NNAP Collaborators Meeting – 16th March 2015

www.rcpch.ac.uk

NNAP UpdateSam Oddie, NNAP Clinical Lead

Birmingham

NNAP Collaborators Meeting – 16th March 2015

www.rcpch.ac.uk

• Background• 2013 data report• Parents and carers• Survey Monkey• Widening clinical input• Changes in NNAP reporting• Changes in data flow• Mortality

National Neonatal Audit Programme (NNAP)

Commissioned - HQIP (NCAPOP).

Funding - NHS England and the Welsh Government.

Delivered RCPCH. 2006 – 2015 (contract extension)Wales since 2012 data

www.rcpch.ac.uk

www.rcpch.ac.uk/nnap

NNAP PB supports inclusion of Scottish NNUs

Logistics – no barrier

Next stepsHQIP/ RCPCH, Scottish National Neonatal Project, Scottish Clinical Outcomes and Measures for Quality Improvement

(COMQI)

Inclusion of Scottish Neonatal Units

National Neonatal Audit Programme (NNAP)

Aims:

i. assess whether babies admitted to NNU

in England and Wales receive consistent

care in relation to the audit questions;

ii. identify areas for quality improvement

in NNUs in relation to delivery and

outcomes of care.

www.rcpch.ac.uk

Audit Questions - 2013 Results: Temperature

Do all babies of less than or equal to 28+6 weeks have their temperature taken within an hour after birth?

www.rcpch.ac.uk/nnap

NNAP data year

Number of eligible

NNU

Number of Eligible babies

% with T taken within an hour of birth

2008 130 2647 78%2009 165 3230 63%2010 169 3380 83%2011 164 2786 90%2012 169 3023 89%2013 170 2908 93%

Audit Questions - 2013 Results: Temperature

Do all babies of less than or equal to 28+6 weeks have their temperature taken within an hour after birth?

www.rcpch.ac.uk/nnap

n <32.0 32.0-35.9 36.0-36.5 36.6-37.4 ≥37.5Other 27 1 15 (56%) 4 (15%) 5 (19%) 2 (7.4%)

SCU 144 0 15 (10%) 38 (26%) 74 (51%) 17 (12%)

LNU 749 0 117 (16%) 224 (30%) 336 (45%) 72 (9.6%)

NICU 1779 1 187 (11%) 505 (28%) 852 (48%) 234 (13%)

Total 2699 2 5 (19%) 5 (19%) 5 (19%) 325 (12%)

Audit Questions - 2013 Results: ANS

Are all mothers who deliver their babies between 24+0 and 34+6 weeks gestation given any dose of antenatal steroids?

www.rcpch.ac.uk/nnap

NNAP reporting year

Number of eligible NNU

Number of eligible

mothersPercentage with any

antenatal steroids given2008 129 9066 63%

2009 167 16031 70%

2010 173 16895 75%

2011 164 15716 76%

2012 173 16576 80%

2013 176 16992 83%

Audit Questions - 2013 Results: Consultation

Is there are documented consultation with parents by a senior member of the neonatal team?

www.rcpch.ac.uk/nnap

NNAP data year

Number of eligible

NNU

Number of eligible episodes Within 24 hours

2008 129 16538 56%2009 167 25704 45%2010 172 40199 67%2011 164 34450 68%2012 174 42792 79%2013 176 50757 84%

Audit Questions - 2013 Results: ROP

Do babies <1501g or 32/40 undego the first ROP screen in accordance with the current guideline recommendations?

www.rcpch.ac.uk/nnap

NNAP data year

Number of eligible

NNU

Number of eligible

babies

Screened on time

2008 148 3414 -2009 167 7913 27%2010 171 8235 58%2011 164 7887 67%2012 173 7996 60%2013 175 8000 78% (87%)

2014 Annual Report on 2013

Data completeness: Feeding and T - very goodROP is much better44% had FU dataInfection – still poor

ROP – big babies not always screened

Non participants and outliers

www.rcpch.ac.uk/nnap

Developing engagement with Parents & Carers

www.rcpch.ac.uk

• Existing strong partnership with BLISS

• Under ToR, add further representation to PB

• Parent & Carer version of 2013 data report

• PREM development work

Patient Reported Experience Measures (PREM)

www.rcpch.ac.uk

RCPCH and Partners• BLISS• Neonatal networks

Patient Reported Experience Measures (PREM)

www.rcpch.ac.uk

RCPCH and Partners• BLISS• Neonatal networks

Engagement with NNUs – Survey Monkey

www.rcpch.ac.uk

June 2014: ‘Developing the future of the NNAP'

Objectives: • Help PB better understand the views of clinicians• Develop work of NNAP in responsive manner including

whole of the neonatal community.

