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Ward rounds – what’s the point?

Opinion piece: Running the NICU ward round

Jess, ST6 Neonatal SPIN Trainee, Severn Deanery

Leadership is a key word that inevitably ends up on every trainee’s development plan as they reach the final years of training.  I had decided that this was an area I was keen to focus on, and agreed with a consultant that they would observe me running a high dependency and special care ward round.  My main worry as I stepped up to the task – would I actually be able to make all those clinical decisions?! The consultants seem to make them with ease, but what happens if I just chose to do the “wrong” thing?

Well, that was my main worry until we were about to begin.  Then the supervising consultant asked a thought provoking question –

“What is the point of a ward round?”

I had never really thought about this before.  I just accepted they were part of life. (Perhaps at a later date I should focus more on my lack of intellectual curiosity…)

We have all been on seemingly terrible ward rounds. Ones that have lasted until mid-afternoon so there is no time to enact any plans. Ones where there have been so many interruptions that the team has lost focus. Oh, and the ones where the whole team has been bleeped away so you are left holding the baby (literally). There are some people who feel that the whole concept of ward round needs an overhaul.1 From a healthcare economics perspective, there are hours of expensive, skilled-labour time being invested into these daily rituals – are they worth it?

The ward round is considered the backbone of hospital medicine. It is so ubiquitous that it is taken for granted by everyone.  Major clinical decisions – often quite complex in nature – are made during this process by senior doctors. It is paramount for patient safety that the most appropriate clinical decisions are made in a timely fashion. On the face of it, that might be all the ward round is for but actually there are many more aspects…

So it turns out ward rounds are important, and complicated! Then came my next question…

“How do I make my ward round successful?”

Considering the sheer amount of medical, nursing and allied health professionals’ time spent ward-rounding, there is a real paucity of evidence on the topic.  The content, process, and decision making are so heterogenous and difficult to measure – how would you even study it? A systematic review of factors influencing ward round quality in adult intensive care showed… 2

I concluded I probably need to start by proactively facilitating allocation of roles in the team, and perhaps have a discussion about the particular focus of the ward round that day.  But how about the other aspects?

Timing seems a huge factor.  In my experience, the longer rounds go on, the more likely it is to suffer from interruptions.  There are competing aspects to timing. On one hand you have the actual length of the round, with associated decision fatigue and physical fatigue of those in attendance.  On the other hand, there is equity of time allocation to each patient.  It is clearly a balance of high quality, safe patient care vs going-as-fast-as-possible.3  Royal College of Physicians guidance for adult physicians on ward round practice is that cognitive fatigue sets in after 120 minutes4 – so aiming for less than 2 hours, or having a break if this isn’t possible, seems sensible. 

Checklists are another factor to consider.  Safety checks have been widely introduced into NICU for the sickest patients, recognising that busy ward rounds are an area of clinical risk.  They are primarily to ensure that there has been comprehensive coverage of all aspects of patient care.  They aim to improve communication, teamwork, and to empower the nurse caring for the baby to fully participate in discussions.  In PICU, checklists have been shown to reduce adverse outcomes.5 Checklists only work if they are fully embraced by senior members of the team.  Then – and only then – would the most junior members feel empowered to speak up and complete the list.  It seems to me that it is more difficult to apply a checklist to the HDU/special care environment, as the most important aspects that require attention seem to vary between patients and the management is generally less acute.  Without a checklist, however, longer term or less acute issues risk being forgotten or drowned in volumes of long-stay patient notes. A team of adult physicians have attempted to tackle this problem.  A “considerative checklist” has been developed for use in adult acute general medicine, which shows that potentially even more heterogenous and complex ward round activities can have some standardisation.  It is named “considerative” because the idea is for areas to be contemplated and discussed, as opposed to a simple tick-box exercise.6

Finally, I am keen to make my ward round a success from the patient and their family’s perspective too. In other words, I am keen to make my round as family-centred as possible. But then I wondered…

“What do families want?”

Qualitative research undertaken after introduction of parent involvement in general paediatric ward rounds has found that parents find being present for their child’s ward round invaluable.7  They reported that the communication about their child’s condition and the plan was their main source of satisfaction, and the use of lay terminology to summarise this was valued.  Parents also felt included as part of the team if they were invited to participate.  They felt their views were valued, and they felt more comfortable voicing their opinions or concerns if explicitly asked to do so.  In addition, simply observing/witnessing the whole team working together to discuss and care for their child was important for the families involved.  Inclusion of the nurse caring for the patient was important, however, in facilitating parental involvement and improving their comfort.  There were some areas of dissatisfaction – feeling rushed and not knowing the times rounds were happening, which has been echoed in other research.8. I learnt that some NICUs have taken the concept of family-centred care further by offering parents the opportunity to “present” their babies on the ward rounds, with reported success.9, 10

So, what happened on my ward round? There were a few interruptions, we ran a little over time and there were multiple deliveries for my team members to attend.  However, I invited several parents to actively participate and we had some interesting educational discussions ranging from antenatal spina bifida surgery to growth optimisation. All in all, not a complete disaster!

Time for a coffee

As I paused over my post-ward round coffee (and cake – I had survived – time for celebration!), I reflected on what I had learnt.  Ward rounds are more complex and involve more skill in combining all their competing demands than I had given them credit for.  In addition to my concern about making safe clinical decisions, I am now focussing on a family-centred approach through which I can aim for holistic care.  

Next, I wonder what the future will bring for ward rounds as my career progresses.  The world is changing in its accessibility and technological advances – but can we become more virtual in our ward rounds without losing the personal touch?  And how much should we rely on technology to make some decisions on our behalf using algorithms rather than clinical acumen?  Somehow I feel that as we have ever increasing information and tools at our disposal to aid decisions, it may require even more refining of our skills to continue to deliver successful rounds in this new era of telemedicine.

