Improvement Story Eleven

Ninewells Hospital, NHS Tayside, Scottish Neonatal Network

Contributor: Dr Lauren Shaw, Neonatal Consultant contributing on behalf of the Perinatal Team

What aspects of culture did you focus on and what changes did you make?

In early 2021, following on from the publication of the BAPM antenatal optimisation toolkit and emphasis on Scottish Patient Safety (MCQIC) Preterm Package we sought to understand and improve our own data around perinatal interventions.  We recognised that many of these interventions spanned the perinatal journey and would therefore involve the spectrum of professionals across maternity and neonates.  We created a perinatal team that included enthusiastic midwives, obstetricians, neonatal nurses, doctors, ANNPs, infant feeding advisors and theatre staff. 

Our ambition was to create shared purpose, knowledge and interventions that were accessible and engaging for the whole perinatal team.

Our first goal was to introduce bedside stabilisation for preterm infants in an effort to improve optimal cord clamping, thermoregulation and to facilitate parental involvement and delivery room cuddles. This was a huge culture shift for us as we have only ever stabilised in separate resuscitation rooms. 

We began by exploring what the barriers might be through questionnaires to maternity, obstetric and neonatal staff. This was a useful exercise which showed that a large proportion of staff were uncomfortable with the idea, worried about impact of space, maternal emergencies and parental privacy/experience. 

Understanding these anxieties allowed us to focus our interventions on reassurance and education for staff involved. We did this in a two pronged way – as a team we adapted resources from BAPM antenatal optimisation toolkit to include our own patients/families stories, so that people would recognise them and relate to their journey and understand the importance of their role in that journey.  We also ran simulated preterm in room stabilisation sessions for the whole maternity and neonatal team.  These sessions were hugely beneficial as they provided realistic opportunities for staff to talk through ideas and trouble shoot any concerns. 

Together we mapped the preterm journey from diagnosis of preterm labour to delivery.  This allowed us to create clear actions to optimise in room stabilisation and allowed each team member to feel valued and autonomous in their role.

With the creation of the perinatal team and establishment of in room stabilisation we have been able to demonstrate sustained improvements in many formal measures of perinatal optimisation, including antenatal steroids MgSO4, OCC and thermoregulation. In addition, we have transformed parents experience of having a preterm baby by involving them in the stabilisation process and advocating for delivery room cuddles for all our families.

What effect this has had on your team culture?

Through establishment of a formal perinatal team we were able to lay the foundations of collaboration, trust and respect for each other’s experiences and expertise.  With shared face to face education sessions and co-produced educational material we have highlighted the importance of perinatal optimisation and the collective roles and responsibilities within that.  We have been successful in implementing a change of practice that has not only impacted positively on preterm infant  outcomes but also on team satisfaction and experience.

We continue to have regular meetings looking at how we maintain improvement and share success with the wider team. 

What barriers have you had to overcome? 

Through the initial discovery phase of this project, we identified many barriers including anxieties about a big change in practice, worries about environment/space, maternal health and impact on parental experience. In addition, we had to consider what barriers the neonatal team might experience as stabilisation next to parents was a new experience for many of our team. We had new considerations about equipment, how many people really needed to be present in the room and escalation plans for maternal and infant emergencies.

With any project that requires multiple professionals from across departments aligning schedules is an on-going challenge.

What helped to make this successful?

One of the benefits of the perinatal team was the vast spectrum of experience from all sides. The shared experience of the team allowed us to think outside our individual experience and produce a process that was acceptable and reassuring to all those involved.  Open, informal and respectful communication was key. We were lucky to have found enthusiastic individuals from all areas and continue to look for and engage with enthusiastic staff.

On introducing a change in process we felt strongly about seeking feedback after each in-room stabilisation so that we could continue to improve.  This helped staff feel listened to and valued.