NNAP Collaborators Meeting – 16th March 2015
NNAP Update
Sam Oddie, NNAP Clinical Lead
Birmingham
www.rcpch.ac.uk
NNAP Collaborators Meeting – 16th March 2015
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Background
2013 data report
Parents and carers
Survey Monkey
Widening clinical input
Changes in NNAP reporting
Changes in data flow
Mortality
www.rcpch.ac.uk
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
Inclusion of Scottish Neonatal Units
NNAP PB supports inclusion of Scottish NNUs
Logistics – no barrier
Next steps
HQIP/ RCPCH, Scottish National Neonatal
Project, Scottish Clinical Outcomes and
Measures for Quality Improvement
(COMQI)
www.rcpch.ac.uk/nnap
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?
NNAP data
year
2008
2009
2010
2011
2012
2013
Number of
eligible
NNU
130
165
169
164
169
170
Number of
Eligible
babies
2647
3230
3380
2786
3023
2908
www.rcpch.ac.uk/nnap
% with T taken within
an hour of birth
78%
63%
83%
90%
89%
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?
n
<32.0
32.0-35.9
36.0-36.5
36.6-37.4
Other
27
1
15 (56%)
4 (15%)
5 (19%)
≥37.5
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%)
www.rcpch.ac.uk/nnap
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?
Number of
NNAP
Number of
eligible
reporting year eligible NNU mothers
2008
129
9066
Percentage with any
antenatal steroids given
63%
2009
167
16031
70%
2010
173
16895
75%
2011
164
15716
76%
2012
173
16576
80%
2013
176
16992
83%
www.rcpch.ac.uk/nnap
Audit Questions - 2013 Results: Consultation
Is there are documented consultation with parents by a senior member of the neonatal
team?
Number Number
NNAP data of eligible of eligible
year
NNU
episodes
2008
129
16538
2009
167
25704
2010
172
40199
2011
164
34450
2012
174
42792
2013
176
50757
www.rcpch.ac.uk/nnap
Within 24 hours
56%
45%
67%
68%
79%
84%
Audit Questions - 2013 Results: ROP
Do babies <1501g or 32/40 undego the first ROP screen in accordance with the current
guideline recommendations?
Number Number
NNAP data of eligible of eligible
year
NNU
babies
2008
148
3414
2009
167
7913
2010
171
8235
2011
164
7887
2012
173
7996
2013
175
8000
www.rcpch.ac.uk/nnap
Screened on time
27%
58%
67%
60%
78% (87%)
2014 Annual Report on 2013
Data completeness:
Feeding and T - very good
ROP is much better
44% had FU data
Infection – still poor
ROP – big babies not
always screened
Non participants and outliers
www.rcpch.ac.uk/nnap
Developing engagement with Parents & Carers
• Existing strong partnership with BLISS
• Under ToR, add further representation to PB
• Parent & Carer version of 2013 data report
• PREM development work
www.rcpch.ac.uk
Patient Reported Experience Measures (PREM)
RCPCH and Partners
• BLISS
• Neonatal networks
www.rcpch.ac.uk
Patient Reported Experience Measures (PREM)
RCPCH and Partners
• BLISS
• Neonatal networks
www.rcpch.ac.uk
Engagement with NNUs – Survey Monkey
June 2014: ‘Developing the future of the NNAP'
Objectives:
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Help PB better understand the views of clinicians
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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”
www.rcpch.ac.uk
Wider clinical input - CRAG
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
www.rcpch.ac.uk
What has NNAP changed? – Infection questions
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
www.rcpch.ac.uk
What has NNAP changed? – ROP
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 place
Significant impact on data completeness
(87% to 91% overall, Units <90% complete 84 to 66)
Change to Badger system
www.rcpch.ac.uk
What has NNAP changed? – Temperature
Unrecordably low temperatures
• Now assumed to be low in analysis
Values in report
www.rcpch.ac.uk
What has NNAP changed? – parental consultation
• Short admissions (<12 hours) no longer included
www.rcpch.ac.uk
What has NNAP decided to change? – BPD/ CLD
Mild: resp support (ETT, BIPAP, CPAP Hi Flow or any O2 for first
28/7) + air at 36/40
Significant: (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 36/60
Data sources and years
Daily data entry form in the Badger systems.
3 year rolling averages (2012/2013/2014)
Assigning BPD/ CLD to a neonatal unit
BPD/ CLD is assigned to the unit of birth
www.rcpch.ac.uk
What has NNAP considered changing?
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Infection
Temperature
Antenatal steroids for term El LSCS
OFC growth
Equity of access to care
Breastmilk analysis
Report format
Reporting process
Mortality
www.rcpch.ac.uk
NNAP support for improved 2014 data quality
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
NNAP reporting process for 2015 data
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
www.rcpch.ac.uk/nnap
Work in progress - Mortality
Competing analyses?
MBRACE/ TNS/ Local analyses
NNAP possible USP is gestationally limited
denominator data to NNU discharge
Challenges
Non NNAP units (eg surgical)
Small numbers (power)
Need to aggregate years
Unit of analysis
Choice of model for risk adjustment
Confidence in our approach
Why?
www.rcpch.ac.uk
Work in progress – Mortality (2)
Expert group met Nov 2014
Recommendation: 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 averages
Primary unit of analysis – networks
Limited adjustment (gestation +/- ethnicity)
www.rcpch.ac.uk
Work in progress - Mortality (3)
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
www.rcpch.ac.uk
Questions
www.rcpch.ac.uk
www.rcpch.ac.uk