References

  1. https://blogs.bmj.com/bmj/2017/08/15/matt-morgan-the-ward-round-is-broken/
  2. Lane, D., Ferri, M., Lemaire, J., MacLaughlin, K., Stelfox, H. A systematic review of evidence-informed practices for patient care rounds in the ICU. Critical Care Medicine. 2013. Volume 41
  3. Herring, R., Desai, R., Caldwell, G. Quality and safety at the point of care: how long should a ward round take? Clinical Medicine. 2011. Volume 11, No. 1: 20-22
  4. Modern Ward Rounds. Good practice for multidisciplinary inpatient review.  Royal College of Physicians and Royal College of Nursing. 2021 https://www.rcplondon.ac.uk/projects/outputs/modern-ward-rounds
  5. Sharma, S., Peters, M., PICU/NICU Risk action group. “Safety by DEFAULT”: introduction and impact of a paediatric ward round checklist. Critical Care. 2013. Volume 17
  6. Herring, R., Caldwell, G., Jackson, S. Implementation of a considerative checklist to improve productivity and team working on medical ward rounds. Clinical Governane: An International Journal. 2011.  Volume 16, No 2, p129-136
  7. Latta, L., Dick, R., Parry, C., Tamura, G. Parental Responses to Involvement in Rounds on a Pediatric Inpatient Unit at a Teaching Hospital: A Qualitative Study. Academic Medicine. 2008. Volume 83, No 3, p292-297
  8. Barrington, J., Polley, C., van Heerden, C., Gray, A. Descriptive study of parents’ perceptions of paediatric ward rounds. Arch Dis Child. 2021
  9. https://www.paediatricfoam.com/2019/07/parent-led-ward-rounds-on-a-neonatal-unit/
  10. https://fabnhsstuff.net/fab-stuff/patient-led-neonatal-ward-round
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Left Holding the Baby: Managing a Clinical Service

Managing a clinical service

I had a recent, unexpected change in my role and have been reflecting on what I have learned and which parts of it might be useful to share. This has given me insight into the tremendous work behind the scenes in the NHS. Thankfully, both my colleagues are now healthy and back at work.

A sudden change

Our clinical director tested positive for covid19 and although he is an extremely healthy and fit person, he got really sick, really quickly. At the same time, one of my other consultant colleagues also became seriously unwell with a non-covid illness. We are a team of 9 whole time equivalents and over the course of about 24 hours, we were suddenly down 2 whole time consultants. The first reaction of everyone was shock and of course, tremendous concern for our colleagues. We felt powerless to help. The unit was going through a particularly busy patch of clinical work and we had big holes in the rota. I think sometimes people think consultants are invincible and all –knowing but believe me we are not! We are human, we get scared and sometimes we don’t know what to do for the best. However, we are good at teamwork and coming together to solve problems. The collective decision (we were able to include our CD in this) was that I would take on the clinical director role- with the rest of the team supporting.

What does a clinical director do?

This is something of which I had very little knowledge as a junior doctor and even as a consultant, was relatively naïve about. I was in a fortunate position though, as the service was in good shape and structures were in place which meant that many things could continue to tick over whilst I was scratching my head trying to figure out the basics.

Who’s who

One significant basic was working out who is who in the organisation. This is essential a. to get anything done and b. not to look like a plonker at various meetings.

As a front line clinician I had little knowledge of the roles, let alone the names and faces of the highly skilled, engaged and passionate people who work in non-clinical roles in our trust. As a trainee I had even less understanding of how the hospital is managed, lines of accountability and how money flows through the organisation. However, better awareness of the workings of a department and organisation would help trainees to effect change in the NHS. Many trainees have great ideas – they work at the coal face of the organisation- they can see the problems and the obstacles but they often don’t know how to get a project off the ground. During my time as acting CD I got to know more about our management team. Their role and working practices are not dissimilar to mine- they also work long hours (often leaving the building later than me) and are on call out of hours as well. Our manager and I met to deal with a varied range of problems from leaky pipes, complaints and rota gaps.

How is our service funded?

Neonatal Medicine is a part of the NHS which is specially commissioned. This means that our funding comes from close to the source of the funding stream for the NHS and not downstream via the clinical commissioning groups.

https://www.kingsfund.org.uk/audio-video/how-is-nhs-structured-funding-flow

A group of experts in the field decide how this money is best spent- they are the Clinical Reference Group. Service specifications set out what each type of unit or service is expected to deliver.

https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e08/

Each neonatal service will collect data to track how it is performing according to the service specifications. For example, each month we receive data on how many babies required intensive, high dependency or special care that month and track this over time which also enables planning for the future.

Inbox overload

Pretty much as soon as I took over the role, my inbox filled. It would crash about twice a day, even after I had requested an expansion! I cannot pretend that I found the solution to this. There are probably lots of brilliant hacks which I haven’t discovered for how to organise email traffic efficiently. My strategy involved trying to check regularly and prioritise. I sent emails acknowledging that I had received the message and asking the sender to prompt me if they didn’t get a response within a particular time frame. With our team we have agreed to set an achievable time frame for when we require responses- eg within a 2 week period- and we send reminders. I tried to ensure my out of office replies and e signature were current. This is definitely an area where I still have lots to learn but I at least now have a better understanding of the volume of emails that anyone in a leadership role has to deal with and will have a more compassionate response when a person might not reply or be slow to do so.

Backup

I was in a new role with no induction and no training. The great thing was I had loads of help – I just needed to ask for it. We ensured as a team we interacted regularly- weekly consultant meetings with good attendance were achieved with video calls and we used WhatsApp in between. We have some rules of engagement around these to protect time off whilst hopefully providing good, rapid support to the team- especially those on clinical service. One of the brilliant things my team did was immediately to offer to share out some of my other workload- various projects and meetings were taken off my hands which was a huge help. Another fantastic source of backup was the matron and nursing senior leadership team, without whom I would have been utterly at sea.

