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National Neonatal Audit Programme (NNAP) Context Page

This document provides guidance to assist interpretation of the key metrics from the National Neonatal Audit Programme (NNAP) as selected by the Royal College of Paediatrics and Child Health (RCPCH). All eligible neonatal units in England participated in the audit in 2017.

View full audit results on the audit website: nnap.rcpch.ac.uk

The audit conducts outlier analysis on all of the key metrics below.

Metrics:

1. Mothers who deliver pre-term (24-34 weeks gestation) and were given any dose of antenatal steroids

  • Rationale: Pre-term is defined as 24 to 34 weeks inclusive; ‘antenatal steroids’ refers to any dose. Antenatal steroids reliably reduce the chances of babies developing respiratory distress syndrome and other complications of prematurity.
  • Guideline/mapping: This metric relates to the NICE guideline [NG25] for Preterm Labour and Birth. Numerous professional groups advocate giving antenatal steroids to women at risk of pre-term delivery; difficulties in accurately predicting which mothers will experience pre-term delivery and those who will have a very rapid delivery mean that a 100% target is unrealistic for this metric; accordingly, the audit board specifies an audit target of antenatal steroid administration for 85% of women who deliver between 24 and 34 weeks gestation.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is not meeting the recommended standard or is a negative alert or alarm level outlier this should prompt inspectors to ask questions about the robustness of clinical care pathways for women at risk of pre-term delivery, the effectiveness of liaison between obstetric and neonatal teams and actions which the Trust is taking to improve the proportion who receive steroids

2. Mothers who deliver babies below 30 weeks gestation given Magnesium Sulphate in the 24 hours prior to delivery

  • Rationale: Administering intravenous magnesium to women who are at risk of delivering a preterm baby reduces the chance that the baby will later develop cerebral palsy by around 30%. Royal College of Obstetricians and Gynaecologists guidance supports its use.
  • Guideline/mapping: This metric relates to the NICE guideline [NG25] for Preterm Labour and Birth and NICE Quality Standard 135 (QS135) Preterm Labour and Birth Quality Standard 6. NICE guidance recommends that all women who may deliver at less than 30 weeks should be offered treatment.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is a negative alert or alarm level outlier this should prompt questions as to the identification and treatment of women at risk of delivering a preterm baby. The audit recommends neonatal and maternity care staff should formally review records of babies born at less than 30 weeks where magnesium sulphate was not given to the mother in order to identify potential missed opportunities and themes as to why these were not given and develop appropriate action plans.

3. Babies <32 weeks gestation who had temperature taken within an hour of admission that was between 36.5ºc and 37.5ºc

  • Rationale: Appropriate body temperature is defined as 36.5°C to 37.5°C inclusive; ‘on admission’ refers to location (any Neonatal Unit (NNU), including Special Care Units (SCUs), Local Neonatal Units (LNUs) and Neonatal Intensive Care Units (NICUs). Low body temperature on admission is associated with increased complications (such as hypoglycaemia, jaundice and respiratory distress) and death in pre-term infants.
  • Guideline/mapping: The Resuscitation Council (UK) guideline for Resuscitation and Support of Transition of Babies at Birth (2015) suggests that the temperature of newly born infants is actively maintained between 36.5°C and 37.5°C after birth unless a decision has been taken to start therapeutic hypothermia. The importance of achieving this has been highlighted and reinforced because of the strong association with mortality and morbidity. Even the mild hypothermia that was once felt to be inevitable and therefore clinically acceptable carries a risk. The admission temperature should be recorded as a predictor of outcomes as well as a quality indicator; the audit board accordingly specifies a target of 90% achieving a body temperature of 36.5°C to 37.5°C inclusive within 1 hour of birth.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is not meeting the recommended standard or is a negative alert or alarm level outlier this should prompt questions as to the effectiveness of protocols to manage hypothermic admissions and actions which the unit is taking to reduce the proportion of pre-term infants experiencing hypothermia. The audit recommends Neonatal units should ensure that they have a care bundle in place, developed with multidisciplinary input, which mandates the use of evidence-based strategies to encourage admission normothermia of very preterm babies.

