milk and breastfeed when possible Nutrition, protection and nurture 3. Parents as partners in care

“Bite size” Teaching • Ward based training for all staff (nurses and midwives) • Key drivers

– UNICEF BFI, RCPCH and QIS training standards, BLISS audit and accreditation

• 20-30min sessions, utilise a variety of teaching methods – Case discussions, presentations, simulations, boxes

• Modules – Psychology and family integrated care – Lactation and Breastfeeding – Developmental care – skin to skin – Nursing care

Integrated Family Delivered Neonatal Care Quality Improvement Project

Integrated Family Delivered Neonatal Care Quality Improvement Project

Unifying goal: To support parents to become equal members of the

neonatal team and participate in providing active care for their infant with the help of a competency-based training.

“We understand and believe that even the best medical care cannot replace your presence and the love you can

provide to your baby”

Family centred and family integrated care

Banerjee et al. J Neon Nurs 2018

Family integrated care

The evidence goes back to 1979 Shortage of trained neonatal intensive care nurses in Tallinn, Estonia prompted Levin to implement a “Humane Neonatal Care" model Parents provided nursing care for the infant (except for admin of IV fluid and medication) Nurses provided teaching and guidance to parents. Results: 30% improvement in weight gain, 30% reduction in infections, 20% reduction in NICU length of stay, 50% reduction in nurse utilisation and overall improved satisfaction among parents and staff (Levin 1994)

Family Integrated Care

Project outline

Information about Integrated Family Delivered Care:

• Parents approached before/after delivery

• Parent Information Leaflet, introduction to the project and orientation

• Parents welcome to join the educational program/ group activities at any time

• When infants are medically stable the parents can decide if they wish to participate (formally)

• Parents are expected to stay 6-8 hours a day providing care to their babies.

Project outline

Enrolment and training:

• Enrolled parents receive more intensive training for a short period (around 2 weeks) from nursing and AHPs

• Based on a prepared curriculum with 1:1 personal training, group exercises, competency assessments, and written and electronic material.

• Access to training manual

Project outline

Providing on-going care:

• Parents who were trained became the primary caregivers to their baby under supervision of the nurses for 6-8 hours every day.

• Involved equally in the team: presenting on WR, discussing plan

• They helped train newly enrolled parents

• Rolling programme of weekly parent education and support sessions

Project outline

After discharge:

Parents have on-going support from

• neonatal outreach community team

• Next Steps Parent Group - MDT

• Veteran parents to participate in training sessions

• IFDC project co-ordinator and psychologist

IFDC Project materials

• IFDC Mobile App (available free to download)

• Parent information leaflet

• Parent Binder

• Ward round presentation proforma

• Competency Assessment Booklet

• Parent Observation chart

• Staff education and parent education programme

IFDC project update • Nearly 70 families recruited to the neonatal project

• More than 750 IFDC neonatal app downloads across the world

• Outcome measures awaited

• Semi-structured interviews

• Further plan to extend to network

• Plan to extend to the transitional care settings

• Veteran parents’ peer mentoring programme

Family “There is no such thing as a baby only, a baby and someone”

Winnicott 1947

“We’re not just nursing a baby we’re building a family”

Mother, father, grandparents and siblings