Meetings

There are a lot of meetings in the NHS! I remember my brother, who is also an NHS consultant, telling me he once went to a meeting about going to meetings! My first challenge was finding out which meetings there were and then which I was expected to attend and after that which ones it was useful for me to attend! Chairing meetings is also something of which I had minimal experience. My tip for this is taking time to prepare. Write an agenda and follow it to structure the meeting and keep it running to time. Find out who everyone is on the attendance list and their role- I used the hospital connect email system to look at role titles and then occasionally Google, when I didn’t know what a role meant. Being new does bring a huge advantage because people don’t expect you to know a great deal and so I could ask daft questions about how systems worked and what roles everyone had (and to be honest, I occasionally got the feeling that others in the meeting were pleased I had asked those things as well).

Workforce

There were huge pressures on the medical rota, as I’m sure most departments have experienced in the pandemic. Our department has a meeting first thing Monday morning to look at all the rotas for the coming week- this is essential to plan for unexpected absences. One of my wonderful colleagues manages our “locum army” who are an amazing group of junior medical staff who will cover short notice rota gaps for us. I have to say we really do feel like they are an invisible back up force who will swing into action when we call- thank you so much guys. Recruitment and retention is a significant area and another colleague does a tremendous behind the scenes role preparing job adverts and then short listing (we are very fortunate to get many applicants). Running interviews on line has become the norm and I think we are providing a pretty good and efficient experience for people with this.

Care & Self Care

Having an open door is an important part of the clinical lead role. It is a huge privilege to work with a large and wonderful group of people. From time to time, all of us will have additional pressures from outside work, which will inevitably impact upon us and sometimes our capacity to work in our usual way. I realised that being a clinical leader also means caring for the team, listening and being flexible to help in whatever practical way possible. Self-care is an essential component of this. As they say, you need to fit your own oxygen mask before helping others.

Management Experience for Trainees

I asked a couple of colleagues in management if there was anything they would wish trainees to know about their role. They both said that they are very much part of the team and there to assist where needed- from anything from problems in the here and now to securing funding for the service for the future. Always feel free to approach them with any issues. Their role is to enable services to run smoothly and develop over time, not to block or obstruct changes. Trainees might want to spend a day shadowing a manager (I did this when I was training and it was very helpful) and also to sit in on some departmental meetings- ask your clinical directors about this.

So now I’m back in my usual role as a NICU consultant and subspecialty tutor. I’ve learned so much- about the service, the team and about myself which was a tremendous privilege and I’m so thankful that my colleagues are back at work and healthy again.

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Neonatology in the Spotlight

I expect lots of trainees, clinicians and nurses will have experienced the feeling of being a small cog in the churning wheel of the healthcare system. It can be difficult to stay motivated at times when we do not feel as though our hard work is being recognised or rewarded. It can be helpful therefore to occasionally take a wider view and see where our field of practice sits within the landscape of the NHS. This is a great time to be working in neonatal medicine, during this post I hope to show you why.

I remember my supervisor once telling me that although neonatal medicine is a little fish in a big pond, it creates far-reaching ripples. In this post, I am going to describe an overview and signpost to the interventions currently focussed on improving neonatal care in our network and in the UK.

Here is a chart of infant mortality rates per 1000 live births by country:

In the landscape of medicine, our little corner of neonatology is currently in the spotlight. International benchmarking data shows we have improvements to make in delivering safer care for newobrn infants. Sometimes this can feel threatening, especially for those in leadership roles, with targets to address and data to collect. However, this also represents a once in a generation opportunity to have the attention of the state, the press and the public turned towards us. We can harness this money and momentum to create lasting change in our specialty, to ensure that the next generation of infants requiring neonatal care will have even better outcomes.



This diagram shows the current landscape of neonatal care in Southwest England.

It can be pretty confusing to look at all the different quality improvement drivers and standards and it’s easy to get bamboozled in acronyms and NHS management language so I will try and summarise these now and provide links for further resources.

Maternity Transformation Programme

NHS England programme aiming to deliver safer, more personalised care for pregnant women and babies. The overall aim is to halve the rates of stillbirths, neonatal mortality, maternal mortality and brain injury by 2025.

NCCR= Neonatal Critical Care Review

Review by the Clinical Reference Group (a group of experts in neonatal care) for NHS England which describes the core standards necessary for delivery of a high quality service and describes areas for development. This falls within the wider Maternity Transformation Programme. Specialist Commissioners, who commission services for the NHS use these reference standards to know they are getting a high quality service. You can read more about their recommendations if you are interested here https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-e/e08/

MatNeoSIP = Maternity and Neonatal safety improvement programme

NHS England safety programme aiming to reduce rates of maternal and neonatal deaths, stillbirths, and brain injuries that occur during or soon after birth by 50% by 2025. Here are more details https://www.england.nhs.uk/mat-transformation/maternal-and-neonatal-safety-collaborative/

GIRFT= Getting It Right First Time

NHS improvement programme aiming to reduce variations in the NHS. For example, they have been looking at staffing in neonatal care- you may remember filling out a survey for this about a year ago. They found that 10% of neonatal units had gaps in medical staffing and 15% had gaps in nursing staffing. https://www.gettingitrightfirsttime.co.uk/medical-specialties/neonatal-intensive-care/

NICE= National Institute of Health and Care Excellence

In August 2019, NICE published recommended standards for preterm labour and preterm birth management: https://www.nice.org.uk/guidance/ng25

Saving Babies’ Lives Carebundle 2

NHS England care bundle of evidence-based or best practice interventions. This is specifically aimed at improving the national infant mortality rate and the still birth rate. Despite falling to its lowest rate in 20 years, one in every 200 babies is stillborn in the UK, which is more than double that of some other nations. https://www.england.nhs.uk/mat-transformation/saving-babies/

BAPM Toolkits= British Association of Perinatal Medicine Resources

Toolkits targeting key NNAP (National  Neonatal Audit Programme) measures so that departments can access quality improvement tools and methods. https://www.bapm.org/pages/104-qi-toolkits

Periprem- Perinatal Excellence to Reduce Injury in Premature Birth

A WEAHSN (West of England Academic Health Sciences Network) care bundle, currently being implemented in units in the Southwest of England. https://www.weahsn.net/our-work/transforming-services-and-systems/periprem/

PReCePT= Prevention of Cerebral Palsy in Preterm Labour

National quality improvement work to improve uptake of magnesium sulphate in preterm labour.https://www.health.org.uk/improvement-projects/precept2-reducing-brain-injury-through-improving-uptake-of-magnesium-sulphate

Phew!