4. Documented consultation between parents/carers and a senior neonatal team member within 24 hours of admission.

  • Rationale: Admission refers to the NNU. Timely consultation with parents/carers is crucial to allaying fear and anxiety, provides reassurance and improves the parent/carer experience; this metric is known to vary across regions.
  • Guideline/mapping: There is no national guideline related to documentation of clinical consultation for neonatal admissions; this metric was selected by the audit board through consensus.  The audit specifies a target of 100% of cases having a documented consultation with senior clinicians within 24 hours of admission.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is not meeting the recommended standard or is a negative alert or alarm level outlier this should prompt questions as to the quality of the parent/carer experience and actions which the Trust is taking to improve documentation of prompt consultations. Neonatal units should regularly review the reasons why timely parental consultations did not occur. They should look for themes among the reasons, provide regular feedback to neonatal staff, and put processes in place to strengthen their support of parental partnership in care.  Neonatal units should ensure that parents are aware of the standard, for example as part of a welcome pack or signage in the neonatal unit. Neonatal units with poorer data completeness should review and improve their documentation process. For example, by use of a dedicated notes sheet or a document in electronic records to record parental consultations.

5. Babies <32 weeks gestation or of very low birthweight who received appropriate screening for retinopathy of prematurity (ROP)

  • Rationale: Very low birthweight is defined as less than 1501g. Appropriate screening is based on the joint Retinopathy of Prematurity guideline 2008 ROP is a preventable cause of blindness in pre-term infants provided it is detected and treated in a timely manner.
  • Guideline/mapping: This metric maps approximately to the joint Retinopathy of Prematurity guideline 2008. Mapping is approximate because the audit board exercises some pragmatism by specifying slightly longer screening windows than those in the guidelines; accordingly, the audit sets a standard of 100% receiving screening for ROP.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is not meeting the recommended standard or is a negative alert or alarm level outlier this should prompt questions as to the robustness of clinical care pathways for detecting ROP in babies (including effective liaison with ophthalmology, administrative systems to track eligible babies and case-note review of instances where the target was missed) and actions which the Trust is taking to ensure that all eligible babies are appropriately screened. The audit recommends efforts should be focused at those babies whose birthweights and gestations are just inside the criteria for screening, because these babies constitute the majority of those not screened. The audit recommends units with negative outlier status, and especially those who have been recurrently identified as such, should urgently review their clinical, administrative and organisational arrangements, and keep them under detailed regular review to optimise retinopathy screening and treatment outcomes.

6. Babies with gestation at birth <30 weeks who had received documented follow-up at 2 years gestationally corrected age

  • Rationale: It is important that the development of very preterm babies who were admitted to a neonatal unit is monitored by a paediatrician or neonatologist after discharge from the neonatal unit. Babies born prematurely do not always reach key developmental milestones so these checks at age two provide a valuable opportunity to identify any potential issues at an early stage.
  • Guideline/mapping: NICE Guideline NG 72 Developmental follow-up of children and young people born preterm Section 1.3.6 recommends a detailed face-to-face developmental assessment at 2 years (corrected age).
  • Graph/relative performance: Almost two in five (37.4%) of 4,043 babies born at less than 30 weeks gestational age between July 2014 and June 2015 were not recorded as having been seen for a follow up assessment at two years of age, despite the service specification and longstanding concern about practice in this area. Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. If the unit is not meeting the recommended standard or is a negative alert or alarm level negative outliers should prompt questions as to how are units developing specific plans to improve documented follow up of babies born at <30 weeks gestation. The audit recommends medical staff discuss the indications and arrangements for two year follow up with families in the period leading up to the discharge home of their baby, and how is this followed up in writing.

7. Babies born at less than 27 weeks who were born in a hospital with a Neonatal Intensive Care Unit onsite

  • Rationale: Evidence suggests that outcomes are improved by providing the care of the most vulnerable babies in units with a higher turnover, and minimising postnatal transfers. This is a network level measure rather than a hospital or trust level measure. Results are shown for the network where the baby was born.
  • Guideline/mapping: Not applicable guideline.
  • Graph/relative performance: Statistically derived limits in relation to expected performance are used to identify statistical outliers.  More than two standard deviations higher or lower than the expected value is considered to be worse or better than expected (or alert level outlier); more than three standard deviations is considered an ‘alarm’ level outlier.
  • Quality improvement prompt question: Negative alarm level outliers should be treated as a priority. Negative alert or alarm level outliers should prompt questions as to how the hospital cooperating with other providers in the network to improve outcomes for babies born at less than 27 weeks? The audit recommends Neonatal networks, maternity networks and local maternity systems which do not achieve delivery of 85% of babies less than 27 weeks in a hospital with an onsite NICU should review whether they have realistic plans to achieve improvements in this area and develop plans if required.
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