Neonatal Care in Scotland: A Quality Framework

3.2 Safe

Public assurance regarding the quality and safety of care will be supported through a robust governance structure which is focused on the safety of patients. The service will monitor and act upon data and information gathered from quality outcome measures, clinical outcomes and other audit methodologies. This will demonstrate a culture of continuous service improvement and sustainability. This care will be underpinned by child protection policies and recommendations of patient safety initiatives.

A high quality service will provide care in line with approved patient pathways; ensuring staff with the appropriate skills are available; treating babies in units with facilities appropriate to their needs; undertaking regular audit of practice and ensuring staff have appropriate training.

3.2.1 Patient Pathways

Patient pathways will be developed in partnership with staff, parents and key stakeholders to deliver and demonstrate a standardised high quality safe neonatal service across all the regions.

This will be evidenced by:

• A streamlined pathway between obstetric and neonatal care.
• Babies being managed in the appropriate level of facility, so that when severity of illness increases or decreases, babies are cared for in the safest environment.
• Support and advice where required, within local services and across the network.
• Availability of specialist services, on a national and regional level.
• Availability of surgical services.
• Community care being provided following discharge if required.
• Neuro-developmental assessment and follow-up being undertaken, where clinically appropriate to comply with BAPM Standards.
• Care being provided in line with the recommendations of condition-specific MCNs.
• Clear referral pathways for specific neonatal conditions not wholly managed within the local unit, e.g. therapeutic hypothermia.
• Palliative/end-of-life care pathways.
• Units demonstrating that these pathways are in place, staff have knowledge of same; pathways are universally complied with and, where local guidelines exist, they promote adherence to the agreed pathways.

3.2.2 Available Skills

A high quality service will have the following availability^[4] of skills:

Medical Care

Three tiers of staff will be available to provide medical care:

Tier 1 - Direct care (foundation or specialist trainee/advance neonatal nurse practitioner (ANNP)).
Tier one staff are available at all levels of neonatal care;

Tier 2 - Resident experienced support (specialist trainee/ANNP);

Tier 3 - Consultant

The availability and experience of tier two and tier three staff are different between the three categories of neonatal services. This is reflected in the complexity of care provided. Nevertheless the competencies and capabilities required to ensure safe practice in these differing models of service delivery are assured through education and training frameworks as agreed by professional bodies.

• Duty rotas will identify the following are in place:

Level One

• 24-hour availability from a consultant paediatrician (or equivalent non-consultant career grade doctor); out-of-hours cover is provided as part of a general paediatric service; available as part of the general out-of-hours service.
• 24-hour availability of staff experienced in providing basic airway management; supported by staff experienced in advanced airway management.

Level Two

• 24-hour availability of consultant paediatrician (or equivalent non-consultant career grade doctor) with experience and training in neonatal care; out-of-hours cover is usually provided as part of a general paediatric service.
• 24-hour cover of resident experienced support with the ability to respond immediately to neonatal emergencies (specialist trainee/ANNP); although out-of-hours cover is usually provided as part of a general paediatric service.
• 24-hour cover for provision of direct care with sole responsibility for the neonatal service (this could be a member of medical staff or an ANNP or QIS nurse who has undertaken extended training to support taking on additional roles^[5]).

Level Three

• 24-hour availability of a consultant neonatologist^[6] whose principal duties, including out-of-hours cover, are to the neonatal unit.
• 24-hour cover of resident experienced support for sole cover of the neonatal service and associated emergencies (specialist trainee/ANNP).
• 24-hour cover for provision of direct care with sole responsibility to the neonatal service (FY2 - ST3 or ANNP).
• All units will be able to demonstrate:
  • The availability of a duty level three consultant at all times to provide advice and support by telephone to paediatricians delivering neonatal care at other network units. For networks with more than one neonatal intensive care unit, an agreed system for designating the daily availability of this clinical advice is in place.
  • Where it is necessary for a consultant to be resident on call, another consultant is available for telephone advice and/or attendance if necessary.
  • Medical workforce planning takes account of the European Working Time Directive (EWTD) in job planning.
  • A specialist paediatric surgeon is on call for the neonatal surgical service to provide advice to referring centres at all times.
  • All services providing surgery to newborn babies have access to a consultant neonatologist, available at all times.
  • Availability of a pharmacist whose job plan contains identified and protected capacity for providing advice and support in neonatal pharmacy.
  • Staff with appropriate training, knowledge and skills available to provide support in the community after discharge, where required.
  • Cardiology advice is available 24-hours a day within Scotland.
  • Access to the perinatal pathology service.
  • Access to a multi-disciplinary team specialising in and trained in neuro-developmental assessment and therapy for high-risk infants.
  • Access to individuals trained and competent in dealing with child protection issues, which will be managed in line with the latest national child protection guidance.
  • Access to a radiologist with expertise in reporting neonatal images across the network.