Well done if you made it to the end of all those acronyms. There may be more which I haven’t included. Hopefully I have shown how much national focus and drive there is to improve outcomes for infants born in the UK at the current time. We may be small cogs, but we all make important contributions which mean that progress and advances in care quality are being made all the time. So stay strong, keep submitting high quality data with your badger entries and get involved with quality improvement work where you can!

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The NICU Team: The Unsung Shining Stars

The survival of a sick or premature baby requires hard work and dedication from the whole team, including the family. How often do we take time to understand all these roles and celebrate the efforts of the individuals involved? Understanding the roles of others in the team can help us work together more effectively.

It was my pleasure to talk with Sharon, who works as a cleaner in our NICU department at St Michael’s.

Interview with Sharon

First of all Sharon, what is your official job title?

Hotel Services Assistant

How long have you been working in NICU?

4 years

I notice you are always there really early in the morning, especially if I’ve had a bad night shift and I’m still here early in the morning and I see you! What time do you start?

Officially 7 O’clock, but we get here about quarter to 6 so that we can make up our trollies, check the notice boards, so if there’s a patient that has gone into isolation we have to make up different buckets, we have to use different materials and then we can arrange when to do that room. Or if we have a patient going to x ray or another department we can plan to do their room while they are away. So we can plan our day. Then a very important part of the day- coffee and toast! That makes all the nurses and doctors smile because we are having toast when they come in and they know it’s almost the end of their night shift when they see that! We work until 13:30. After leaving the ward there’s a process to clear the trolleys and re-stock the cupboards.

How many people are there in your team?

Six. We rotate, with an overlapping shift system so every day is covered including the weekends.

Talk me through your daily tasks

HDU first- bins, towels, soaps, then special care and the side rooms.

I try and start very early with cleaning before the parents come in. We go into the rooms and dry mop the floors (to get the dust up first) followed by wet mop. There’s often quite a lot of stains on the floor from different medications which can be sticky or coloured. There’s no set pattern because we need to be flexible around the patient needs and movements in the day. For example, this morning a patient went down for eye laser, which meant I could come in and clean the room whilst they were out, which was brilliant because it was all done before any of the team needed to go in there.

How has your job changed in the pandemic?

Right. [Pause].

We obviously have to wear masks, aprons, gloves and goggles and these have to be fully changed for every room. We have to wash our hands even more often than before. We are carefully cleaning surfaces very regularly for example door handles, touch plates, and door locks- the key pads. Before we would be doing these once or twice in a shift and now we wipe them down basically every time we pass them. We are trying to make stocks last because everyone is hand-washing more often, so we’ve changed where dispenser soaps are available- only above the silver sinks. The rest of the sinks are the pump operated soaps.

I’ve been thinking about this and I think you and your team are doing such an important role, I hope you know that, I’m sure you do know that, you are keeping our staff safe and also the babies safe. Obviously infection in a baby is so devastating.

What’s the best thing about working here?

I just love the interactions with everybody.

With parents.

I just had a really nice letter from a parent which they sent in to my boss saying what I’m like!- it was lovely to get it. I like to make people happy.

And you do!

Even if I come in with a headache, I try and smile. Because, I know, their situation must be awful really. We’ve got to think about them and what they’re going through. I always try and say good morning to the babies! I do have my favourites sometimes as well

[gasp of shock] – we won’t tell anyone about that!

It must be lovely to see the babies who do well and see them getting bigger?

Oh yes. And when they go home! And then when they come back to visit and you go “my gosh- they’ve got big- what are you feeding them on?!”

 It’s the interactions I love when they come back. When they come to clinic sometimes they’ll just pop in and come back and see us all. Its really, really nice. I always get asked to come and see them when they visit- the parents always ask – they say “can we see Sharon?”.

They probably remember you better than they remember the consultants!

Yes probably, because they see me more often.

When I’m on holiday or have a few days off work and I come back, the parents say “we missed you”.

No-one ever says that to me!

-Well there you are 😊

Is there anything else you think I should put in this interview?

I don’t think so. The majority of staff we have here, whatever their status, will say “Good Morning” to us cleaners. Even one who didn’t for ages has now started to say hello to me.

I think that’s really good. We are all one big team here working to keep the babies safe and actually, if you didn’t come to work one day rather than I didn’t come to work one day, the patient care would suffer more quickly. I think people need to understand that!

I think some of the team also need to understand that I’m looking after 4 rooms. Sometimes the hand soap might run out and you get a complaint but you might be in a different room. One day this week a doctor walked into a room and noticed the floor was dirty, but the nurses explained that I hadn’t had the chance to get into that room yet. Now the doctors’ round was on, I couldn’t get in there. Once they’d gone I went in and cleaned it. Because there’s 4 main rooms to look after, you need to be checking all the time.

So what you have to have is good situational awareness isn’t it?!- a bit like the medical team- you’ve got to be aware all the time of what’s happening in the areas and what things have changed.

Exactly.

Thankyou so much Sharon!

Sharon, one of our wonderful team of Hotel Services Assistants

Finely Balanced: Preoperative Congenital Heart Disease

Author: Beth Osmond, Consultant Neonatologist

At St Mike’s, we provide care for newborn infants with an antenatal diagnosis of congenital heart disease. For newcomers to the medical team in the unit, attending these deliveries can be an anxious prospect. This blog post is written to give some general pointers about the clinical problems you could encounter in the infant with preoperative congenital heart disease.

