1. WMNTS Stabilsation Audit April 2012-Dec 2012 Maria Francis

2. Parameters WMNTS Staff document time of arrival and time of departure at referral units. The intervening time is taken to be the stabilisation time. WMNTS Staff document time of arrival and time of departure at referral units. The intervening time is taken to be the stabilisation time. WMNTS aims to provide a stabilisation time of: WMNTS aims to provide a stabilisation time of: < 2 hours for ITU Transfers < 2 hours for ITU Transfers < I hour for SC Transfers < I hour for SC Transfers The data for this audit was taken from the WMNTS computerised database and the manually compiled datasets. The data for this audit was taken from the WMNTS computerised database and the manually compiled datasets. The time period was 1 st April 2012 to 31 st Dec 2012. The time period was 1 st April 2012 to 31 st Dec 2012. The audit details compliance with WMNTS self imposed stabilisation aims. The audit details compliance with WMNTS self imposed stabilisation aims. The audit was compiled by Maria Francis, WMNTS Sister. The audit was compiled by Maria Francis, WMNTS Sister.

3. Transfers Graph. Total no of transfers performed :910 Total no. ITU transfers >2 hours: 78 Total no. of SC transfers >1 hour : 7 Non compliance broken down into: Clinical, Administrative and Combination of both reasons.

4. Transfers Graph. Graph. Clinical, admin, combination. Clinical, admin, combination.

5. Reasons for Non-compliance Clinical 45/78 ITU 45/78 ITU 2/7 SC 2/7 SC Instability of Patient, requiring increasing amounts of ITU care after WMNTS arrive.. Eg requiring intubation before transfer, administration of inotropes, administration of sedation, administration of phenobarbitone, commencement of Nitric oxide,untreated hypothermia, undetected pneumothorax. Instability of Patient, requiring increasing amounts of ITU care after WMNTS arrive.. Eg requiring intubation before transfer, administration of inotropes, administration of sedation, administration of phenobarbitone, commencement of Nitric oxide,untreated hypothermia, undetected pneumothorax. Baby not fully prepared prior to WMNTS arrival.Eg insertion of lines, readjustment of lines and ET tubes, fluids not prepared, X rays not performed or not reviewed.Delays obtaining X rays. Baby not fully prepared prior to WMNTS arrival.Eg insertion of lines, readjustment of lines and ET tubes, fluids not prepared, X rays not performed or not reviewed.Delays obtaining X rays. Staffing issues. Eg Unavailability of senior staff to handover Locum staff unfamiliar with Unit or unable to access PACS systems. Staffing issues. Eg Unavailability of senior staff to handover Locum staff unfamiliar with Unit or unable to access PACS systems. Visiting mothers on D/S or Wards areas prior to Transfer. Visiting mothers on D/S or Wards areas prior to Transfer. Failure of WMNTS equipment ( 2 incidences) Failure of WMNTS equipment ( 2 incidences) Handover of care from one WMNTS team to another. Handover of care from one WMNTS team to another. Change in Patient condition requiring alternative care pathway not transfer by WMNTS. Change in Patient condition requiring alternative care pathway not transfer by WMNTS. Delayed by timing of Opthamology review. Delayed by timing of Opthamology review.

6. Reasons for non-compliance. Administrative Administrative 13/78 ITU 13/78 ITU 5/7 SC 5/7 SC Delays receiving handover, Incomplete or inaccurate discharge summaries. Delay receiving discharge summaries. Call handling by NTS 1 whilst in Stabilisation period Loss of Cots prior to departure. Delay waiting for Photocopying required for surgical case. WMNTS arrival by request before receiving Cot secured. Combination of Both Clinical and Administrative Combination of Both Clinical and Administrative 20/78 ITU 20/78 ITU

7. Findings There where no specific hospital trends as to frequency of delays although specific clinical situations arise more often in SCU, possibly due to reduced number of staff available to assist prior to transfer. There where no specific hospital trends as to frequency of delays although specific clinical situations arise more often in SCU, possibly due to reduced number of staff available to assist prior to transfer. WMNTS largely comply with their own aim with regard to stabilisation times with over 91% of transfers stabilised in a timely manner. A change in data gathering may further improve this figure. WMNTS largely comply with their own aim with regard to stabilisation times with over 91% of transfers stabilised in a timely manner. A change in data gathering may further improve this figure.

8. Recommendations WMNTS review method of documenting stabilisation time to record actual time spent in just stabilisation and preparing for transfer, not arrival and departure times. WMNTS review method of documenting stabilisation time to record actual time spent in just stabilisation and preparing for transfer, not arrival and departure times. WMNTS to gain consensus as to exactly when times are recorded ie At arrival/departure at Hospital…or on actual ward. Differences between staff documentation could account for a significant number of breaches WMNTS to gain consensus as to exactly when times are recorded ie At arrival/departure at Hospital…or on actual ward. Differences between staff documentation could account for a significant number of breaches Referral units continue to be encouraged to seek transfer once baby is in an optimal condition to transfer. Referral units continue to be encouraged to seek transfer once baby is in an optimal condition to transfer.