182 responses from 166 units. “I think measuring (temperature) is important AND ensuring it is in (the) normal range” ROP “I am glad this question was audited……..no one listened……. we are making progress!! Finally!!”BrMilk: “The aim is laudable - the attempt to shame is not”

Wider clinical input - CRAG

www.rcpch.ac.uk

Clinical Reference and Advisory Group

Purpose:• Represent full range of NNUs by geography and unit size• Broaden base of clinical representation into NNAP• Reconsider existing questions and analyses• Suggest and refine new questions

• Meetings by teleconference/ face to face meeting

What has NNAP changed? – Infection questions

www.rcpch.ac.uk

LOI – hopefully preventable

Current measures in NNAP relate to EOI + LOI

Most quality improvement work focussing on blood cultures taken >72 hours

NB views of CRAG

What has NNAP changed? – ROP

www.rcpch.ac.uk

NNAP interpretation of RCOPhth guidance ROP screen in window, but after discharge = “adherent”

ROP in Badger• Daily data• Ad hoc forms

PB agreed “daily data” OR “ad hoc forms” would count as evidence that an ROP screen had taken placeSignificant impact on data completeness

(87% to 91% overall, Units <90% complete 84 to 66)Change to Badger system

What has NNAP changed? – Temperature

www.rcpch.ac.uk

Unrecordably low temperatures• Now assumed to be low in analysis

Values in report

What has NNAP changed? – parental consultation

www.rcpch.ac.uk

• Short admissions (<12 hours) no longer included

What has NNAP decided to change? – BPD/ CLD

www.rcpch.ac.uk

Mild: resp support (ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) + air at 36/40Significant: (mod+severe) resp support (ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) + resp support(ETT, BIPAP, CPAP Hi Flow or any O2 for first 28/7) at 36/40 corrected.

Eligible babies: <32/40 or <1500g, and alive at 36/60Data sources and years

Daily data entry form in the Badger systems.3 year rolling averages (2012/2013/2014)

Assigning BPD/ CLD to a neonatal unitBPD/ CLD is assigned to the unit of birth

What has NNAP considered changing?

www.rcpch.ac.uk

• Infection• Temperature• Antenatal steroids for term El LSCS• OFC growth• Equity of access to care • Breastmilk analysis• Report format• Reporting process• Mortality

NNAP support for improved 2014 data quality

www.rcpch.ac.uk/nnap

Process for the 2014 data report

Beginning of May - NNAP will notify all units with:

• provisional outlier status for particular questions

• current non-participant status (i.e. less than 90% data completeness for a particular question)

Throughout June - All neonatal units will be offered

• the opportunity to review their data for accuracy before the final data download is taken for analysis and reporting at the end of June.

www.rcpch.ac.uk/nnap

Process for 2015 data report

Mini quarterly unit reports for all NNAP units to include:

• Data completeness reporting• Adherence to audit standards • Definitive 2015 NNAP dataset will be established after data

quality window closes• Publication in Summer rather than Autumn without the need

to highlight provisional outlier status.

Full details will be communicated to all NNAP units later in March 2015

NNAP reporting process for 2015 data

Work in progress - Mortality

www.rcpch.ac.uk

Competing analyses?MBRACE/ TNS/ Local analysesNNAP possible USP is gestationally limited denominator data to NNU discharge

ChallengesNon NNAP units (eg surgical)

Small numbers (power)Need to aggregate yearsUnit of analysis

Choice of model for risk adjustmentConfidence in our approachWhy?

Work in progress – Mortality (2)

www.rcpch.ac.uk

Expert group met Nov 2014Recommendation: that NNAP can and should report

Denominator: All born alive @ 23 (or 24) - 31/40 inclusive

Numerator: Inpatient deaths (including LW, NNU deaths, deaths on non NNAP units) and babies discharged with LOTA and expected death.Excluded deaths: Those due to lethal congenital malformation. (Eurocat classification)

3 year rolling averagesPrimary unit of analysis – networksLimited adjustment (gestation +/- ethnicity)

Work in progress - Mortality (3)

www.rcpch.ac.uk

Implications:• Need for reporting of LW deaths via badger• Development of system to for units to validate their

deaths (incl LW deaths)• Development of mechanisms to report late deaths

prior to 44/40 GCA on non NNAP units

Consultation:• Lower gestational age limit• Risk adjustment for ethnicity• Case mix adjustment model – unit level reporting

• More communication from NNAP in 2015

Questions

www.rcpch.ac.uk

www.rcpch.ac.uk