3.2.3 Nursing Skills

A high quality service will have the following availability of nursing skill:

• Staffing records evidence that units have a minimum of two registered nurses on duty at all times, of which at least one is qualified in specialty (QIS).
• Babies requiring special care are looked after with a minimum of 1:4 staff-to-baby ratio at all times by either registered nurse or non-registered staff with the appropriate competencies and skills, working under the supervision of a registered nurse (QIS).
• Babies requiring high dependency care are cared for by staff who have completed accredited training in specialised neonatal care or who, while undertaking this training, are working under the supervision of a registered nurse (QIS). A minimum of a 1:2 staff-to-baby ratio is provided at all times (some babies may require a higher staff-to-baby ratio for a period of time).
• Babies requiring intensive care are cared for by staff who have completed accredited training in specialised neonatal care or who, while undertaking this training, are working under the supervision of a registered nurse (QIS). A minimum of a 1:1 staff-to-baby ratio is provided at all times (some babies may require a higher staff-to-baby ratio for a period of time).
• Neonatal nursing establishments in each unit are calculated against activity with an uplift of 22.5% to accommodate expected leave (annual, sick, maternity, paternity, mandatory training and continuous professional development (CPD)), based on an 80% occupancy level.^[7]

3.2.4 Allied Health Professional Skill

A high quality service will ensure all units have access to Allied Health Professionals whose job plans contain sufficient capacity to provide advice and support across the network, to meet BAPM standards.

Diagnostic imaging services will be provided by professionals with expertise in paediatric and neonatal imaging.

This will be evidenced by:

• The availability within the neonatal team of specialist neonatal dietitian, physiotherapist and/or occupational therapist, speech and language therapist and clinical psychologist.
• Compliance with IRMER (2000) and IRMER Amendment (2006) and ALARP principle.

3.2.5 Facilities

A high quality service will ensure babies will be treated in a facility that promotes patient safety and is appropriate to the clinical need.

This will be evidenced by:

• Suitable equipment being available in any location where neonatal resuscitation maybe required.
• Centres providing neonatal surgery have an emergency theatre available at all times to provide neonatal surgery as close to the neonatal unit as possible. This theatre has equipment appropriate for very small babies and appropriately skilled operating theatre staff are available. Future builds will ensure this theatre is adjacent to the neonatal unit.
• Specialist neonatal surgery services being located in the same hospital site as specialist paediatric (including surgery and anaesthesia), maternity and neonatal intensive care services.
• NHS Boards working towards centralising the care of babies requiring surgery into a combined medical and surgical neonatal unit, where this is not currently in place.
• All medical equipment in the neonatal unit being of a safe standard and being routinely maintained, including laboratory/near patient testing equipment.
• The provision of suitable facilities for diagnostic imaging and reporting services, including access to national PACS.

3.2.6 Measurement

A high quality neonatal service will promote an improvement-focused culture through a commitment to patient safety and the delivery of quality improvement and sustainable services.

This will be evidenced by:

• Participation within local, regional and national audit programmes.
• Provision of data to support and demonstrate clinical quality and service improvement.

3.2.7 Staff Training

Staff within a high quality neonatal service will have a high standard of knowledge and skills.