Preparation

Many cardiac lesions in the UK are now diagnosed in the antenatal period, which means that we can take advantage of the opportunity to plan delivery in an appropriate setting, with an experienced team present to provide stabilisation measures at birth. At St Mike’s, we regularly review and plan for expected antenatal cases and have the opportunity to discuss with our fetal medicine and cardiology colleagues to identify which infants are at highest risk of early instability.

Birth: Placenta-ectomy

When you think about it, the fetus is on antenatal “life support”: the placenta providing both ECMO and dialysis- so the moment of “placenta-ectomy” is the first moment of challenge for the baby’s cardiovascular system to function independently.

In reality, most infants with congenital heart disease transition well from intrauterine life to air-breathing. When we run into early problems in the delivery room, this is usually because there is an additional problem with the respiratory system. The respiratory system blood circuit has hither-to been collapsed and insignificant, but must now expand to become a major circulatory route- imagine suddenly turning a Cornish country lane into a motorway. Our focus in the delivery room is providing good basic life support- warmth, airway position and chest expansion- as per NLS principles. Once the lungs are expanded, blood will be drawn into the pulmonary circulation as evidenced by an increase in heart rate. Target saturations are less important here than chest expansion, heart rate and other immediate clinical measures of adequate end-organ perfusion: tone & reactivity.

Neonatal Unit Care

Congenital heart lesions which are dependent on a patent ductus to achieve blood flow are the babies who are interesting and challenging to look after in the newborn period. We put these infants on a continuous infusion of prostaglandin E1- this must be given by a secure route – with an alternative source of venous access swiftly available in case there is an unforeseen line-patency problem. The prostin line is the patient’s lifeline.

Regardless of the specific cardiac lesion, the key aim is to achieve a balance of circulations. This simply means ensuring there is both adequate blood flow to the pulmonary vascular bed and the systemic vascular bed.

Thinking again about the traffic analogy, blood flowing through the circuit has the option of following 2 major motorways – if more goes one way or the other we will run into trouble.

Ventilation/ perfusion matching

As well as achieving adequate blood flow to both circulations, once the blood reaches the pulmonary vascular bed, it needs to be matched with adequate ventilation so oxygen can be taken up and carbon dioxide disposed of. When there is a mismatch in a large area of lung, this will cause significant issues in an already compromised system. Perhaps the motorway to Cornwall is open but none of the shops or beaches are accessible (maybe they are in lockdown) and thus the journey is rendered pointless.

Hypoxia causes pulmonary vascular constriction (unlike in the systemic ciruclation, where it causes vasodilatation). Hypoxic pulmonary vasocontriction is a built- in mechanism to reduce areas of VQ mismatch- diverting blood away from areas where there is poor oxygenation/ atelectasis.

In preoperative duct-dependent congenital heart disease, we also have the added component of shunting of blood away from the pulmonary vascular bed. Increasing the amount of inspired oxygen will not improve the situation and could infact make matters worse.

The overall aim is to achieve good VQ matching – ie adequate ventilation and blood flow.

Unbalanced

When making your bedside assessments of a baby with a prostin-dependant circulation, consider both circulations and whether you have adequate flow to each vascular bed or if the system is unbalanced. You do not need an echo to tell you this.

Think about the vulnerable post-ductal large vascular beds and you will probably be able to infer what we need to measure and track in NICU for the babies with a duct dependent circulation.

Cyanosis

Cyanosis to some degree is expected with many lesions. Target oxygen saturations will be given by the cardiologists depending on the expected degree of pulmonary blood flow. If the saturations are falling, especially if the baby is becoming compromised, they need an urgent cardiology review and may require in interventional procedure.

High Saturations

Do not be falsely reassured by monitors reading sats in the high 90s-100% in a patient with a duct-dependant circulation- be worried and assess the baby. Whilst in the delivery room we sometimes have problems encouraging blood into the lungs, after the pulmonary vascular resistance falls, we can run into the opposite scenario- too much blood going to the lungs and therefore, inadequate perfusion of the systemic system.

Think what the expected saturations are for this patient (and check the bedside card from the cardiologists with target levels). If the sats are high and the baby looks unwell, too much blood is flowing into the lungs.

Lactate Levels:

We monitor these regularly and would be concerned that a rising lactate could represent inadequate end organ perfusion.

Femoral Pulses:

These are a good bedside marker for blood flow to the “south”- at the start of your shift it’s a good idea to palpate them and then you will have a reference point against which to check every few hours.

Urine Output:

Since placenta-ectomy (birth) the kidneys have been functioning independently. They are essentially an elaborate seive and are dependent on adequate blood flow to work efficiently. A reduction in urine output is therefore a worrying early sign that they are inadequately perfused- and will alert staff on NICU in advance of any lab tests of renal function, that something isn’t right.

Gut blood flow:

This is an area which can cause us significant anxiety, particularly if the baby is concurrently preterm and has a duct-dependent circulation. Gut perfusion can be estimated on echo by looking at flow in the mesenteric artery. A good beside test is monitoring for bilious gastric aspirates and regularly palpating the abdomen for distension, discolouration or tenderness. If there are concerns of poor flow to the gut, parenteral feeding is given, although we would always try to offer non-nutritive expressed breast milk to promote healthy development of the microbiome.

Other important clinical signs:

Monitor heart rate and BP (invasive if possible).Examine and touch the patient- feel their skin temperature with the back of your hand centrally and peripherally. Check their central capillary refil time. Observe their colour- a baby with a duct dependent lesion who is pale but 100% saturated should raise alarm bells. A baby who is cyanosed with a good urine output, normal femorals and lactate is less worrying.

Manipulating the Pulmonary Circulation

Lung Expansion

As we know from NLS principles, lungs need to be optimally expanded in order to draw blood into them. You might think that deflating the lung could therefore reduce excessive pulmonary blood flow. Unfortunatley, since  placenta-ectomy (birth) we no longer have an alternative vascular-bed to use for oxygenation. Lung atelectasis is therefore of no benefit and will cause lung injury.