This will be evidenced by:

• All staff involved in the clinical care of the newborn immediately following delivery being competent in newborn life support and other key clinical skills as identified by BAPM. This can be evidenced by appropriate staff demonstrating current accredited certification in newborn life support.
• All staff caring for babies within neonatal services undergoing and maintaining appropriate training in neonatal resuscitation for the level of care they are expected to provide, and a record of training being maintained.
• All staff caring for babies within neonatal services undergoing training and maintaining competence in the management of child protection issues, in line with NHS Education for Scotland's Core Competency Framework for the Protection of Children.
• All staff caring for babies within neonatal services complying with the local Equality and Diversity policies.

Nursing Staff

• Registered staff achieving the competencies identified within the Career and Developmental Framework for Neonatal Nurses in Scotland (2010) within the recognised timescale.
• Non-registered staff providing direct nursing care undertaking appropriate training and achieving set competencies identified for their clinical support worker role within the recognised timescale.
• All staff providing direct nursing care being supported to participate in continuing professional development of relevance to their role on the neonatal unit.
• Robust training records being maintained for all levels of staff within the neonatal unit.
• Nurses providing care for babies requiring surgery being competent in both neonatal medical and surgical care.
• A minimum of 70% (in level one units) and 80% (level two and three units) of the workforce establishment holding a current Nursing and Midwifery Council (NMC) registration.
• A minimum of 70% of the registered nursing workforce establishment holding an accredited post-registration qualification in specialised neonatal care (qualified in specialty (QIS)).
• All staff being supported to maintain appropriate skills and performance being formally reviewed on an annual basis through appraisal and e-KSF or other appropriate performance management process.

Consultant Paediatricians/Neonatologists

• Consultants who supervise neonatal care being able to demonstrate continuing professional development in neonatal care as part of their job planning and appraisal process.
• New consultant appointments to neonatal intensive care units having a Certificate of Completion of Training (CCT) in Paediatrics (Neonatal Medicine) or equivalent.

Paediatric Surgeons:

• Specialist paediatric surgeons being appropriately skilled and trained to care for babies. These skills will be maintained via continuing professional development. This will include all relevant specialties.
• New consultant specialist paediatric surgeon appointments holding a CCT in Paediatric Surgery or equivalent.

Anaesthetists:

• Anaesthetists who are expected to undertake neonatal anaesthesia and resuscitation being appropriately trained as recommended by the Royal College of Anaesthetists' competency-based higher and advanced training documents (ST 5, 6, 7) or equivalent.
• Units providing neonatal surgery having a consultant anaesthetist designated to provide anaesthesia for newborn babies available at all times. Each of these consultant anaesthetists will have regular involvement in emergency and elective neonatal surgery.

Sonography

• Any member of staff providing ultrasound within the neonatal unit must have appropriate training and competence relevant to their role.

Allied Health Professionals:

All AHP staff involved in neonatal care will be trained effectively, supported to maintain skills and will have their performance formally reviewed on an annual basis via appraisal and e-KSF within their own professional departments. They will have access to appropriate specialised post-graduate training and education and will be supported to participate in continuous professional development of relevance to their role. The following list identifies some of the specific requirements for the individual AHP professions to provide a high quality service:

Dietitians

Dietitians providing neonatal care will have completed the British Dietetic Association Paediatric masters module two or have equivalent levels of knowledge and skills with achieved competencies.

Specialist neonatal dietitians will have completed the British Dietetic Association Paediatric masters module five neonatal nutrition training course or have equivalent levels of knowledge and skills and achieved competencies.

Speech and Language Therapists

Speech and language therapists providing neonatal care will undergo accredited post-registration training or training appropriate to the neonatal unit. This will include paediatric dysphagia training or equivalent skills, knowledge and competencies.

Physiotherapists

Physiotherapists will have access to training in line with the requirements of the Association of Paediatric Chartered Physiotherapists competence framework.

Radiographers

Radiographers working within neonatal units will comply with the College of Radiographers Practice Standards for the imaging of children and young people (2009) and the "Child and the Law; The roles and responsibilities of the radiographer" (2005).

Pharmacists

Pharmacists will be experienced in neonatal care and as a minimum will have successfully completed the Centre of Postgraduate Pharmacy Education paediatric distance learning pack or have equivalent levels of skills, knowledge and competence.