What we need to achieve is matched ventilation/perfusion without atelectasis.

Does PEEP/CPAP increase or decrease pulmonary blood flow?

This depends if there is atelectasis.

In a lung which is unhealthy or under-expanded (eg RDS) PEEP will reduce atelectasis and draw blood into the pulmonary circulation, reducing VQ mismatch.

In a healhy, expanded lung, PEEP might actually reduce blood flow, by a simple pressure mechanism of expanded air sacs on the pulmonary vascular bed. Our cardiologists will sometimes therefore ask us to give CPAP to some babies who are pulmonary over-circulating, to see if this will reduce pulmonary blood flow.

In a ventilated baby with a duct-dependent circulation, manipulation of intra-thoracic PEEP becomes a little easier and more controlled, so we can reduce or increase the PEEP depending upon the status of balance of the circulations. High mean airway pressures/ high PEEP can be used to reduce pulmonary blood flow.

pH

Acidosis (both metabolic and respiratory) constricts the pulmonary vasculature and increases pulmonary vascular resistance, whereas alkalosis selectively decreases PVR.

In a ventilated patient, we can therefore quickly manipulate the CO2, depending upon which direction of blood flow we wish to achieve. We can also manipate the pH by controling any metabolic acidosis, provided we can adequately clear any CO2 which accumulates.

CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3

Promotion of homeostasis: trying to be a placenta

We are trying to do the same job that the placenta did so well- promoting normal physiology will help the baby. We therefore aim for normal electroytes, calcium levels and normothermia. Keeping the baby settled is important- if they are aggitated, they can quickly decompensate. Choice of sedatives is important and should be discussed with a consultant as some agents will cause hypotension. If a baby with a duct-dependent circulation requires induction agents for intubation, this must be done with caution and with guidance from a senior clinician- they can rapidly decompensate in these circumstances.

Controling the size of the Duct

Ductal blood flow is regulary assessed by echo.

The size of the duct and it’s contribution to shunting blood towards or away from the lungs can be manipulated by changing the rate of the prostin delivery.

If you are currently working with us, or are coming to work in our unit or another cardiac unit in the future I hope this post has helped to explain some management points in this fascinating and vulnerable group of patients.

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Blog-post: Stepping Up Week

Author: Dr Liam Mahoney, Senior Neonatal Trainee, Severn Deanery

It’s Sunday evening, the night before stepping up on the NICU.

Oh my days what am I doing?!

Thoughts were pacing through my mind-

Can I really do this?

Do I know enough Neonatology?

What if a patient gets worse?

What about all the other stuff that goes with being a consultant?

A wee time ago during my Educational Supervisor meeting it was suggested that I try and organise a week of acting up on the Neonatal Unit in ITU. Whilst a scary prospect, the idea of coming out of my “comfort zone” and pushing myself was very tempting. First hurdle- the practical/governance aspects. Find a Consultant willing to do this. One of the consultants kindly offered me to act up in her week which was great (she was amazing as a supervisor). You also need to have your START assessment for the Hospital to officially sign off you acting up. Even though COVID has stopped START you can still do a week acting up but your Supervisor will still be the official Consultant.

Now I have been wondering how to write this up, without waffling to much. I thought that instead of writing about each day I thought I would summarise some of my most important take home messages about the challenges/difference/opportunities of acting up as a Consultant.

Clinical stuff

In terms of different pathologies and presentations, St. Michael’s has a plethora of really interesting and varied cases. This was the part of acting up that I was most worried about- Would I know how to manage hydrops well? When should I bail out and intubate a term baby on CPAP with a rising FiO2 -now or wait longer?  My first reaction was that I needed to make sure I knew the latest research for all of the conditions. However, NICU cases have a habit of not exactly following the textbook and there are multiple different “right” ways of managing any particular sick patient. As the week went on, I did begin to feel more comfortable with the clinical decisions I had to make. But this wasn’t the main take home message for me.

I used to think that as the Consultant you have to be this all knowing entity and that everyone looks to you. However, in the week of acting up I learnt its just as important to be ok with not knowing the answer but knowing where to find answers with extremely challenging cases. Two minds are better than one and this week I learnt how important it was to use your colleagues and bounce ideas of each other. By doing this you not only benefit from others experience (and learn something) but I also felt a little burden was offloaded when talking through a case. I also learnt a secret in that the Consultants do this a lot!

Managing the unit stuff

Conserving bandwidth

This was the part of the job I learnt the most about, but strangely was the part of the week I was least worried about. I WAS WRONG. I now feel quite lucky to have done a week of acting up and have some (albeit little) experience in this aspect of the job. I think when you are given your CCT they must implant a second brain- you really need it. Brain 1 to think about the clinical stuff and  brain 2 to manage the governance/safety/risk issues that come up on the unit.

St. Michael’s is a very busy unit and patient flow is key- you need to ensure you have that bed for the unexpected HIE cooled baby. It became apparent important the safety brief was. I began to make mental notes during safety brief of patients that could be transferred out of ITU so that potential beds could be made. This was a very pressing issue during the week and was compounded further by acute issues coming up on the ward round e.g. a neurosurgical emergency in DGH or the transfer of a patient for contrast etc. This made knowing the nursing and medical staffing levels/skill mix so important so the right people could peel off to deal with the issue. I found it hard to keep the ward round flowing when this would occur.

Olive, 1996

Phew! Just writing down all of extra stuff you needed to think about outside the ward round is making me dizzy. However during the week I soon realised again, as Olive said in her 1996 Dance hit, “You’re not alone”. I always knew the Nurse in Charge was amazing, but I didn’t realise how amazing they were. So many of the issues were resolved with Nurses it really eases the burden on the whole medical team. I was constantly talking to the nurse in charge throughout the day and I was staggered at the amount of stuff they have to deal with. I felt they were almost playing a filter/gatekeeping role for the unit and medical team- so many of the problems are fixed by them before you even know about them. Their skill in doing this is something to behold really.

I feel like a broken record here but I feel like I need to emphasise the point- I don’t think I anticipated the amount of non-clinical things I would have to deal with. As a registrar you know that you have ITU to look after and many of the managerial aspects of the unit are being looked after by the powers that be. I learnt that during the acting up week that sometimes I needed to walk away and allow the team manage the clinical work and make a very conscious effort to ensure that I was available for people/to deal with other issues that arise. The situations that come up (e.g. admission of a baby with potential COVID that has just meant HDU is down two nurses) are unpredictable, tricky, need time and careful problem solving. This means that you inevitably some things you may not get to or (and this is a lesson for me as I think I’m a people pleaser by nature) you need to learn to, and be ok with, saying no. This makes delegating key. I think as Neonatologists we like doing things- procedures is one of the reasons I love this job. But again appropriately leaving tasks to different members of the team (e.g. leaving the intubation of a preterm baby)  helps to give you the headspace to deal with everything else.

Looking after yourself stuff

Make sure you eat! This is obvious but medics as breed (I feel) often may forget to do this. Being designated the “Consultant” you need to be available in multiple capacities and there is not a lot of time for yourself. Make sure you eat and drink when you can. I get HANGRY so this a must.

There Are LOTS of Meetings- Set alarms for these so you are not late and also set a 15 minute warning (pre-alarm) is useful.

Switching off! This is something that I am poor at. However, you need to do it if you are going to get through a service week. During the week I began to make sure that I did the home workouts, even dabbled in a spot of meditation and made sure I spent time with my family.

Celebrating the wins– I found myself at the end of the week thinking about the babies who became unwell rather than the ones that got better. Again, I think Medics might be pre-programmed to be a self-deprecating bunch on people, but at the end of the week it was important to highlight those wins with the team, “remember the no. of babies that extubated during the week”.

Final bit of waffle

I am so pleased to have been given the opportunity to do this. If you are thinking about doing it then just do it; you will get so much from acting up.  It made me realise how different the Consultant role is to anything else I have done in medicine. It was daunting, there are certainly lots of things I need to work on (great for old e-portfolio PDP). I hope to do another period of time acting up before my CCT certainly. Overall it made me rather excited for the new role I hope to undertake in the not so distant future.

I want to say thank you to the nurses and doctors team on that week for being generally an awesome bunch of people to have the privilege to work with. I want to use this final bit to thank Beth for allowing me to steal her ITU week and for being a really supportive mentor during that week!

Re-thinking simulation in the Covid-era

Authors:

Catarina Couto, Education Fellow St Michael’s NICU

Beth Osmond, lead for simulation

We’re only halfway through 2020, but already it feels inevitable that this year will be remembered for the way a tiny pathogen (aka COVID-19) has forced us to change the way we live our personal, professional and social lives. With social distancing still in place for the forceable future, we have needed to adapt our mode of delivering teaching. While traditional formats are quite easy to be delivered in this highly connected world (we have recently started sharing some of our teaching on an online platform alongside North Bristol NICU) providing simulation experience is undoubtedly more challenging.

Our team brainstormed ideas on how to run a simulation session entirely online. We tested out the waters of online meetings with a neonatal quiz, which got great feedback from our staff.

Traditional point of care simulation, when done well, has sufficient fidelity to create an immersive experience for participants to encourage decision-making and behaviours to be as realistic as possible. This is very difficult, if not impossible, to recreate in an online experience.

Challenges and constraints will often present opportunities to have a different approach. One of our grid trainees suggested that the online experience could be used in a “Choose Your Own Adventure” simulation.

When planning the session, we considered what we wanted the participants to learn from the experience. We used videos of a simulated clinical scenario with a deteriorating patient with introductions from a facilitator. The team of online participants then had time to discuss and decide on a course of action from two potential options. We felt that both options should be equally reasonable so as not to induce participants to error. We also recognised the educational benefit of having the participants watch a video of effective teamwork and good clinical practice. They were then showed the video for the option they chose.

As is often the case with simulation, less is more. We quickly realised that what could on first glance be viewed as a simplistic choice, when discussed in detail as a multidisciplinary team can throw up complexities as the team have time to consider the question from multiple viewpoints – a huge advantage of this format. We observed this promoting critical thinking as the team considered different perspectives. The de-brief was built in to the scenario as we progressed. As facilitators, we did not need to speak much beyond the pre-designed script for the video introduction. The participants de-briefed themselves – very effectively.

Instead of having the usual hierarchical team organisation, we decided to dispense with the leadership role and have participants contribute equally, with their own set of skills and knowledge, to the decision making process. This structure helps junior staff members, who might otherwise not feel involved, consider the challenges of decision making. We also hope to empower our colleagues with clinical knowledge and confidence to contribute in a real life emergency.

Our first “Choose Your Own Adventure” simulation took place in June 2020 and received great feedback.

Participants fed-back that they learned how there can be different reasonable approaches to a clinical situation. They learned the importance of teamwork and discussion to overcome these challenges.

Here is some of the feedback we received:

“It’s difficult to replicate the clinical setting but I thought the approach was innovative. It sparked discussion and debate. I enjoyed it and felt I gained as much if not more than face to face sims.”

“It was a relatable topic area, utilising each other’s previous experiences and knowledge base. The safe and relaxed environment enhanced team work and collaboration across disciplines.”

The simulation team felt it was a fluid, fun and relaxed experience. We were delighted with the team dynamic and felt everyone engaged in a respectful discussion of the management of an unexpected event.

While this type of simulation cannot replace the traditional format, we feel it complements it and intend to keep running these sessions parallel to our simulations on the unit. Once filmed, the session is complete and can be run remotely with little preparation required. By having to rethink the norm, we found a format that works well for us and the participants.

We’re happy to share the blueprint of the simulations we have designed so far with other simulation teams 😊

We are very grateful to Alex Doerr, Maddie Gould, Louise Bridge, Katie Hunt and Paul Cawley for the help they provided, and also want to thank all the participants so far for their valuable feedback.

St Mike’s Simulation Team 2020 – Adele Farrow, Asha Persaud, Carolyn Donovan, Catarina Couto, Elizabeth Osmond

Blog post: Improving Quality of Quality Improvement

  • Are you befuddled by acronyms in quality improvement?
  • Can you tell your audit from your elbow? Or your Fishbone from your Driver diagram?
  • Would you like to know more about change in the NHS?

This short article is a beginner’s guide to QI and a pitch as to why it is a cornerstone of clinical practice in neonatology.

What is QI?

QI at its core is making sure that evidenced-based advances in science are translated into routine clinical practice to improve outcomes for our babies.

In neonatal medicine, QI opportunities are abundant, thanks to our specialty’s strong relationship with research.

Here are a few examples:

  • interventions to keep babies warm in the delivery room
  • interventions to reduce catheter-associated blood stream infections
  • interventions to ensure the group most likely to benefit receive hypothermia in a timely manner

The Phases of QI

  • Step One: Define the problem

How do you know if your unit is a “good” unit?

What does a “good” neonatal unit look like?

If data is collected accurately according to standardised definitions, it can then be used for comparison. For example this can be with a historical dataset from the same unit (before and after an intervention) or with other, similar units. Large datasets from NNAP (National Neonatal Audit Programme) and VON (Vermont Oxford Network) are used to tell us if we are on the right track for key quality indicators. If you are not already familiar with these, you might want to have a guess at what these could be, for example for infants <1500g- have a think about what we can easily measure and collect.

So first of all we need to identify where we may have a problem area at which to target our QI interventions- this is why all those painful hours completing audits and collecting data are worth it!

How did we get here?

A Driver Diagram can be used to show how different systems and problems interact

A Fishbone Diagram looks at cause and effect

Pareto Charts can help to decide which areas to focus your energy- based on what problems are the most frequent and significant.

Process Maps look in detail at all stages of the process- it is important to consider critical steps from other team members here eg the pharmacist, the porter.

  • Phase 2: Develop a Shared Purpose

So using data we have clearly defined our problem. Now the teamwork begins! This requires great enthusiasm, tenacity and a good dose of diplomacy- to ensure that the other key stakeholders in the department understand that a problem area for improvement has been identified. Other team members will have different perspectives on problems and solutions, the result will be a shared plan of action.

Some examples of stakeholders:

  • Medical team: junior and senior
  • Nursing team: junior and senior
  • Wider MDT pharmacy, physios
  • Non clinical staff: ward clerks, portering services
  • Parents and families
  • Phase 3: Plan and Implement Change

Formulate ideas, prioritise and test. In this phase, change ideas are launched and then continuously reviewed through PDSA (Plan, Do, Study, Act) cycles. Again, data collection and tracking at this stage are essential.

  • Phase 4: Test and Measure Improvement

Run charts are used to track your outcomes as close to “live” as possible- so you can see if changes are working and adapt as needed.

  • Phase 5: implement, Embed and Sustain
  • Spread the word!
  • Look in detail at when and why your change hasn’t happened- exception reports
  • Explore barriers and how they change over time
  • Keep people motivated

So there we have it, a beginner’s guide to QI. Hope you enjoyed it, I’m off to clean the cafetiere…

Other useful resouces:

BAPM Toolkits/ QI https://www.bapm.org/pages/2-quality

NHS improvement website: https://improvement.nhs.uk/

NHS Scotland Quality Improvement Hub: http://www.qihub.scot.nhs.uk/qi-basics/quality-improvement-glossary-of-terms.aspx

Journal Club Report: Impact of Rudeness on Team Performance

Author: Rebecca Treleaven, Paediatric Trainee, Severn Deanery

Article citation:

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

Arieh Riskin, Amir Erez, Trevor A. Foulk, Amir Kugelman, Ayala Gover, Irit Shoris, Kinneret S. Riskin, Peter A. Bamberger

Pediatrics Sep 2015, 136 (3) 487-495; DOI: 10.1542/peds.2015-1385

Study question:

What impact does rudeness have on team performance?

Study design:

Randomised intervention, simulation

Methods:

This was a double blind randomised control trial carried out in a neonatal unit in Israel. Each team’s task was to identify and resuscitate a preterm infant with NEC. Instructions were provided on how the simulation would run with the intervention groups receiving additional non-specific rude comments about the standard of healthcare in their country from a bogus external professor observing via a weblink.


Intervention:

Instructions were provided on how the simulation would run with the intervention groups receiving additional non-specific rude comments about the standard of healthcare in their country from a simulated bogus external observer. Four outcome measures were subjectively scored by 3 blinded independent judges: help seeking behaviour, information sharing, diagnostic performance and procedural performance; with moderate to high reliability between judges. Participants were also asked to rate perceived rudeness post-simulation.

Results

The study demonstrated that external rudeness had a significant impact on team performance within a simulation setting compared to a control group. This was seen across the majority of outcome measures. Help-seeking behaviour positively impacted procedural performance and similarly information sharing improved diagnostic performance.

Analysis/critical appraisal

Some limitations of the study included; a lack of a power calculation, no documentation on the randomisation process and no data provided on age, gender or expertise between the two groups. Though the teams were debriefed, there was no detail on how they supported the psychological welfare of participants.

Overall the study provides good evidence that an individual’s behaviour can impact the performance of a team and therefore patient care. Though this was in a simulation setting, the comments were relatively mild and impersonal and still performance was significantly reduced. Future research could look in to the effect praise has on team performance and how that differs from rudeness versus a control.

Conclusion

This study highlights the importance of creating an open and compassionate culture within healthcare settings to ensure the best outcomes for patients.